Evaluating Intraocular Pressure After Myopic Photorefractive Keratectomy: A Comparison of Different Tonometers.

PRCIS: All devices evaluated in this study showed a significant underestimation in intraocular pressure (IOP) measurement after myopic photorefractive keratectomy (PRK), Goldmann tonometer more than others. Corneal biomechanics indicated a different influence on the different kinds of tonometry. PURPOSE: The aim was to investigate the reliability of Goldmann applanation tonometry (GAT), rebound tonometry (RT), ocular response analyzer (ORA), Corvis ST (CST), and dynamic contour tonometry (DCT) in IOP evaluation after myopic PRK. MATERIALS AND METHODS: One eye of 145 patients who underwent myopic PRK for a refractive defect ranging from -10.25 to -0.50 D (mean -4.69±2.00 D) was included in this retrospective comparative study. A complete eye visit with corneal tomography and IOP measurement with GAT, DCT, ORA, RT, and CST was performed before surgery and at 1, 3, and 6 months follow-up. Values provided by each device were tested and compared at each follow-up. Correlation analyses were run between changes in IOP and the corneal, morphologic and biomechanical parameters were measured after PRK. RESULTS: GAT, DCT, ORA, RT, and CST showed a significant (P<0.01) underestimation of IOP at 6 months follow-up. GAT showed the greatest underestimation (-14.1%) and stronger correlations with corneal deformation parameter changes, whereas ORA, DCT, and RT appeared to be less conditioned by these variations. At 6 months follow-up DCT, ORA, RT, and CST provided IOP values with nonsignificant differences compared with GAT before PRK. CONCLUSIONS: Each tested tonometer showed a significant IOP underestimation after myopic PRK. As this was most observed with GAT compared with all devices, we suggest DCT, ORA, RT, or CST to evaluate IOP in these patients following surgery.

Comparison of IOP obtained in different kind of eyes with contact and no contact tonometers.

BACKGROUND: The aim of this study is to analyze and compare the intraocular pressure (IOP) values measured in three different kinds of participants such as healthy subjects (HS), keratoconus patients (KP), and those who underwent myopic photorefractive keratectomy (MPRK). The devices used in this study are the Goldmann Applanation Tonometry (GAT), the dynamic contour tonometry (DCT), the ocular response analyzer (ORA), and the Corvis ST (CST). SUBJECTS AND METHODS: This research included 92 eyes of 92 h, 63 eyes of 63 KP, and 58 eyes of 58 MPRKM. Each participant underwent a complete ophthalmic evaluation and IOP measurement with GAT, DCT, ORA, and CST. A statistical analysis was conducted to detect possible differences and correlations. RESULTS: First, according to the observed data, HS eyes displayed mean IOP values measured with GAT, DCT, ORA, and CST, respectively, 15.82 ± 2.74 mmHg, 17.63 ± 2.28 mmHg, 16.24 ± 3.14 mmHg, and 17.31 ± 3.21 mmHg. Then, KP eyes showed mean IOP values measured with GAT, DCT, ORA, and CST of, respectively, 14.89 ± 1.64 mmHg, 16.97 ± 2.08 mmHg, 13.09 ± 3.12 mmHg, and 13.78 ± 2.11 mmHg. Finally, MPRK eyes showed mean IOP values measured with GAT, DCT, ORA, and CST of, respectively, 13.92 ± 1.34 mmHg, 15.39 ± 2.86 mmHg, 16.63 ± 2.51 mmHg, and 15.06 ± 1.56 mmHg. CONCLUSION: According to the observed data, ORA and GAT might be used interchangeably in HS, whereas GAT, ORA, and CST in KP eyes. Moreover, it has been noticed that in those eyes that previously undergone a myopic PRK, GAT provided lower values of IOP in comparison with other devices.

Classification Tree to Analyze Factors Connected with Post Operative Complications of Cataract Surgery in a Teaching Hospital.

