Guideline for the treatment of no light perception eyes induced by mechanical ocular trauma.

Severe mechanical ocular trauma with no light perception (NLP) predicts a poor prognosis of visual acuity and enucleation of the eyeball. Since the innovative treatment concept of exploratory vitreoretinal surgery has developed and treatment technology has advanced, the outcomes of severe ocular trauma treatment in NLP patients have greatly improved. However, there remains a lack of unified standards for the determination, surgical indication, and timing of vitrectomy in NLP eye treatment. To address these problems, we aimed to create evidence-based medical guidelines for the diagnosis, treatment, and prognosis of mechanical ocular trauma with NLP. Sixteen relevant recommendations for mechanical ocular trauma with NLP were obtained, and a consensus was reached. Each recommendation was explained in detail to guide the treatment of mechanical ocular trauma associated with NLP.

Supporting IOL'S in a Deficient Capsular Environment: The Tale of No "Tails".

PURPOSE: To evaluate the efficacy and safety of the following three distinct surgical procedures for secondary IOL implantation without capsular support: Iris-claw lens, flanged transscleral fixated IOLs (Yamane technique), and sutureless transscleral hook IOL fixation (Carlevale IOL). MATERIALS AND METHODS: In this retrospective comparative study, three different sutureless IOL implantation techniques were compared in patients without any capsular support. Visual acuity and outcomes were analyzed in 24 eyes of 23 patients (14 male and 9 female). Study included 13 iris-claw lenses (Artisan Ophtec), 6 flanged transscleral fixated IOLs (Yamane technique using a MA60MA Alcon Inc IOL), and 5 transscleral Carlevale IOLS (Carlevale IOL, Soleko, Italy). RESULTS: logMAR mean best-corrected visual acuity (BCVA) improved from 0.49 ± 0.19 to 0.19 ± 0.10 at three months after surgery (p < 0.05). Postoperative BCVA was similar in all three groups, and no intergroup difference was noted. Three eyes (12.5%) had a raised IOP >25 mmHg, 2 eyes (8%) presented a subluxated/dislocated IOL, 4 eyes (16%) had corneal edema longer than 7 days, 3 eyes (12.5%) had irregular pupil profile, 2 eyes (8%) had vitreous hemorrhage, 7 eyes had (29%) corneal astigmatism over 3 diopters, and one patient (4%) developed cystoid macular edema (CME). CONCLUSIONS: All three surgical procedures can be considered adequate to correct aphakia in patients without capsular support with significant improvement in visual acuity and low complication.

One Year Outcomes and Stability of a Novel Scleral Anchored Intraocular Lens.

PURPOSE: To assess one year results and stability of the implantation of a scleral anchored intraocular lens (IOL). DESIGN: Interventional prospective case series. METHODS: Sixty eyes of 60 patients affected by either aphakia or IOL dislocation were included in this study. Patients underwent vitrectomy, scleral fixation of the IOL, and, if present, dislocated IOL removal. Patients were evaluated preoperatively and at 1, 3, 6, and 12 months after surgery by best-corrected distance visual acuity (BCVA) assessment, intraocular pressure (IOP) measurement, corneal specular microscopy, and optical coherence tomography (OCT) of both the macula and anterior segment. RESULTS: At twelve months, mean BCVA significantly improved (p < 0.0001), and none of the patients experienced a decrease of visual acuity. A 10% decrease of endothelial cell count occurred after surgery. Cystoid macular edema occurred in three patients (5%). A transient increase of intraocular pressure was noted in 7 cases (12%). At one month, horizontal and vertical IOL tilt was 1.04 ± 0.87 and 0.74 ± 0.71 degrees, respectively, and did not significantly change in the follow-up (p > 0.05). None of the patients had decentration or dislocation of scleral-fixated IOL during the follow-up. CONCLUSION: Implantations of scleral plug fixated IOL provide good visual results, low complication rate, and excellent stability of the lens until one-year follow-up.

Utility of anterior segment optical coherence tomography in the surgical planning of superficial sclerectomy in oculodermal melanocytosis (nevus of Ota): A case report and review of literature.

