Improving keratoconus management with central cor neal regularization and corneal collagen cross-linking protocol treatment.

Purpose: To evaluate safety and efficacy of customized central corneal regularization (CCR), together with simultaneous accelerated corneal collagen cross-linking (A-CXL) - CCR-CXL protocol, to treat keratoconus-related corneal ectasia. Design: Retrospective, comparative observational case series. Methods: Patients that had undergone combined CCR-CXL protocol. Main inclusion criteria were keratoconus visual acuity deterioration and contact lens intolerance. All patients underwent complete ophthalmological evaluation, corrected distance visual acuity (CDVA) and Scheimpflug-corneal tomography. Central corneal regularization was performed by ablation using flying spot laser. Subsequently, the stroma was saturated with 0.17% riboflavin-5-phosphate added every 2 minutes, followed by A-CXL 9 mW/cm2 for 10 minutes. CDVA, medium keratometry value (Kmed), and total corneal morphological irregularity index (CMI) of patients were analyzed before surgery and after 1, 3 and 12 months. A P value of .05 or less was considered statistically significant. Results: 46 eyes of 39 keratoconus patients were treated. At 1 month, the mean CDVA (LogMar) increased from 0.19 ± 0.02 to 0.12 ± 0.02 (P < .05), and the difference remained stable at month 12. Kmax decrease was statistically significant from 57.02 ± 5.65 to 50.21 ± 4.48 (P < .05). CMI decreased significantly from 47.8 ± 2.84 to 30.1 ± 2.4 (P < .01). Conclusions: CCR-CXL protocol is safe and effective in arresting keratectasia progression and increasing corneal optic regularity in keratoconus. These findings showed a significant improvement in CDVA, keratometry values and corneal optical aberrations after being treated with the CCR-CXL protocol.

Juvenile idiopathic arthritis-associated uveitis in the era of biological therapy: how the disease changed in more than 20 years of observation in a tertiary referral center in Rome (Italy).

OBJECTIVES: To describe the ophthalmological characteristics in a Juvenile idiopathic arthritis (JIA) cohort and to evaluate how therapeutic advances have changed the course of the uveitis. METHODS: Analysis of a retrospective cohort study of consecutive JIA pediatric patients including JIA-associated uveitis (JIA-U) and comparison with a previous study in the same uveitis center assessed before the wide-spread of biological therapy. RESULTS: The total of 49 JIA patients were analyzed, of whom 18 JIA-U, compared with a JIA-U past cohort of 66 patients. Systemic corticosteroids were used significantly less in the current JIA-U group (p = 0.008) than in the past one. JIA-U present cohort was on therapy more frequently with conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) than the past group (p = 0.039), mostly treated with methotrexate (93.3%). Furthermore, a larger use of biologic disease-modifying anti-rheumatic drugs (bDMARDs) was described in the current JIA-U group (p = 0.005) also associated with csDMARDs (p = 0.003). Adalimumab was used more (72.7%) in the present JIA-U cohort compared to a larger treatment with infliximab (61.5%) in the past (p = 0.005). Higher number of uveitis recurrences was observed in the previous cohort compared to the current one (p = 0.005). Fewer complications were described in this study than in the previous: posterior synechiae (p = 0.007), cataract (p < 0.001), band keratopathy (p < 0.001), and elevated intraocular pressure (IOP) (p = 0.047). CONCLUSION: Current therapies reduced the uveitis recurrences and ocular complications including cataract due also to the lower use of corticosteroids. The new close collaboration with the pediatric rheumatologic center in the same University has contributed to the care improvement and decrease of uveitis complications.

A new method to assess foveal morphology with optical coherence tomography.