BACKGROUND: Artificial intelligence (AI) is becoming ever more frequently applied in medicine and, consequently, also in ophthalmology to improve both the quality of work for physicians and the quality of care for patients. The aim of this study is to use AI, in particular classification tree, for the evaluation of both ocular and systemic features involved in the onset of complications due to cataract surgery in a teaching hospital. METHODS: The charts of 1392 eyes of 1392 patients, with a mean age of 71.3 ± 8.2 years old, were reviewed to collect the ocular and systemic data before, during and after cataract surgery, including post-operative complications. All these data were processed by a classification tree algorithm, producing more than 260 million simulations, aiming to develop a predictive model. RESULTS: Postoperative complications were observed in 168 patients. According to the AI analysis, the pre-operative characteristics involved in the insurgence of complications were: ocular comorbidities, lower visual acuity, higher astigmatism and intra-operative complications. CONCLUSIONS: Artificial intelligence application may be an interesting tool in the physician's hands to develop customized algorithms that can, in advance, define the post-operative complication risk. This may help in improving both the quality and the outcomes of the surgery as well as in preventing patient dissatisfaction.

Evaluation of efficacy and safety of new high-density dyes for chromovitrectomy.

The purpose of this study is to evaluate the safety and efficacy of two novel heavy dyes for macular surgery: DoubledyneTM and TwinTM. One eye from each of 144 patients undergoing surgery for macular hole or macular pucker was included in the study. The eyes were randomly divided into two groups according to the dye used during surgery. Best correct visual acuity (BCVA), intraocular pressure (IOP) and retinal morphology assessed by ocular coherence tomography (OCT) were evaluated before and 1, 3, 6 and 12 months after surgery. Only one surgeon performed each operation and provided a score ranging from 1 (poor) to 10 (excellent) for quality of staining and comfort in surgery. Statistical analysis was carried out with SPSS to compare parameters before and after surgery and between the two groups. No statistical differences were recorded in quality of staining (p = 0.11), in surgery comfort (p = 0.17) and total time of surgery (p = 0.44) between the two groups. BCVA statistically improved and central macular thickness (CMT) statistically decreased after surgery in both groups (p < 0.05). No toxic dye-related complications or long-term ones affecting the retina were observed in either group. According to this data, although confirmation in further studies with larger populations and longer follow up is required, DoubledyneTM and TwinTM proved to be safe and effective dyes for macular surgery.

Evaluation of Donor and Recipient Characteristics Involved in Descemet Stripping Automated Endothelial Keratoplasty Outcomes.

Aims: To evaluate both donor and recipient features involved in visual acuity restoring and complication insurgence in eyes that have undergone Descemet stripping automated endothelial keratoplasty (DSAEK). Methods: In this retrospective study, charts of 111 eyes of 96 patients (mean age 70.25 ± 8.58 years) that underwent DSAEK were evaluated. Only Fuch's Distrophy (FD) or Bullous Keratopathy (BK) due to cataract surgery eyes were included. A complete ophthalmic check with endothelial cell density (ECD) and central corneal thickness (CCT) measurement was performed before surgery and at 1, 3, 6, and 12 months follow-up. Each DSAEK was performed by the same well-trained surgeon; only pre-cut lenticules, provided by same Eye Bank, were implanted. Results: A total of 48 (43%) complications have been observed (most of them were 22 partial graft detachments and 17 IOP spikes). At the last follow-up (mean: 8.58 ± 4.09 months), a significant increase (p < 0.05) of best corrected visual acuity (BCVA) was detected. Overall mean BCVA of the eyes evaluated was 0.40 ± 0.43 LogMAR with BK eyes showing a significantly higher improvement (p < 0.05) compared to FD eyes. The only factor showing a significant correlation (p < 0.05) with visual acuity enhancement was the implant of a lenticule thinner than 100 µm. Recipient features significantly (p < 0.05) associated with complications observed after surgery were glaucoma and diabetes mellitus. Conclusion: The use of a graft thinner than 100 µm can provide better visual acuity recovery while recipients affected by glaucoma or diabetes mellitus are more prone to develop complications after surgery.

To estimate the safety and efficacy of a 3-D visualization helmet for vitreoretinal surgery.