PURPOSE: to report the utility of Anterior Segment Optical Coherence Tomography (AS OCT) for planning superficial sclerectomy in a patient with nevus of Ota. OBSERVATIONS: Oculodermal melanocytosis, also called nevus of Ota, is a benign pigmentary disorder that involves the skin innervated by the first and second branches of the trigeminal nerve. To reduce these black or brownish lesions, different surgical treatments have been reported, such as flipped scleral flap, sclera allograft and the grabbing method. Superficial sclerectomy is a recent technique that has proven effective in improving scleral pigmentation. Although this procedure allows the operating time to be reduced and results in a smoother scleral bed surface, it has a limitation, represented by the difficulty of estimating the depth of the sclerectomy: an inaccurate estimate or incorrect depth could cause an inadequate deep scleral dissection with excessive weakening of the sclera. We report a case of a 27-year-old patient with nevus of Ota undergoing superficial sclerectomy. The depth of scleral pigmentation was evaluated with AS OCT images before the surgery, allowing a superficial sclerectomy to be performed with a precalibrated diamond blade. CONCLUSIONS AND IMPORTANCE: In oculodermal melanocytosis (nevus of Ota) the use of AS OCT images showing the depth of scleral pigmentation could lead to the most effective and safest surgical choice for each case.

In vivo evaluation of a 1-piece foldable sutureless intrascleral fixation intraocular lens using ultrasound biomicroscopy and anterior segment OCT.

PURPOSE: To evaluate the optic plate and haptics of a specially designed sutureless intrascleral-fixated intraocular lens (IOL) using ultrasound biomicroscopy and anterior segment optical coherence tomography (AS-OCT). SETTING: Department of Ophthalmology, San Marino Hospital, Republic of San Marino. DESIGN: Retrospective observational case series. METHODS: Eyes that underwent intrascleral fixation with IOL implantation (Carlevale) were included. Preoperative and postoperative refractive outcomes were reported. Optic plate tilt and haptics position were assessed with ultrasound biomicroscopy, whereas intrascleral plug depth and conformation were evaluated with AS-OCT. RESULTS: The study comprised 10 aphakic eyes. Postoperative visual acuity improved in all patients. At postoperative month 3, 3 eyes (30%) had a vertical tilt of more than 100 µm, whereas no horizontal tilt was observed in any patient. The mean vertical intraocular tilt was 0.19 ± 0.22 mm. Of 20 haptics, 13 (65%) passed through the ciliary sulcus, 4 (20%) posterior to the ciliary body, and 3 (15%) through the ciliary body. AS-OCT scans showed a mean intrascleral plug depth of 247.20 ± 62.82 µm in the nasal sector and 265.50 ± 30.11 µm in the temporal sector, with adequate integration of the T-shaped plugs in the scleral tissue. CONCLUSIONS: This secondary IOL showed good intraocular stability and safe haptics fixation, making it suitable for the intrascleral fixation technique. The specific foldable design results in a low predisposition to optic plate tilt and haptic torsion. In long eyes, the sulcus-to-sulcus distance should be carefully evaluated preoperatively because the flexible structure of the IOL could be subjected to excessive stretching.

A novel intraocular lens designed for sutureless scleral fixation: surgical series.

PURPOSE: To report a retrospective series of patients implanted with a novel hydrophilic acrylic single-piece intraocular lens (IOL) designed for sutureless scleral fixation (FIL-SSF Carlevale lens, Soleko, Italy) injectable through a 2.2-mm incision. METHODS: Seventy-eight patients with minimum 6-month follow-up were divided into 6 groups: dropped nucleus, luxated IOL, trauma, aphakia, IOL exchange, and Marfan's syndrome. Surgery included peritomy and scleral flap creation at 3 and 9 o'clock position. The IOL was then injected and grasped with 25G forceps through a hole created 2 mm posterior to the limbus underneath the sculped scleral flap. RESULTS: The study included 78 patients (mean age 71.9 ± 12.6 years) and average follow-up 10.2 ± 4.2 months. Average surgery duration was 69.4 ± 26.1 min and vision significantly improved from 0.86 ± 0.56 logMAR to 0.38 ± 0.42 logMAR at 6 months post-operative (p < 0.001). Intraoperative complications included corneal edema, retinal tears, and vitreous bleeding each in 2/78 patients (2.5%); 1/78 (1.3%) localized retinal detachment and 1/78 (1.3%) rupture of one T-shaped IOL harpoon. Post-operative complications included 4/78 (5.1%) cystoid macular edemas, 2/78 retinal tears, 2/78 retinal detachments, 2/78 developed ocular hypertension, and 1/78 corneal decompensation requiring DSAEK. CONCLUSION: The Carlevale lens is designed for sutureless intrascleral fixation and can be successfully used in a variety of indications including difficult trauma cases with good rehabilitation. An implant requires experience and delicate manipulation.

Intraocular lens implantation in the absence of capsular support: scleral-fixated vs retropupillary iris-claw intraocular lenses.

