Orbital myositis and scleritis after anti-SARS-CoV-2 mRNA vaccines: A report of three cases.

PURPOSE: To report three cases of ocular myositis and scleritis, bilateral scleritis and unilateral single muscle myositis after mRNA COVID-19 vaccination. METHODS: Case series of three patients who presented to the Orbit Outpatient Service of Fondazione Policlinico Universitario A. Gemelli with a history of unilateral proptosis, diplopia and pain, bilateral red eye and pain during eye movements and unilateral proptosis and inconstant diplopia respectively with onset 5-10 days after m-RNA COVID-19 vaccine. A thorough hematologic work up and orbital contrast enhanced magnetic resonance imaging (MRI) in patients with proptosis was performed. RESULTS: Patients were females, 64, 58 and 45 years old respectively. MRI showed enlargement of all right rectus muscles, with both muscle belly and insertion involvement in the first case associated to right scleritis. A bilateral scleritis was diagnosed in the second patient and a single muscle myositis in the third patient. Serological tests excluded thyroid diseases. The first and second patient were treated respectively with oral and topical glucorticoids with a complete clinical response. Two 2 cycles of oral non-steroidal anti-inflammatory drugs were administered to the third patient with a partial response. CONCLUSION: As far as we know these are the first report of orbital myositis and scleritis presenting after mRNA BNT162b2 vaccine (Pfizer/BioNTech) and mRNA-1273-(Moderna) vaccine, an uncommon effect of a likely autoimmune reaction triggered by the virus antigen.

Red Reflex-Guided Big-Bubble Deep Anterior Lamellar Keratoplasty: A Simple Technique to Judge Dissection Depth.

PURPOSE: To report the results of a modified big-bubble deep anterior lamellar keratoplasty technique using the intraoperative red reflex to visualize the amount of residual stroma beneath the inserted cannula. METHODS: A total of 132 consecutive keratoconic eyes were included in this retrospective, noncomparative, interventional case series. Before starting surgery, pharmacologic mydriasis was induced in all eyes undergoing a big-bubble deep anterior lamellar keratoplasty procedure. After partial trephination of the recipient cornea, a spatula was inserted at the base of the incision and advanced into depth using as a reference the thin dark line seen in the red reflex ahead of the advancing tip; the stromal depth reached was measured using anterior segment optical coherence tomography. Finally, the spatula was exchanged for a 27-gauge cannula, and air was injected to create a big bubble. The stromal depth reached with the spatula, success rate of big-bubble formation, and complications were recorded. RESULTS: The big bubble was obtained in 118 of 132 eyes (89.4%). Of the remaining 14 eyes, 11 underwent completion of the procedure by manual dissection and 3 were converted to penetrating keratoplasty because the bubble burst while trying to enlarge it. Perforation did not occur in any case during cannula insertion. The average thickness reached with the stromal dissection was 64.3 ± 19.5 µm. CONCLUSIONS: The thin dark line, seen in the red reflex obtained with pharmacologic dilation, provides a useful and effective reference that can be used to visualize and judge the depth of dissection, thus allowing a safer and reproducible approach to the pre-Descemetic stroma.

Surgical technique for graft exchange after big-bubble deep anterior lamellar keratoplasty.

PURPOSE: The aim of this study was to describe a surgical technique for repeat deep anterior lamellar keratoplasty (DALK) by baring Descemet membrane again in eyes affected by stromal opacity of the donor lamella. METHODS: Repeat DALK was performed in 5 eyes of 5 patients affected by central stromal opacity not involving the endothelium; indications for repeat surgery were postbacterial or postherpetic corneal scars (n = 3), postphotorefractive keratectomy haze (n = 1), and recurrence of granular dystrophy (n = 1). The surgical procedure consisted of the following: (1) superficial trephination, 250 µm in depth, on the original peripheral scar; (2) blunt detachment of the donor graft completed by means of corneal forceps; (3) apposition of the new lamella. Best spectacle-corrected visual acuity, topographic astigmatism, and endothelial cell density were evaluated preoperatively, as well as 3, 6, 9, 12, and 18 months after surgery. RESULTS: At the latest follow-up examination, with all sutures removed from all eyes, the best spectacle-corrected visual acuity was 20/30 or better in all cases with 3 eyes achieving 20/20. Postoperative refractive astigmatism averaged 3.0 ± 1.2 diopters (mean ± SD); endothelial cell density was not significantly affected by surgery. CONCLUSIONS: Repeat DALK is effective in removing diseased corneal stroma while keeping the recipient endothelium unaffected; the procedure is simple and does not require pneumatic dissection, thus eliminating the most challenging surgical step; postoperative visual recovery does not differ from that experienced after primary DALK.