PURPOSE: To measure foveal morphology using optical coherence tomography (OCT). METHODS: Three examiners classified normal subjects and patients with macular edema and epiretinal membranes from a normative database (299 OCT scans) and a study sample (80 OCT scans) on the basis of the foveal depression appearance (reference classification). The following parameters were measured for each OCT scan: Central Foveal Thickness (CFT), Central Subfield Thickness (CST), Central Subfield Volume (CSV), Centrofoveal Index (CI), Parafoveal Index (PI), and Foveal Indices (FI1, FI2, FI3). Foveal depression of OCT scans in the study sample were classified based on the values of OCT parameters using Bayesian statistics (test classifications). RESULTS: Agreement between reference and test classifications was of 70% for CFT, 58.7% for CST, 60% for CSV, 80% for CI, 72.5% for PI, 88.7% for FI1, 96.2% for FI2 and 97.5% for FI3. CONCLUSIONS: IF3 seems to provide a reliable measure of the foveal morphology.

Fixation Improvement through Biofeedback Rehabilitation in Stargardt Disease.

Stargardt disease is the most common hereditary macular degeneration in juveniles. It is characterized by macular dystrophy associated with loss of central vision in the first or second decade of life, a "beaten-metal" appearance in the fovea or parafoveal region, yellowish flecks around the macula or in posterior area of the retina, progressive atrophy of the bilateral foveal retinal pigment epithelium, and the "dark choroid" sign on fundus fluorescein angiography in most cases. We report a case of Stargardt disease in a 26-year-old Caucasian female submitted to rehabilitative training with microperimetry MP-1 to find a new preferred retinal locus (PRL) and to train her to better her quality of life. Best corrected visual acuity, mean retinal sensitivity, fixation, bivariate contour ellipse area, and speed reading were evaluated before and after the training and results were discussed.

Macular hole in retinitis pigmentosa patients: microincision vitrectomy with polydimethylsiloxane as possible treatment.

PURPOSE: To investigate long-term retinal changes after microincision pars plana vitrectomy surgery (MIVS) for macular hole (MH) in retinitis pigmentosa (RP) patients-retrospective and observational study. METHODS: Three RP patients suffering from MH were evaluated by means of best corrected visual acuity, anterior and posterior binocular examination, spectralis high-resolution optical coherence tomography, MP-1 microperimetry (MP-1), and full-field electroretinogram (ERG), before MIVS and during the 36-month follow-up. Patients underwent simultaneous MIVS and microincision cataract surgery; IOL was positioned in capsular bag. Patients were hospitalised for 2 days after the surgery. Surgical procedure was performed according the following schedule: surgical removal of crystalline lens, MIVS with 23-gauge sutureless system trocars, core vitreous body removal, peeling of the inner limiting membrane, and balanced sterile saline solution-air-micro-structured polydimethylsiloxane (PDMS) exchange. PDMS tamponade, after 6 months starting from MIVS, was removed. RESULTS: In all patients visual acuity increased after vitrectomy as a consequence of complete MH closure and restoration of retinal architecture. None of the patients developed ocular hypertension, or re-opening of MH during the 3-year follow-up. MP-1 bivariate contour ellipse area was reduced in its dimensions and improved in all patients demonstrating a better fixation. CONCLUSIONS: MIVS could be an effective treatment in RP patients with MH if medical therapy is not applicable or not sufficient. Finally more studies will be needed to improve knowledge about this genetic disease.

Electro-oculographic abnormality in eyes with uveal melanoma.

PURPOSE: To seek out correlations between preoperative electro-oculogram (EOG) recordings with different types of uveal melanomas, after surgery. METHODS: We analysed the EOG recordings of 120 patients with uveal melanomas, histologically verified, 100 in the choroid and 20 in the iris and ciliary body. The EOG data were correlated with the site, size and histological type of the tumor. RESULTS: In 100 eyes with choroidal melanoma the Arden Index (AI) was less than in fellow eyes (mean 126.6, SD +/- 23.8 and 202.9, SD +/- 47.0; p=0.01). The EOG values were not different with respect to the histological type, site and size of tumor. In cases with iris and ciliary body melanomas the AI were not significantly different from the fellow eyes (mean 180.6, SD +/- 23.6 and 203.2, SD +/- 38.7; p=0.07). CONCLUSIONS: Since the EOG is abnormal in eyes with choroidal melanoma, it can be considered a powerful auxiliary for diagnosing these tumors.

