Advances in Transepithelial Photorefractive Keratectomy versus Laser-Assisted In Situ Keratomileusis.

(1) Background: Laser-assisted refractive surgery is a safe and effective surgical correction of refractive error. For most patients, both the newer Trans-PRK and the established LASIK technique can produce the required surgical correction, sparking the question of which technique should be opted for. (2) Methods: The study prospectively evaluated 121 patients (230 eyes) for at least one month postoperatively; 66 patients (126 eyes) and 45 patients (85 eyes) returned for 6 months and 1 year follow-up. (3) Results: No statistical difference was recorded at 1 week or 1 month post-operation. At 6 months, a difference was found for spherical diopters (Trans-PRK -0.0476 ± 0.7012 versus FS-LASIK +0.425 ± 0.874, p = 0.004) and spherical equivalent (Trans-PRK -0.1994 ± 0.0294 versus FS-LASIK +0.225 ± 0.646, p = 0.025) but not for CYL D (Trans-PRK -0.3036 ± 0.5251 versus FS-LASIK -0.4 ± 0.820, p = 0.499). Uncorrected visual acuity was better for Trans-PRK 6 months post-operation (UCVA logMAR 0.02523 versus 0.0768 logMAR; p = 0.015 logMAR). At 1-year, Trans-PRK was favored for spherical diopters (Trans-PRK -0.0294 ± 0.6493 versus FS-LASIK +0.646 ± 0.909, p < 0.001) and spherical equivalent (Trans-PRK -0.218 ± 0.784 versus FS-LASIK 0.372 ± 1.08, p = 0.007). Overall speed in visual recovery, variance of results and surgically induced astigmatism were in favor of Trans-PRK. (4) Conclusions: The study reported improvements for Trans-PRK patients, with both techniques found to be safe and effective.

Evaluation of the efficiency and safety of TransPRK and FS-LASIK refractive procedures on patients with astigmatism and amblyopia.

Purpose: To compare the outcomes of transepithelial photorefractive keratectomy (transPRK) with femtosecond laser assisted in situ keratomileusis (FS-LASIK) for the correction of astigmatism on amblyopic eyes. Methods: The design was a retrospective interventional study on 37 eyes with hyperopic or mixed astigmatism and refractive amblyopia, which underwent transPRK or FS-LASIK. The patients were distributed into 2 groups according to the technique used. Data was collected from patient files and comparison between groups was performed. The main outcomes measured were corrected distance visual acuity (CDVA), sphere, cylinder, spherical equivalent (SEQ), efficiency and safety indexes. Results: In the transPRK group, SEQ improved significantly after 1 month, from 2.08 ± 2.02D (p<0.01) to 0.125 ± 0.86D and at the 12 month visit to -0.04 ± 0.62D (p>0.05), sphere improved from 4.03 ± 1.44D preoperatively to 0.67 ± 0.9D at 1 month (p<0.05) and further to 0.44 ± 0.71 at 12 months (p<0.05). CDVA improved from 0.194 ± 0.11 logMAR to 0.115 ± 0.1 logMAR at the 1-year visit. Safety index after 1 month was 1.09 ± 0.2 and 1.12 ± 0.35 at the 1-year visit. Efficiency index was 0.95 ± 0.22 at 1 month and 1.03 ± 0.34 after 1 year. In FS-LASIK group, SEQ improved after 1 month, from 2.28 ± 3.04 to -0.79 ± 0.73D (p<0.01), and further to -0.49 ± 0.79 (p>0.05) at the 12 month visit, sphere improved from 4.11 ± 2.35D preoperatively to -0.42 ± 0.66D at 1 month (p<0.05) and further to -0.08 ± 0.75D at 12 months (p<0.05). CDVA also improved from 0.191 ± 0.1 logMAR to 0.140 ± 0.1 logMAR at 1 year. Safety index after 1 month was 1.1 ± 0.2 and 1.16 ± 0.21 at the 1-year visit. Efficiency index was 0.98 ± 0.27 at 1 month and 1.06 ± 0.23 after 1 year. Conclusion: Both procedures were safe and efficient in improving visual acuity for patients with mixed and hyperopic astigmatism and refractive amblyopia. Abbreviations: transPRK = transepithelial photorefractive keratectomy, FS-LASIK = femtosecond laser in situ keratomileusis, logMAR = logarithm of the Minimum Angle of Resolution, BCVA = best corrected distance visual acuity, CDVA = corrected distance visual acuity.