PURPOSE: To evaluate a 3-D visualization helmet (3DVH) during 23-gauge pars plana vitrectomy (PPV) for macular holes (MH) and macular puckers (MP). METHODS: A total of 184 eyes of 184 patients undergoing PPV for MH or MP were randomly selected for surgery with 3DVH or standard Galilean microscope (GM). Only one highly trained surgeon performed each PPV. A surgical comfort score, ranging from 1 to 10 was recorded after each operation. Statistical analysis was run with SPSS to compare parameters before and after surgery and between the two groups. RESULTS: No statistical differences were found between the two groups for mean best correct visual acuity improvement after surgery (p < 0.001). Mean surgery comfort evaluation was 7.63 ± 0.48 in 3DVH eyes and 8.21 ± 0.62 in GM ones (p = 0.09); mean overall surgical time was 35.12 ± 3.8 min in 3DVH eyes and 32.7 ± 2.27 min in GM ones (p < 0.001); mean peeling time was 14.24 ± 3.42 min in 3DVH eyes and 13.61 ± 4.63 min in GM ones (p = 0.11). CONCLUSIONS: According to the data observed in this study, the 3DVH provides adequate safety and efficacy in retinal and macular visualization during PPV for MH and MP.

Analysis of Corneal Distortion after Myopic PRK.

The purpose of the study is to evaluate the corneal biomechanical properties (CBP) and their behaviors after myopic refractive surgery both with Ocular Response Analyzer (ORA) and Corvis ST (CST). This retrospective study included 145 eyes of 145 patients with a mean age of 33.13 ± 9.24 years, who underwent myopic photorefractive keratectomy (PRK) for a refractive defect, measured as spherical equivalent, of mean -4.69 ± 2.04 D and have been evaluated before surgery and at 1, 3 and 6 months follow-up. Corneal hysteresis (CH) and corneal resistance factor (CRF) values significantly decreased after 1 month and remained statistically stable during further follow-ups. CST parameters had a different evolution: only second applanation time (AT2) differences showed a significant variation after 1 month that did not statistically change over time. Highest concavity deformation amplitude (HCDA), highest concavity peak distance (HCPD), first applanation time (AT1) and velocity (AV1) showed continuous significant differences both after 3 and after 6 months. This study suggests that after central surface ablation surgery, such as myopic PRK, corneal shape is remodeling, and its deformation parameters are going to change even at 6 months follow-up. This indicates that it should be important to evaluate refractive surgery patients during a longer follow-up because this could allow earlier diagnosis and better management of late-onset complications.

Application of Artificial Intelligence in the Analysis of Features Affecting Cataract Surgery Complications in a Teaching Hospital.

Aims: To evaluate the ocular and systemic factors involved in cataract surgery complications in a teaching hospital using artificial intelligence. Methods: One eye of 1,229 patients with a mean age of 70.2 ± 10.3 years old that underwent cataract surgery was selected for this study. Ocular and systemic details of the patients were recorded and then analyzed by means of artificial intelligence. A total of 1.25 billion simulations of artificial intelligence learning and testing were conducted on several variables and a customized model of analysis was developed. Results: A total of 73 complications were recorded in this study. According to the analysis performed, the main factors involved in cataract surgery complications were: a surgeon in training, axial length and intraocular lens power. The model predicted how long surgery would last with an error of <6 min compared to the effective time needed. Conclusions: According to the data here obtained, artificial intelligence could be an interesting option to build customized models able to prevent complications and to predict actual surgery time. The customized algorithm option allows the development of better models adaptable to different units as well as the possibility to be calibrated for the same unit along time.

ASSOCIATION BETWEEN GENOTYPE AND DISEASE PROGRESSION IN ITALIAN STARGARDT PATIENTS: A Retrospective Natural History Study.

PURPOSE: To investigate the natural history of Stargardt disease over a multiyear follow-up. METHODS: We reviewed medical records of Stargardt disease patients, with clinical diagnosis of Stargardt disease at a single institution, which was also supported by molecular diagnosis. All patients underwent best-corrected visual acuity, fundus photography, optical coherence tomography, and full-field electroretinography. RESULTS: The study cohort consisted of 157 Stargardt disease patients aged 30.4 ± 1.1 years. Longitudinal analysis (mean follow-up: 3 years) showed a significant worsening of best-corrected visual acuity at an average rate of 1.5 Early Treatment Diabetic Retinopathy Study letters/year (P < 0.001), an enlargement of retinal pigment epithelium lesion area by optical coherence tomography at an average linear rate of 0.10 mm/year (P < 0.001), and a thinning of central macular thickness at a mean rate of -1.42 µm/year (P < 0.001). Survival analysis showed that patients with 2 alleles harboring likely-null variants, on average, reached most severe disease stage, i.e., legal blindness, alteration in both dark-adapted and light-adapted electroretinographic responses, and retinal pigment epithelium lesion area larger than 2.5 mm significantly earlier than patients with at least one allele harboring a missense variant. CONCLUSION: The current longitudinal study showed a significant genotype-phenotype correlation characterization, because patients harboring 2 likely-null alleles reach a severe disease stage about 10 years earlier than patients with at least one missense allele.