Treatment of vascular retinopathies with Pycnogenol.

The aim of our study was to investigate the effects of Pycnogenol on the progression of diabetic retinopathy and other vascular retinal disorders. The study consisted of a double-blind phase in which 20 patients were recruited and randomly treated with placebo or Pycnogenol (50 mg x 3/day for 2 months) and an open phase in which another 20 patients were treated with Pycnogenol at the same dose schedule. In total, 40 patients with diabetes, atherosclerosis and other vascular diseases involving the retina were enrolled; 30 of them were treated with Pycnogenol and 10 with placebo. The results demonstrated a beneficial effect of Pycnogenol on the progression of retinopathy. Without any treatment (placebo) the retinopathy progressively worsened during the trial and the visual acuity significantly decreased; on the contrary, the Pycnogenol-treated patients showed no deterioration of retinal function and a significant recovery of visual acuity was also obtained. The fluorangiography showed an improvement of retinal vascularization and a reduced endothelial permeability and leakage in the Pycnogenol, but not in the placebo-treated, patients. The ophthalmoscopy and the electroretinogram (ERG) also confirmed the beneficial effects of Pycnogenol. The mechanism of action of Pycnogenol may be related to its free radical (FR) scavenging, anti-inflammatory and capillary protective activities. It has been suggested that Pycnogenol may bind to the blood vessel wall proteins and mucopolysaccharides and produce a capillary 'sealing' effect, leading to a reduced capillary permeability and oedema formation.

Role of the corneal epithelium in refractive changes following laser in situ keratomileusis for high myopia.

PURPOSE: Epithelial hyperplasia is one of the factors that plays a role in myopic regression after photorefractive keratectomy (PRK). We evaluated the role of the epithelium following excimer laser in situ keratomileusis (LASIK) performed on highly myopic eyes. METHODS: Fifty eyes of 32 patients (18 females and 14 males; mean age, 31.7+/-6.5 years) were treated with LASIK for myopia with an attempted correction ranging between -8.50 and -12.25 D (mean, -10.48+/-1.43 D). No sutures were placed. The thickness of the central epithelium was evaluated either with a 50-MHz ultrasonic pachymeter or an ultrasound biomicroscope. Postoperatively, topical corticosteroid drops were administered for at least 1 month. RESULTS: Follow-up was at least 12 months. Epithelium measurements were thicker compared to preoperative measurements from the first week postoperatively (mean, +1.9 microm, +2.77%; P<.05). Epithelial thickness peaked at the third month after LASIK (mean, +6.5 microm, +9.5%; P<.05) and remained stable through 12 months. A negative correlation between epithelium thickness and manifest refraction from the first month postoperatively to the end of follow-up was present. CONCLUSION: The epithelium seemed to have a role in the regression of refractive effect after LASIK to correct high myopia.

Effectiveness of LASIK to correct refractive error after penetrating keratoplasty.

OBJECTIVE: Refractive errors may invalidate the good results of penetrating keratoplasty (PK). The Authors evaluate the effectiveness of excimer laser in situ keratomileusis (LASIK) in the correction of refractive error after PK. MATERIALS AND METHODS: Four patients, a 26-year-old woman, a 54-year-old man, a 19-year-old man, and a 51-year-old woman, showed refractive errors: -11 = -4.5 x 85 ; -8, -4.5 = -11 x 95 ; and -4.5 = -4 x = 1200, with a clear graft at least 20 months after penetrating keratoplasty secondary to keratoconus. However, they underwent the LASIK procedure with a nasal-hinged flap of 160 um. No sutures were placed. RESULTS: At follow-up, 24, 18, 12, and 12 months, respectively, the graft remained clear and the endothelial cells were unchanged. The uncorrected visual acuities were 20/50, 20/25, 20/50, and 20/25, respectively with an unchanged best corrected visual acuity (20/20) for all patients. No significant complications were observed. CONCLUSIONS: LASIK procedure seems to be an effective technique to correct refractive error after successful penetrating keratoplasty.