Inadvertent donor button inversion during big-bubble deep anterior lamellar keratoplasty.

PURPOSE: The aim of this study was to describe clinical outcomes and histopathologic findings in a case of repeat deep anterior lamellar keratoplasty (DALK) performed because of inadvertent inversion of the donor button at the time of primary surgery. METHODS: A 34-year-old woman underwent big-bubble DALK for keratoconus in her right eye; 4 days postoperatively, slit-lamp examination revealed the presence of several inclusions in the interface, whereas anterior segment optical coherence tomography (AS-OCT) showed pathologically marked wrinkling of the posterior stroma; inadvertent intraoperative inversion of the graft was diagnosed and the interface inclusions were assumed to be of epithelial origin. Repeat surgery was performed: donor tissue was removed and submitted to histological examination, marking the external surface of the lamella; the recipient residual bed was carefully washed and a new lamellar graft was sutured into position. Three months postoperatively, the patient underwent a complete ophthalmologic examination, including best-spectacle corrected visual acuity testing, refraction, biomicroscopy, AS-OCT, and endothelial microscopy. RESULTS: Histological examination confirmed that the donor button had been implanted with the epithelium facing the residual bed. Three months postoperatively, normal corneal curvature was visible at AS-OCT, the best-spectacle corrected visual acuity was 20/25, and the interface appeared perfectly clear. Endothelial cell density had not been substantially affected by the 2 surgical procedures. CONCLUSIONS: Inadvertent inversion of donor tissue at the time of DALK is reported for the first time. Prompt exchange of the lamellar graft was instrumental in avoiding epithelial colonization of the interface, as well as in restoring excellent vision.

Anti-vascular endothelial growth factor drugs safety and efficacy in ophthalmic diseases.

Macular degeneration is the leading cause of blindness in developed countries. In the treatment of neovascular age-related macular degeneration, vascular endothelial growth factor (VEGF) has emerged as a key target for therapy. The intravitreal injection of anti-VEGF drugs has been widely employed to reduce the disease progression and improve the visual outcomes of the affected patients. However, each intravitreal inoculation poses a risk of several complications as infection, inflammation, endophthalmitis, intraocular inflammation, increase of intraocular pressure and vitreous hemorrhage. This short review evaluates the efficacy and the incidence of adverse drug reactions related to intravitreal administration of the main anti-VEGF drugs actually available: Bevacizumab, ranibizumab and aflibercept.

Epithelial-disruption collagen crosslinking for keratoconus: one-year results.

PURPOSE: To evaluate the efficacy of epithelial-disruption collagen crosslinking (CXL) for progressive keratoconus using a corneal disruptor device and a riboflavin solution designed for a transepithelial technique. SETTING: Magna Graecia University Eye Clinic, Catanzaro, Italy. DESIGN: Prospective comparative case series. METHODS: The most severely affected eye of patients with bilateral progressive keratoconus was treated. The fellow eye served as a control. Follow-up was 12 months. A corneal disruptor device was used to create pockmarks in the epithelium. Riboflavin solution was applied for 30 minutes and irradiation for 30 minutes. Three days postoperatively, patients were asked to assess the level of pain. RESULTS: The study comprised 28 patients (mean age 28 years). The mean postoperative pain score was 4.3, 2.6, and 2.1 at 1 day, 2 days, and 3 days. The mean preoperative uncorrected (UDVA) and corrected (CDVA) distance visual acuities improved from 0.73 logMAR ± 0.21 (SD) and 0.30 ± 0.11 logMAR to 0.48 ± 0.15 logMAR and 0.25 ± 0.1 logMAR, respectively, at 12 months (P=.02). The mean spherical equivalent refraction decreased 0.96 diopter (D). The mean baseline apical keratometry, apical gradient curvature, average pupillary power, inferior-superior index, and cone area were 59.21 D, 8.91 D, 47.9 D, 11.49 mm(2), and 10.32 mm(2), respectively. At 12 months, these values were 56.18 D, 7.32 D, 41.34 D, 9.65 mm(2), and 7.75 mm(2), respectively. No adverse effects were observed. CONCLUSIONS: Corneal epithelial-disruption CXL was safe and effective in medium-term stabilization of keratoconus with an improvement in topographic and refractive parameters and less patient discomfort.

Anterior segment optical coherence tomography-guided big-bubble technique.