Choroidal effusion and suprachoroidal hemorrhage during phacoemulsification: intraoperative management to prevent expulsive hemorrhage.

PURPOSE: To describe the intraoperative management of choroidal effusion (CE) or suprachoroidal hemorrhage (SCH) during cataract surgery with the phacoemulsification technique. METHODS: The study is a retrospective interventional study through which we describe the intraoperative management adopted in 6 cases of CE or SCH during cataract surgery. The study involved 6,400 eyes (phacoemulsification) in 6 years observational time (incidence rate 0.094%). The surgical time at which these complications happened differed: nucleolus phacoemulsification in 2 eyes, cortex removal by bimanual irrigation-aspiration in 3 eyes, and intraocular lens implant for 1 eye. Once the complication was recognized, each patient was quickly moved to an extreme reverse Trendelenburg position and pharmacologically treated to manage high blood pressure, pain, and anxiety (150 mL of an 18% mannitol solution delivered in rapid infusion intravenously; 1-3 mg intravenous midazolam; 5 nifedipine sublingual drops). RESULTS: In all the cases reported, the surgery was completed after resolution of the acute choroidal exudation or SCH. In the follow-up evaluation, the intraocular pressure was normal at each examination. The visual acuity of the patients was between 6/7.5 and 5/6 Snellen after 4 weeks. We observed a statistically significant reduction in endothelial cells in the 2 eyes in which the CE or SCH happened during the phacoemulsification compared with the other cases; this finding likely results from mechanical damage (p = 0.04 [95% confidence interval]). CONCLUSIONS: Choroidal effusion or SCH can be intraoperatively managed to avoid expulsive hemorrhage and maintain the possibility of completing the surgery.

Shallow Anterior Chamber After Trabeculectomy: Risk Reduction by Use of Removable Compression Sutures.

PURPOSE: To evaluate the risk of shallow anterior chamber after trabeculectomy with removable compression sutures. METHODS: A total of 263 eyes affected by primary open-angle glaucoma that was unresponsive to medical treatments were divided into 2 groups: 126 eyes were treated with conventional trabeculectomy (group A) and 137 with a modified surgery technique using 3 removable compression 10-0 nylon sutures (group B). All the participants received intraoperative antimetabolites (mitomycin 0.04%). Increased intraocular pressure (IOP) of >14 mm Hg in the eyes of group B patients was followed by removal of compression sutures. Best corrected visual acuity, slit lamp examination, IOP, and anterior chamber depth were evaluated 1, 7, 30, 60, 90, and 180 days after surgery. RESULTS: On the first postoperative day, 12 eyes from group A (9.5%) exhibited a shallow anterior chamber with marked hypotony and no eyes in group B showed flat anterior chamber at any control evaluation (P<0.001). The day after surgery, group A showed a mean IOP of 5.3 mm Hg (± 2.02), whereas group B had a mean of 7.4 mm Hg (± 2.10). At 7 days postoperation, the values for IOP were 10.95 (± 1.55) and 11.7 mm Hg (± 1.66) in groups A and B, respectively. One month later, mean IOP was 11.05 mm Hg (± 1.08) for group A and 13.9 mm Hg (± 3.26) for group B. The surgeon removed the compression sutures from all eyes with IOP>14 mm Hg (90%). The day after suture removal, mean IOP decreased to 10.45 mm Hg (± 1.37). There was no significant statistical difference in visual acuity between the 2 groups at any point during follow-up (P>0.001). At 180 postoperative days the difference in mean IOP between the 2 groups was statistically significant (P<0.001). CONCLUSIONS: The application of removable corneoscleral compression sutures during trabeculectomy reduced the risk of postoperative shallow anterior chamber and allowed for safe IOP control after the procedure giving further postoperative chance to reduce the intraocular pressure.