Videokeratographic changes after laser in situ keratomileusis to correct high myopia.

PURPOSE: To evaluate the videokeratographic changes and patterns after laser in situ keratomileusis (LASIK) in high myopia using computerized videokeratography. SETTING: San Salvatore Hospital, Chair of Ophthalmology, University of L'Aquila, L'Aquila, Italy. METHODS: Forty-one eyes of 26 patients treated with no-suture nasal-hinged flap LASIK for an attempted mean spherical equivalent correction of -13.9 diopters (D) +/- 4.1 (SD) (range -8.0 to -22.0 D) were evaluated. Mean patient age was 35.2 +/- 9.8 years. Mean follow-up was 15.1 +/- 6.7 months (range 6 to 26 months). RESULTS: Thirty-five eyes (85.4%) were within +/- 2.0 D of the planned correction, with a refractive error greater than 3.0 D in the 7.3% of eyes. Mean central corneal power decreased from 43.2 +/- 1.8 D (range 38.70 to 47.40 D) to 35.8 +/- 3.8 D (range 30.3 to 42.6 D). Mean preoperative corneal astigmatism decreased from 1.2 +/- 0.9 D (range 0.2 to 4.2 D) to 0.9 +/- 0.9 D (range 0.2 to 3.3 D). Videokeratographic qualitative analysis showed corneal shape changes within 15 days after surgery. Corneal patterns then stabilized, and 37 eyes (90.3%) had no significant modifications in corneal refractive power after 1 month. CONCLUSION: After LASIK in highly myopic eyes, videokeratographic maps showed corneal power stabilized within 1 month in most eyes and there was no irregular astigmatism if the treatment was well centered.

Unilateral retinitis pigmentosa: clinical and electrophysiological report of four cases.

Unilateral retinitis pigmentosa (URP) is a rare tapetoretinal dystrophy affecting only one eye. The François and Verriest criteria are necessary to make a correct diagnosis of URP: exclude all infective etiologies, check that the clinical signs of retinitis are present in the affected eye and ensure the total absence of any signs or symptoms of retinitis pigmentosa in the fellow eye. The standard electroretinogram and standard electro-oculogram are very useful for the correct diagnosis. Other pigmentary retinopathies simulating retinitis pigmentosa have to be excluded, such as previous retinal inflammatory diseases like syphilis, rubeola, other viral diseases and onchocerciasis. In this paper, 4 cases of URP are reported.

Long-term results of excimer laser photorefractive keratectomy in high myopia: a preliminary report.

BACKGROUND AND OBJECTIVE: To evaluate the results of 193-nm excimer laser photorefractive keratectomy (PRK) performed on highly myopic eyes with a follow-up of at least 2 years. PATIENTS AND METHODS: Fifty-three eyes of 41 patients were treated with a myopic PRK for an attempted correction ranging between -8 and -17 D (mean -10.9 +/- 2.8 SD). RESULTS: The follow-up ranged from 24 to 60 months (mean 34.1 months +/- 10 SD). Fifty-three percent of the eyes achieved a refraction within +/- 2 D of the planned correction, with a refractive error greater than 4 D in 21% of the treated eyes. The uncorrected visual acuity was 20/40 or better in 45% of the eyes. There were no significant opacities in 85% of the eyes examined. A second treatment was performed on 5 eyes. CONCLUSION: The results suggest that excimer laser PRK is a safe and relatively effective alternative for treating highly myopic eyes, and its effects are stable over a long period of time.

Normal EOG values in intraretinal metastasis from cutaneous melanoma: a case report.