Cataract surgery via phacoemulsification with intraocular lens (IOL) placement in the capsular bag is the gold standard in the presence of adequate capsular support. However, when capsule and/or zonular fibers are weak or absent, alternate fixation strategies are required. Common alternative options include retropupillary iris-claw IOLs (RP-IC IOLs) and scleral-fixated IOLs (SF IOLs). In the present review of 87 articles with 2174 eyes implanted with RP-IC IOLs and 2980 eyes with SF IOLs, we discuss the published literature with respect to safety and efficacy. Although the studies reporting outcomes of these IOLs have been performed in patients with different concomitant conditions, visual and refractive outcomes were found to be comparable between RP-IC IOLs and SF IOLs. RP-IC IOL implantation seemed to provide equivalent or a potentially lower rate of complications than SF IOL implantation. Data from the literature also suggest that the surgical technique of RP-IC IOL implantation is relatively simpler with correspondingly shorter surgical times.

Limited Vitrectomy versus Complete Vitrectomy for Epiretinal Membranes: A Comparative Multicenter Trial.

PURPOSE: To evaluate whether limited vitrectomy is as effective as complete vitrectomy in eyes with epiretinal membrane (ERM) and to compare the surgical times and rates of complications. METHODS: In this multicentre European study, data of eyes with ERM that underwent vitrectomy from January 2017 to July 2018 were analyzed retrospectively. In the limited vitrectomy group, a posterior vitreous detachment (PVD) was induced up till the equator as opposed to complete PVD induction till the vitreous base in the comparison group. Incidence of iatrogenic retinal breaks, retinal detachment, surgical time, and visual outcomes were compared between groups. RESULTS: We included 139 eyes in the analysis with a mean age being 72.2 ± 6.9 years. In this, sixty-five eyes (47%) underwent limited vitrectomy and 74 eyes (53%) underwent complete vitrectomy. Iatrogenic retinal tears were seen in both groups (5% in limited vitrectomy versus 7% in complete vitrectomy, p=0.49). Retinal detachment occurred in 2 eyes in the limited vitrectomy group (3%) compared to none in the complete vitrectomy group (p=0.22). Best-corrected visual acuity (BCVA) and central macular thickness improved significantly with no intergroup differences (p=0.18). Surgical time was significantly shorter in the limited vitrectomy group with 91% surgeries taking less than 1 hour compared to 71% in the complete vitrectomy group (p < 0.001). CONCLUSION: A limited vitrectomy is a time-efficient and effective surgical procedure for removal of epiretinal membrane with no additional complications.

Intravitreal Dexamethasone Implant as a Sustained Release Drug Delivery Device for the Treatment of Ocular Diseases: A Comprehensive Review of the Literature.

Drug delivery into the vitreous chamber remains a great challenge in the pharmaceutical industry due to the complex anatomy and physiology of the eye. Intravitreal injection is the mainstream route of drug administration to the posterior segment of the eye. The purpose of this review is to assess the current literature about the widening use of the intravitreal 0.7 mg dexamethasone (Dex) implant, and to provide a comprehensive collection of all the ocular disorders that benefit from Dex administration. Although anti-vascular endothelial growth-factors (VEGFs) have been largely indicated as a first-choice level, the Dex implant represents an important treatment option, especially in selected cases, such as vitrectomized eyes or patients in whom anti-VEGF failed or are contraindicated. In this article, the safety profile as well as the list of the possible complications related to intravitreal Dex injection are also discussed.

Optical Coherence Tomography Angiography in Neurodegenerative Disorders.

Retinal microcirculation shares similar features with cerebral small blood vessels. Thus, the retina may be considered an accessible 'window' to detect the microvascular damage occurring in the setting of neurodegenerative disorders. Optical coherence tomography angiography (OCT-A) is a non-invasive imaging modality providing depth resolved images of blood flow in the retina, choroid, and optic nerve. In this review, we summarize the current literature on the application of OCT-A in glaucoma and central nervous system conditions such as Alzheimer's disease, Parkinson's disease, and multiple sclerosis. Future directions aiming at evaluating whether OCT-A can be an additional biomarker for the early diagnosis and monitoring of neurodegenerative disorders are also discussed.

Choroidal Vascularity Index: An In-Depth Analysis of This Novel Optical Coherence Tomography Parameter.