PURPOSE: To evaluate the feasibility of intraoperative anterior segment (AS) optical coherence tomography (OCT) for quantification of the corneal depth reached with the dissecting cannula used for deep anterior lamellar keratoplasty, as well as its correlation with the success rate of big-bubble formation. DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: One hundred consecutive keratoconus patients. INTERVENTION: Deep anterior lamellar keratoplasty was performed using the big-bubble technique. During surgery, the cannula used for pneumatic dissection was inserted into the peripheral stroma and advanced as deep and far toward the center as believed adequate by the surgeon. Then, after retracting the cannula, AS OCT was performed. The cannula was placed back in position and creation of the big bubble was attempted. MAIN OUTCOME MEASURES: Stromal depth reached with the cannula tip, success rate in achieving big-bubble formation, and complication rate. RESULTS: Bubble formation was obtained in 70 of 100 eyes (70%). In all remaining eyes, the procedure was completed by manual deep lamellar dissection. The average depth reached by the cannula tip was 104.3±34.1 µm from the internal corneal surface; the mean value recorded in cases of successful big-bubble formation (90.4±27.7 µm) was statistically lower than that measured in failed procedures (136.7±24.2 µm). In 1 case, corneal perforation occurred during the insertion of the cannula and required conversion to penetrating keratoplasty (PK). In 8 eyes, small microperforations occurred during stromal excision but could be managed conservatively, avoiding conversion to PK. In 2 advanced cones, an incomplete bubble formation was obtained, necessitating manual peripheral stromal removal. CONCLUSIONS: Successful big-bubble formation can be anticipated if pneumatic dissection is attempted at a sufficiently deep level. Although an ideal depth could not be defined, AS OCT allows objective evaluation of the depth reached by the cannula tip used for pneumatic dissection. The AS OCT findings may confirm the decision to proceed with air injection. It is possible that cannula repositioning based on the AS OCT depth may improve the success rate for big-bubble formation.

Curcumin protects against NMDA-induced toxicity: a possible role for NR2A subunit.

PURPOSE: Curcumin, a phenolic compound extracted from the rhizome of Curcuma longa, was found to attenuate NMDA-induced excitotoxicity in primary retinal cultures. This study was conducted to further characterize curcumin neuroprotective ability and analyze its effects on NMDA receptor (NMDAr). METHODS: NMDAr modifications were analyzed in primary retinal cell cultures using immunocytochemistry, whole-cell patch-clamp recording and western blot analysis. Cell death was evaluated with the TUNEL assay in primary retinal and hippocampal cultures. Optical fluorometric recordings with Fura 2-AM were used to monitor [Ca(2+)](i). RESULTS: Curcumin dose- and time-dependently protected both retinal and hippocampal neurons against NMDA-induced cell death, confirming its anti-excitotoxic property. In primary retinal cultures, in line with the observed reduction of NMDA-induced [Ca(2+)](i) rise, whole-cell patch-clamp experiments showed that a higher percentage of retinal neurons responded to NMDA with low amplitude current after curcumin treatment. In parallel, curcumin induced an increase in NMDAr subunit type 2A (NR2A) level, with kinetics closely correlated to time-course of neuroprotection and decrease in [Ca(2+)](i). The relation between neuroprotection and NR2A level increase was also in line with the observation that curcumin neuroprotection required protein synthesis. Electrophysiology confirmed an increased activity of NR2A-containing NMDAr at the plasma membrane level. CONCLUSIONS: These results confirm the neuroprotective activity of curcumin against NMDA toxicity, possibly related to an increased level of NR2A, and encourage further studies for a possible therapeutic use of curcumin based on neuromodulation of NMDArs.

Pentacam assessment of posterior lamellar grafts to explain hyperopization after Descemet's stripping automated endothelial keratoplasty.

PURPOSE: To evaluate changes in posterior corneal curvature as a possible cause of the hyperopic refractive shift observed after Descemet's stripping automated endothelial keratoplasty (DSAEK). DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: Thirty-four eyes of 29 patients with Fuchs' endothelial dystrophy or pseudophakic bullous keratopathy. METHODS: A standard DSAEK procedure was performed in 34 eyes using the pull-through technique for graft delivery. When cataract was present (n = 7), phacoemulsification with posterior chamber intraocular lens implantation was combined. Each eye underwent Pentacam (Oculus, Wetzlar, Germany) evaluation 1, 3, and 12 months after surgery. Corneal graft thickness was calculated on Scheimpflug scans at 9 locations (1 central, 4 peripheral, and 4 mid peripheral). The mean radius of posterior corneal curvature (Rm) was recorded. At each postoperative examination time, manifest refraction was determined and compared with pre-DSAEK values in simple procedures or with intended postoperative refraction, if cataract surgery had been performed. MAIN OUTCOME MEASURES: Manifest refraction, Rm, and corneal graft thickness at 1, 3, and 12 months after surgery. RESULTS: The mean+/-standard deviation posterior corneal curvature was 6.5+/-0.56 mm before surgery and varied from 5.52+/-0.39 mm 1 month after surgery to 5.83+/-0.37 mm at 3 months after surgery and 5.92+/-0.35 mm at 12 months after surgery. The grafts were significantly thicker in the periphery and mid periphery than in the center at all examination times. Thickening diminished significantly over time at all locations. The average reduction of corneal thickness was higher at the edges (91.5 microm) than in the mid periphery (38.3 microm) or in the center (24.2 microm). The average postoperative spherical equivalent+/-standard deviation changed from -0.31+/-2.35 diopters (D) before surgery to 1.03+/-2.21 D 1 month after surgery, 0.61+/-2.07 D 3 months after surgery, and +0.31+/-2.03 D 12 months after surgery. CONCLUSIONS: The difference in thickness between center and periphery of the DSAEK graft induces a change in posterior corneal curvature, resulting in a hyperopic shift that decreases with time and is negligible for spectacle correction. However, when performing a triple procedure, intraocular lens selection should take into account the refractive change induced by DSAEK. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Biocompatibility assessment of liquid artificial vitreous replacements: relevance of in vitro studies.