Frontiers of Cranial Base Surgery: Integrating Technique, Technology, and Teamwork for the Future of Neurosurgery.

The landscape of cranial base surgery has undergone monumental transformations over the past several decades. This article serves as a comprehensive survey, detailing both the historical and current techniques and technologies that have propelled this field into an era of unprecedented capabilities and sophistication. In the prologue, we traverse the historical evolution from rudimentary interventions to the state-of-the-art neurosurgical methodologies that define today's practice. Subsequent sections delve into the anatomical complexities of the anterior, middle, and posterior cranial fossa, shedding light on the intricacies that dictate surgical approaches. In a section dedicated to advanced techniques and modalities, we explore cutting-edge evolutions in minimally invasive procedures, pituitary surgery, and cranial base reconstruction. Here, we highlight the seamless integration of endocrinology, biomaterial science, and engineering into neurosurgical craftsmanship. The article emphasizes the paradigm shift towards "Functionally" Guided Surgery facilitated by intraoperative neuromonitoring. We explore its historical origins, current technologies, and its invaluable role in tailoring surgical interventions across diverse pathologies. Additionally, the digital era's contributions to cranial base surgery are examined. This includes breakthroughs in endoscopic technology, robotics, augmented reality, and the potential of machine learning and AI-assisted diagnostic and surgical planning. The discussion extends to radiosurgery and radiotherapy, focusing on the harmonization of precision and efficacy through advanced modalities such as Gamma Knife and CyberKnife. The article also evaluates newer protocols that optimize tumor control while preserving neural structures. In acknowledging the holistic nature of cranial base surgery, we advocate for an interdisciplinary approach. The ecosystem of this surgical field is presented as an amalgamation of various medical disciplines, including neurology, radiology, oncology, and rehabilitation, and is further enriched by insights from patient narratives and quality-of-life metrics. The epilogue contemplates future challenges and opportunities, pinpointing potential breakthroughs in stem cell research, regenerative medicine, and genomic tailoring. Ultimately, the article reaffirms the ethos of continuous learning, global collaboration, and patient-first principles, projecting an optimistic trajectory for the field of cranial base surgery in the coming decade.

From Genes to Therapy: Pituitary Adenomas in the Era of Precision Medicine.

This review presents a comprehensive analysis of pituitary adenomas, a type of brain tumor with diverse behaviors and complexities. We cover various treatment approaches, including surgery, radiotherapy, chemotherapy, and their integration with newer treatments. Key to the discussion is the role of biomarkers in oncology for risk assessment, diagnosis, prognosis, and the monitoring of pituitary adenomas. We highlight advances in genomic, epigenomic, and transcriptomic analyses and their contributions to understanding the pathogenesis and molecular pathology of these tumors. Special attention is given to the molecular mechanisms, including the impact of epigenetic factors like histone modifications, DNA methylation, and transcriptomic changes on different subtypes of pituitary adenomas. The importance of the tumor immune microenvironment in tumor behavior and treatment response is thoroughly analyzed. We highlight potential breakthroughs and innovations for a more effective management and treatment of pituitary adenomas, while shedding light on the ongoing need for research and development in this field to translate scientific knowledge into clinical advancements, aiming to improve patient outcomes.

Underlying Ciliary Body Uveal Melanoma in a Patient with Chronic Lymphocytic Leukemia Presenting for Hyphema.

(1) Background: Ciliary body uveal melanoma is a rare subtype of uveal melanoma which comprises 3-5% of melanomas, an immunogenic cancer, and can present multifaceted initial clinical manifestations, masquerading as various ocular pathologies. Chronic lymphocytic leukemia (CLL) presents immunodeficiency and risk for the development of a secondary malignancy, with Bruton's tyrosine kinase inhibitor treatment having a mutagenic effect and a secondary anti-platelet aggregation effect. We present the case of a 65-year-old patient undergoing treatment for CLL with ibrutinib who presented with recurrent hyphema that masked an underlying, inferiorly situated, ciliary body uveal melanoma; (2) Methods: Retrospective case review; (3) Results: An ophthalmological examination together with imaging via mode B ultrasound and contrast-enhanced magnetic resonance imaging resulted in the clinical and imagistic diagnosis of a ciliary body uveal melanoma. A pathological examination of the enucleated eye confirmed the diagnosis. Postoperative tumoral reoccurrence was not detected for 1½ years, however, CLL immunosuppression worsened with admission for severe COVID-19 disease. (4) Conclusions: CLL patient screening for melanoma should also include detailed ophthalmological examinations, which could also include ultrasound ophthalmological imaging. The avoidance of uveal melanoma metastatic disease is paramount for patient survival. CLL manifests additional profound immunosuppression.