Remarkable improvements in optical coherence tomography (OCT) technology have resulted in highly sophisticated, noninvasive machines allowing detailed and advanced morphological evaluation of all retinal and choroidal layers. Postproduction semiautomated imaging analysis with dedicated public-domain software allows precise quantitative analysis of binarized OCT images. In this regard, the choroidal vascularity index (CVI) is emerging as a new imaging tool for the measurement and analysis of the choroidal vascular system by quantifying both luminal and stromal choroidal components. Numerous reports have been published so far regarding CVI and its potential applications in healthy eyes as well as in the evaluation and management of several chorioretinal diseases. Current literature suggests that CVI has a lesser variability and is influenced by fewer physiologic factors as compared to choroidal thickness. It can be considered a relatively stable parameter for evaluating the changes in the choroidal vasculature. In this review, the principles and the applications of this advanced imaging modality for studying and understanding the contributing role of choroid in retinal and optic nerve diseases are discussed. Potential advances that may allow the widespread adoption of this tool in the routine clinical practice are also presented.

Evaluation of the Morphology of Ganglion Cell Complex and Functional Outcomes after Internal Limiting Membrane Peeling with Macular Abrasion in Idiopathic Macular Hole.

AIM: This study aims to evaluate the morphology of ganglion cell complex (GCC) along with functional outcomes in patients undergoing vitrectomy with ILM peeling and macular abrasion with Tano diamond dusted membrane scrapers (DDMS) for three different stages of the idiopathic macular hole (IMH). METHODS: This retrospective study was conducted between April 2019 and December 2019. 33 patients with IMH were included and divided into three groups: stage I, stage II, and stage IV. All patients were subjected to vitrectomy with ILM peeling. Gentle and vigorous macular abrasion was additionally performed for stage II and stage IV patients, respectively. The best-corrected visual acuity (BCVA), GCC thickness (measured by spectral domain-optical coherence tomography (SD-OCT)), and photopic contrast sensitivity (Rodenstock CV 900 Chart Panel) were determined before surgery and at 1- and 3-month follow-ups. RESULTS: Closure of MH was achieved in all the patients. The difference between the preoperative and one- and three-month postoperative values of BCVA was statistically significant in the three groups (P < 0.01). Contrast sensitivity progressively improved in all patients and was statistically significant (P < 0.01). The reduction in GCC thickness during follow-up was 34%-42% of the preoperative measurements. On comparing the mean GCC thickness of the operated and healthy eyes, it was not statistically significant in stage I patients. However, the same when done in stage II and IV was statistically significant with P value < 0.05 and P < 0.01, respectively. CONCLUSION: Combining ILM peeling with macular abrasion in advanced stages of MH may facilitate its closure without significantly affecting the functional outcome.

Microscope-Assisted ab externo Surgery for the Treatment of Primary Rhegmatogenous Retinal Detachment - New Tech Meets Old Art.

AIM: To report the outcomes of ab externo surgery using a surgical microscope, wide-angle viewing system, and chandelier endoilluminator (microscope-assisted ab externo surgery) for rhegmatogenous retinal detachment (RRD). METHODS: This was a retrospective study. Consecutive charts of patients with RRD who underwent microscope-assisted ab externo surgery were analyzed. The following demographic parameters were analyzed: age (years), gender (male/female), and eye (right/left). Clinical parameters were axial length (AL) measured in millimeters (mm), preoperative best-corrected visual acuity (BCVA) measured in logarithm of minimum angle of resolution (logMAR), intraocular pressure (IOP), and lens status (phakic/pseudophakic). The parameters of RRD were number and type of retinal breaks, location of retinal breaks, extent of retinal detachment (RD) (number of detached quadrants), and macular detachment (MD), as well as retinal breaks not detected preoperatively. Use of cryopexy, circumferential or segmental scleral buckle, drainage of subretinal fluid, injection of air or gas, and duration of surgery were recorded. The postoperative parameters analyzed were BCVA, IOP and recurrence of RD and postoperative complications. Follow-up was established at 3 months. RESULTS: A total of 213 eyes (97 right, 116 left) of 205 patients (114 males, 91 females) affected by primary RRD were included. Fifty-two eyes (24.4%) were affected by high myopia (AL >26.5 mm), and 160 patients (75.1%) were affected by RRD caused by a single retinal break and involving only one quadrant. The superior quadrant was the most frequently involved (49.3%). Forty-two eyes (19.7%) were affected by MD. In 13 eyes (11.3%), retinal breaks were not detected preoperatively. The duration of surgery was 75.5 ± 42 min. No significant BCVA changes were observed in the whole group, whereas a significant improvement of BCVA from the baseline (2.83 ± 0.87 logMAR) to each time point of follow-up was observed in the subgroup of patients affected by MD. Six eyes (2.8%) developed a recurrent RD, secondary to proliferative vitreoretinopathy (3 eyes) and secondary to a new retinal break (3 eyes). Two eyes developed a persistent vitreous hemorrhage, and one eye developed a macular hole after 1 week. PPV was performed for both. CONCLUSION: Microscope-assisted ab externo surgery is effective and safe, it reduces discomfort, it allows the surgeon to work with both hands free, and provides an adequate visualization of each step being performed.