PURPOSE: The electro-oculogram (EOG) is a powerful test to diagnose primary and metastatic choroidal tumors. While in benign tumors light-peak to dark-trough ratio values are in the range of normal subjects, these values appear highly altered in eyes affected by malignant choroidal tumors. Here we report a clinical case of a patient with intraretinal metastasis from cutaneous melanoma; notwithstanding the malignancy of the tumor, the EOG doesn't present alterations. METHODS AND RESULTS: Standard electro-oculographic recordings were performed before and after local excision of the tumor: recordings from the normal eye were taken as control. The EOG values were always normal in both eyes. Histological sections showed no evident change in the cell population of the retinal pigment epithelium (RPE) and Bruch's membrane. CONCLUSION: Our results suggest that the presence of an intact RPE is a crucial requirement to obtain a normal EOG.

Early detection of P-VEP and PERG changes in ophthalmic Graves' disease.

BACKGROUND: In Graves' disease the optic neuropathy (ON) is due to direct compression of the nerve and/or of its blood supply. The aim of the present study was to detect early changes in the visual functions of patients affected by ophthalmic Graves' disease (OGD) by using electrophysiological tests (P-VEP and PERG). METHODS: We studied 50 OGD patients who were in a range between class 2 and class 5 according to the Donaldson-American Thyroid Association classification, i.e. had no evident ON and normal visual acuity. We recorded transient reversal PERG and P-VEP in response to the stimulation of one eye at three spatial frequencies (2.2, 1.1 and 0.5 c/d). RESULTS: Our results showed a statistically significant reduction in PERG amplitude in class 5, while the P-VEP amplitude was already reduced in class 2. CONCLUSION: The electrofunctional tests were useful to detect small changes in the visual function of patients affected by initial stages of OGD. Therefore, P-VEP and PERG recordings appear to be a useful tool for early diagnosis of the optic nerve involvement in Graves' disease.

[Electro-functional changes in pseudo-exfoliative syndrome]. / Modification des examens électrofonctionnels dans le syndrome pseudo-exfoliatif.

PURPOSE: Up to date the pathogenetic aspects of exfoliation syndrome which are not well agreed upon even though the vascular damage plays a major role. METHODS: In order to evaluate the electrophysiological changes occurring in patients affected by exfoliation syndrome a case-control study with pattern electrofunctional examinations and oscillatory potentials from standard flash-ERG in 80 eyes affected by exfoliation syndrome with or without ocular hypertension was undertaken. RESULTS: Some statistically significant PERG, P-PEV and OP abnormalities were found in eyes affected by exfoliation syndrome with or without ocular hypertension (p < 0.001). There is no statistically significant difference between affected and control eyes in monolateral syndrome (p > 0.05). The electrofunctional examination did not mark any statistically significant difference between eyes with and without ocular hypertension (p > 0.05). CONCLUSION: The results stressed by pattern and oscillatory potentials examinations may support the hypothesis of a primitive change of the optic nerve.

Four techniques for retreatment after excimer laser photorefractive keratectomy.

BACKGROUND: Retreatment should be considered for patients unsatisfied because of undercorrection and/or haze following excimer laser photorefractive keratectomy (PRK) for myopia. It is unclear if any specific type of retreatment is superior to another, especially in terms of post-treatment myopic shift and haze. METHODS: After a mean follow-up of 12.4 +/- 5.5 months, we retreated 10 eyes by four different techniques following failed PRK: only PRK, PRK with phototherapeutic keratectomy (PTK), only PTK, and mechanical scraping. RESULTS: After a mean follow-up of 11.4 +/- 7.8 months (range, 6 to 28 mos), the final mean refraction was 2.40 +/- 2.00 D (range, 0 to -6.00 D). Corneal clarity improved in 70% of eyes. The mean uncorrected visual acuity improved from 20/200 to 20/40. Of the four retreatment techniques, only scraping proved ineffective, due to unstable outcome. CONCLUSIONS: PRK alone, PRK with PTK, and PTK alone appeared safe and effective methods of retreatment, with no worsening of corneal clarity.