The biocompatibility of liquid artificial vitreous replacements is generally assessed by performing tests in animal models before their clinical use, whereas in vitro experimentation is seldom carried out due to their physico-chemical characteristics. Since their introduction in vitreoretinal surgery, however, the use of some certified vitreous replacements has been discouraged after clinical trials, because of the occurrence of serious side effects. This observation suggests that the tests currently performed for biocompatibility assessment cannot fully guarantee their safety when they are used in humans. Here we review the available literature on in vitro biocompatibility testing of liquid artificial vitreous replacements and survey our own experience on the subject, obtained by using primary retinal cell cultures, seeded on micro-porous inserts. We suggest that in vitro biocompatibility assessment, conducted before experiments in animal models, could improve the required safety evaluation and decrease the risk of undesired side effects, as well as providing a beneficial reduction of animal experimentation.

Induction of apoptosis in rat retinal cell cultures by partially fluorinated alkanes.

PURPOSE: To test whether the partially fluorinated alkanes (PFAs) perfluorobutylbutane (O(44)), perfluorohexylethan (O(62)), and the oligomer OL(62HV), recently proposed as artificial vitreous replacements (AVRs), have pro-apoptotic effect in rat retinal cultures. DESIGN: Laboratory investigation. METHODS: Rat retinal cell cultures were seeded onto microporous inserts to study AVR-cell interaction without impairing cell survival. Cells were treated for 24 hours with O(62), O(44), and OL(62HV). Apoptosis was analyzed by transferase-mediated dUTP-biotin nick end-labeling assay and Hoechst stain. RESULTS: O(44) and O(62) did not affect structural organization and cell survival in retinal cell cultures; however, OL(62HV) induced increased apoptosis compared with control cultures. CONCLUSIONS: OL(62HV), a high-viscosity PFA, induces severe retinal damage in human eyes, although it successfully passed animal experimentation. Our in vitro study showed a remarkable pro-apoptotic effect of OL(62HV) and suggests that in vitro tests can contribute to AVR biocompatibility assessment.

Biocompatibility assessment of silicone oil and perfluorocarbon liquids used in retinal reattachment surgery in rat retinal cultures.

The effects of silicone oil and perfluorocarbon liquids used in retinal reattachment surgery were studied in vitro using rat retinal cultures seeded on microporous inserts. These inserts allow the cell layer to be in contact with the material to be tested on the apical side and with the nutrient medium on the basal side. The materials tested were silicone oil, the perfluorocarbons perfluorophenanthrene and perfluoroctane, and hydroxypropylmethylcellulose. Perfluorophenanthrene, the heaviest of the compounds, induced a very precocious detachment of the cell layer. All the other tested biomaterials were compatible with cell survival and did not alter the structural organization of the retinal cultures, as revealed by scanning electron microscopy. By immunocytochemical techniques we evaluated the cell composition and the differentiation state of each of the cultures. In both control and treated samples, neuronal cells were well preserved. The expression of microtubule-associated protein 2, a marker of differentiated neuronal cytoskeleton, was not affected. Amacrine neurons, immunolabeled for gamma-aminobutyric acid, still were detectable after treatment. Synapses, marked by immunoreactivity for synapthophysin, were equally preserved. Vimentin-positive glial cells did not show modifications. The apoptotic rate, as determined by the terminal transferase-mediated dUTP-biotin nick end-labeling assay, was similar in treated and control samples. The results confirm that the use of biomaterials with a specific gravity close to intraocular fluids is compatible with retinal cell survival and differentiation in vitro.