The Use of a Venous Catheter as a Stent for Treatment of Acquired Punctal and Canalicular Stenosis.

PURPOSE: The aim of this study was to describe a simple technique to insert a venous catheter as a stent for the treatment of acquired punctal and canalicular stenosis. METHODS: We performed this technique using a central venous catheter as a stent for the treatment of acquired punctal and canalicular stenosis. RESULTS: The results show the easy availability of the material used for the intervention, its easy execution, and the low costs of materials. The goal of this technique is to have a lacrimal dot dilated and canalicular duct easy to irrigate. CONCLUSION: The use of a venous catheter as a stent for treatment of acquired punctal and canalicular stenosis seems to be simple, safe, repeatable, and noninvasive.

Evaluation of macular pigment optical density following femtosecond laser-assisted cataract surgery.

Background: To evaluate macular pigment optical density (MPOD) after bimanual femtosecond laser-assisted cataract surgery (FLACS) compared to standard bimanual phacoemulsification (B-MICS). Methods: A prospective, case matched, comparative cohort study conducted at the Institute of Ophthalmology, University of Modena and Reggio Emilia (Italy); 30 eyes underwent bimanual FLACS with low-energy Ziemer LDV Z8 (FLACS) and 30 underwent B-MICS standard technique (B-MICS). All interventions were conducted by the same expert surgeon. MPOD using the Macular Pigment Screener II (MPS II) was evaluated at baseline, 7 and 30 days after surgery. As secondary outcomes, we considered best corrected visual acuity (BCVA) and central macular thickness (CMT) obtained using optical coherence tomography. Results: In all cases, a BunnyLens AF IOL was safely implanted in the capsular bag through a 1.4 mm incision. We found a significant reduction in MPOD in both groups at 7 and 30 days; 0.16±0.14 and 0.10±0.12 (FLACS) and 0.18±0.13 and 0.15±0.14 (B-MICS), respectively (P<0.05). However, there was no significant difference between the two groups at either 7 (P=0.52) or 30 days (P=0.18). BCVA improved significantly in both groups and CMT increased in both groups (P<0.001, P<0.001, respectively). BCVA and CMT were similar between the groups with a significant difference in CMT in favor of the FLACS group at 30 days (P=0.017). Conclusions: MPOD was reduced in both groups without any significant difference between the FLACS and B-MICS cataract interventions. FLACS is associated with a significantly higher increase of macular thickness at 30 days compared to B-MICS.

Five-year follow-up of secondary iris-claw intraocular lens implantation for the treatment of aphakia: Anterior chamber versus retropupillary implantation.

BACKGROUND: Though several procedures of IOL implantation have been described (sutured scleral fixation, intra-scleral fixation, angle-supported anterior chamber, and anterior chamber or retropupillary iris-claw IOLs), there are no randomized trials which are comparing different techniques. Hence, the surgical treatment of aphakia still remains controversial and challenging. The purpose of this study was to compare the long-term efficacy and the rate of complications of anterior versus posterior Iris-claw intraocular lenses (IOL) implantation to correct for the treatment of aphakia without sufficient capsule support. METHODS AND FINDINGS: Consecutive eyes having secondary implantation of aphakic iris-fixated IOLs with a follow-up of at least 5 years were considered. Mean correct distance visual acuity (CDVA) changes, percentage of eyes with CDVA improvement, mean corneal endothelial cell density (CECD) loss and the rate of other complications were used for statistical analysis. The study evaluated a total of 180 eyes (Group A: 87 anterior chamber iris-claw fixation, Group B: 93 retropupillary iris-claw implantation) of 180 consecutive different patients, with aphakia of various reasons. CDVA improved significantly in both groups after surgery (P<0.001, ANOVA), and was remarkably higher than baseline in both groups from first week and during the entire follow-up (P<0.001, Tukey's Honest Significant Difference). There was no statistically significant difference in CDVA between the two groups during each follow-up visits (P = NS, unpaired t-test) and in the CDVA improvement percentage between the two groups (P = 0.882, Chi-square test). No significant changes in CECD were noted after surgery in both groups (ANOVA Group A: P = 0.067, Group B: P = 0.330P). No intra-operative complications occurred in both groups. There was no statistically significant difference in the rate of complications between the two groups (P = NS, Chi-square test), except for pigment precipitates which were higher in Group A (P<0.05, Chi-square test). CONCLUSIONS: Five-year follow-up shows that secondary implantation of aphakic IOLs is effective and safe for the correction treatment of aphakia in eyes without capsule support.