Surgical approach in type II Peters anomaly - case report.

Objective: The aim of this report was to present a rare case of apparently unilateral Peters anomaly and describe the clinical characteristics, surgical approach, and visual prognosis. Methods: We presented the case of a 7-year-old female patient with posterior corneal defect due to kerato-lenticular adhesions along with anterior dislocation and opacification of the lens in the left eye and a history of post-traumatic evisceration of the right eye. Systemic associations included mental underdevelopment, left torticollis and scoliosis. No family history of acquired or inherited diseases were determined. We performed cataract extraction in the left eye and opted for aphakia. Results: Based on clinical findings, we considered unilateral Peters anomaly type II. Cataract surgery slightly improved the visual acuity from hand moving to 20/ 400 UCVA (uncorrected visual acuity) and 20/ 100 with +10.0 diopters at 1 month postoperative. No enlargement of the corneal opacity was observed. Conclusions: In this case, we were able to diagnose Peters anomaly only in one eye. The diagnosis required long follow-up with periodic measurement of intraocular pressure (IOP) to early detect glaucoma. The complexity and uniqueness of the case relied on the difficult approach made by the cloudy cornea and anterior lens dislocation. We applied a combination of techniques including adhesiolysis, cataract extraction and anterior vitrectomy. Further interventions such as secondary IOL (intraocular lens) implantation or PKP (penetrating keratoplasty) will be taken into consideration after six-month and one-year postoperative follow-up. Abbreviations: PA = Peters anomaly, DM = Descemet's membrane, IOL = intraocular lens, VA = visual acuity, OVDs = ophthalmic viscosurgical devices, IOP = intraocular pression, PKP = penetrating keratoplasty, BCVA = best corrected visual acuity, UCVA = uncorrected visual acuity.

Traumatic Intralenticular Neovascularization in a HLA B27+ Pediatric Patient.

(1) Background: Intralenticular tumors are an entity akin to Schrodinger's cat since, although the human crystalline cells themselves are not known to malignly proliferate, various entities can take the appearance and clinical presentation of a tumor originating in the lens. We present the peculiar case of an 11-year-old male patient of African descent, HLA B27+, with a previous history of minor ocular trauma and unilateral anterior uveitis a year before which was admitted to our department with total opacification of the crystalline lens in the right eye and lens neovascularization. During surgery, a vascular, white fibrotic mass measuring 0.1-0.2 cm was discovered inside the lens bag and was excised. (2) Methods: Retrospective case review. (3) Results: The histopathological exam of the excised mass revealed an abundant infiltrate consisting of CD68+ foamy macrophages and lymphoplasmacytic elements. CD68 is a pan-macrophage marker associated with an active inflammatory mechanism soliciting macrophages, and tissue activated macrophages are correlated to increased stromal and serum levels of vascular endothelial growth factor, providing an explanation for lens angiogenesis. (4) Conclusions: The diagnosis is of a "masquerade tumor" resulted from an abnormal inflammatory process in connection with previous ocular trauma and possibly the patient's HLA B27+ status.

Postoperative retinal microstructure and functional outcome after inverted-flap technique associated with silicone oil tamponade in macular hole surgery.