Effect of myopic excimer laser photorefractive keratectomy on the electrophysiologic function of the retina and optic nerve.

PURPOSE: To assess by electrophysiologic testing the effect of photorefractive keratectomy (PRK) on the retina and optic nerve. SETTING: Eye Clinic, S. Salvatore Hospital, L'Aquila University, Italy. METHODS: Standard pattern electroretinograms (P-ERGs) and standard pattern visual evoked potentials (P-VEPs) were done in 25 eyes of 25 patients who had myopic PRK for an attempted correction between 5.00 and 15.00 diopters (D) (mean 8.00 D). Testing was done preoperatively and 3, 6, 12, and 18 months postoperatively. The contralateral eyes served as controls. During the follow-up, 3 patients (12%) developed steroid-induced elevated intraocular pressure (IOP) that resolved after corticosteroid therapy was discontinued. RESULTS: No statistically significant differences were seen between treated and control eyes nor between treated eyes preoperatively and postoperatively. CONCLUSION: Myopic excimer laser PRK did not seem to affect the posterior segment. The transient steroid-induced IOP rise did not seem to cause functional impairment.

Penetrating keratoplasty with donor and recipient corneas of the same diameter.

BACKGROUND AND OBJECTIVE: A retrospective study was conducted to investigate the effect of penetrating keratoplasty (PK) with donor and recipient corneas of equal diameter on astigmatism, corneal curvature, and spherical equivalent. PATIENTS AND METHODS: A total of 89 eyes of 86 consecutive patients who underwent PK with donor and recipient corneas of equal diameter were studied. The surgical techniques were performed using the Hanna suction punch block (endothelial cut) with the trephine system, and a single running 16-bite 10-0 nylon suture. Sixteen eyes underwent a triple procedure (PK, extracapsular cataract extraction, and intraocular lens [IOL] insertion) and 14 eyes underwent PK with sulcus fixation of a posterior chamber IOL. Follow-up ranged from 12 to 30 months (mean +/- SD 17.5 +/- 4.7). The sutures were removed at approximately 12 months postoperatively. RESULTS: The postoperative astigmatism ranged from 0.4 to 10.8 D (mean +/- SD 4.5 +/- 2.8), as evaluated by a computer-assisted videokeratograph topography unit. Twenty-seven eyes (30.3%) achieved a refractive error (spherical equivalent) within +/- 1.5 D of emmetropia. The mean postoperative refractive error (spherical equivalent) was -0.1 +/- 3.5 D (range -6.75 to + 7.25). No wound dehiscences or glaucoma was noted during the follow-up. CONCLUSION: The Hanna suction system creates a sharp, deep, and perpendicular cut on both button cornea and host cornea, making it possible to use donor and recipient corneas of the same diameter in PK with good clinical and refractive results, particularly for myopic (keratoconus) patients.

Specular microscopy of the corneal endothelium after excimer laser photorefractive keratectomy.

PURPOSE: To evaluate endothelial cell morphology and density after excimer laser photorefractive keratectomy (PRK). METHODS: We used a noncontact specular microscope to examine the central corneal endothelium of 50 eyes of 50 patients who had PRK for an attempted correction between -2.5 and -17.0 diopters (D) (mean -7.8 D) beginning 18 to 24 hours postoperatively. RESULTS: After a follow-up of 11.4 +/- 6.1 months (mean +/- standard deviation), mean endothelial cell density was 2577.6 +/- 402.0 cells/mm2 with rare signs of polymegathism and pleomorphism. Preoperative and untreated fellow eye endothelial cell density values were used as a control. Paired Student's t-test and analysis of variance results were not significant (P > .05). CONCLUSION: Excimer laser PRK did not significantly change cell density and morphology.