PURPOSE: Our retrospective study on 27 patients with a large mean macular hole diameter (MH-D) of 480.08±78.62 µm evaluates the usefulness of combining the current internal limiting membrane (ILM) inverted-flap surgical technique with silicone oil tamponade, which has been associated with the classical technique of ILM peeling. RESULTS: Functional results: mean visual acuity (VA) improved to 0.89±0.11 logMar (logarithm of the minimum angle of resolution, at one month), 0.67±0.03 logMar (at three months), 0.52±0.04 logMar (at six months), 0.42±0.15 logMar (at one year) postoperative (final VA), with statistical linkage between preoperative VA and final VA (two-sample t-test, p=0.007), mean MH-D and final VA (regression analysis, p=0.003). We compared the results by MH size (Group A ≤400 µm - eight eyes and Group B >400 µm - 19 eyes), finding statistical variance (Bonett & Levene methods). Group A presented a final VA of 0.21±0.12 logMar, while Group B had 0.51±0.17 logMar. Successful closure was noted in 25 (92.59%) cases, with Group A having complete closure and external limiting membrane (ELM) restoration with ellipsoid zone (EZ) regeneration in six cases. Group B had successful closure in 17 (89.47%) cases with ELM restoration in 16 cases and EZ regeneration in seven (38.88%) cases, with reintervention in two cases. Restoration of the ELM was correlated [Pearson's correlation coefficient (PCC) of 0.999, p=0.022] with successful closure, with overall restoration obtained in 24 (88.88%) cases and EZ regeneration in 13 (48.14%) cases. CONCLUSIONS: ILM inverted-flap technique with silicone oil tamponade had favorable functional and anatomical outcomes. ELM restoration was associated with successful MH closure.

Congenital cataract - clinical and morphological aspects.

Congenital cataract is one of the main causes of blindness in newborns and children. According to the World Health Organization (WHO), there are about 14 million children suffering from congenital cataract. Our study is based on 82 children, males - 46 (56.1%) and females - 36 (43.9%), with congenital cataract operated in the same ophthalmological centre in Bucharest, Romania. Of the 82 patients, 49 (59.76%) had bilateral cataract and 33 (40.24%) unilateral cataract. Clinically, the most frequent was the total cataract, followed by lamellar, nuclear and cerulean. We employed nine surgical approaches in our patients, depending on the type of intraocular lens (IOL). Morphologically, obvious changes were rendered evident at the level of anterior and posterior capsules, as well as subcapsular.

Clinical and therapeutic particularities of congenital cataracts in pediatric patients with Down syndrome.

Objective: This study aims to identify clinical and therapeutic surgical particularities and postoperative complications encountered in children suffering from Down syndrome and congenital cataract, as well as the existence of a correlation with associated systemic anomalies. Methods: A retrospective interventional study that analyzes cases of congenital cataracts operated on a group of 14 children with Down syndrome, respectively on 26 eyes, was performed. The age of the children at the time of the surgery, the presence of associated ocular and systemic anomalies, the employed surgical technique, the frequency and the type of postoperative complications, were examined. Results: Cataracts present at birth, with recommendations for surgical treatment, were rare among children suffering from Down syndrome, but their frequency increased with age. Most children had systemic anomalies, but also other, usually multiple, ocular anomalies. The rate of postoperative complications was higher than among children with congenital cataracts, but without Down syndrome. In six cases, more than one complication/ case was identified. It was not possible to establish a clear correlation between the number and type of the postoperative complication and the systemic anomalies, nor was it possible to establish a correlation with the functional visual outcomes, because those children had other important ocular anomalies as well. Conclusions: Congenital cataracts with recommendations for surgical treatment in children suffering from Down syndrome have a low incidence, but an increase in frequency can be noticed with age. The recommended surgical technique is the one that involves maneuvers for the prevention of visual axis re-opacification. Per primam implantation is definitely indicated. The risk of postoperative complications is high, in terms of both frequency and number, with the possibility that more than one complication occurs, unrelated to a particular systemic anomaly, in one patient.

Enhancing rotational stability of toric intraocular lenses using a type 2L Cionni capsular tension ring in patients with high myopia.

We present the technique used in a patient with high myopia to obtain rotational stability of a plate-haptic multifocal toric intraocular lens (IOL) (AT LISA tri toric 939MP). Both of the patient's eyes had long axial lengths and large capsular bags. The first operated eye experienced consecutive toric IOL malpositions. In the fellow eye, toric IOL alignment was preserved by implanting a type 2L Cionni capsular tension ring. This was reversely inserted so the two eyelets, which are positioned slightly anterior to the ring, pressed the IOL on the posterior capsule. This unsophisticated technical artifice provided rotational stability of the IOL, even at 12 months postoperatively.