Corneal confocal microscopy anomalies associated with cowden syndrome: a case report.

PURPOSE: To describe bilateral corneal alterations through confocal microscopy in a patient affected by Cowden syndrome (CS). METHODS: Evaluation of Schirmer's, fluorescein, and lissamine green dye tests. Confocal microscopy was performed in both eyes to investigate corneal abnormalities. RESULTS: Slit lamp observation showed the focal involvement of anterior stromal and epithelial layers. Schirmer's, fluorescein, and lissamine green dye test results were regular, while corneal confocal examination confirmed the disorganization of anterior stromal and epithelial layers in both eyes. CONCLUSION: CS is a rare autosomal-dominant systemic disorder. In our case, confocal analysis revealed predominance of alterations in the anterior stromal corneal layer, showing an increase of reflectivity, and a totally unstructured architecture in the epithelium layer. Even though the main purpose remains the prevention and the early diagnosis of different systemic tumors that could occur in affected patients, corneal confocal evaluation could play an important role in the early diagnosis of this rare disease.

Aniridia associated with lens coloboma and secondary glaucoma treated with transcorneal argon laser ciliary body photocoagulation: a case report.

PURPOSE: The aim of this study is to describe the management of cataract and refractory glaucoma in a case of congenital aniridia (AN)-1. METHODS: In an 18-year-old female patient affected by congenital AN, bilateral coloboma of the zonula and lens, cataract and glaucoma, pars plana vitrectomy, cataract extraction and subsequent transcorneal ciliary body argon laser photocoagulation were performed. RESULTS: Five years after laser treatment, the best-corrected visual acuity was 20/50 and the intraocular pressure was stable at 18 mm Hg with topical pharmacological management consisting of timolol 0.5% and latanoprost 0.005%. CONCLUSIONS: From our experience, transcorneal ciliary body photocoagulation after cataract extraction and vitrectomy could be a useful technique to manage high ocular pressure in eyes affected by congenital AN.

Health status and patient satisfaction after corneal graft: results from the corneal transplant epidemiological study.

Purpose. To evaluate effects of corneal transplantation on the health-related quality of life and patients' satisfaction. Methods. Patients scheduled for elective penetrating or anterior lamellar keratoplasty completed by telephone interview the SF-12 Health Survey, before and one year after surgery, and a 6-item questionnaire on the satisfaction for graft outcomes. Results. The two questionnaires were answered by 1,223 patients. Transplantation did not influence the PCS-12 in males (ES = -0.01) and had a negative effect in females (ES = -0.18). Both sexes improved their MCS-12 (ES = 0.18 and 0.23, resp.). The majority of patients (83.1%) were satisfied by the outcome of the graft. Conclusions. This is the first report on the use of the SF-12 and one of the few that assess quality of life in patients after corneal transplantation. We showed that grafting improves patients' health-related quality of life results of patients, influencing mental health (i.e., psychological attitude, social interaction, and emotions) with minor effects on physical health (limitation, pain, and vitality).

Confocal microscopy after descemet stripping endothelial keratoplasty: a case report.

PURPOSE: To evaluate the clinical findings, visual outcomes, and confocal microscopic corneal features after Descemet stripping endothelial keratoplasty (DSEK) technique in Fuchs endothelial dystrophy. METHODS: A 70-year-old female patient with pseudophakia and Fuchs endothelial dystrophy underwent small-incision DSEK surgery. Best spectacle-corrected visual acuity was 1.30 (20/400) logarithm of the minimum angle of resolution (Snellen) before treatment. Confocal microscopy (ConfoScan 4; Nidek Technologies, Padova, Italy) was performed before surgery, after 7 days, at 1 month, and 6 months after descemet stripping endothelial keratoplasty. Images of corneal structures, including endothelium, donor stroma, and recipient stroma, were obtained. RESULTS: Best spectacle-corrected visual acuity improved to 0.3 (20/40) logarithm of the minimum angle of resolution (Snellen) at 6 months. Endothelial cell density was 850 cells per square millimeter 6 months after surgery. Interface and donor stroma reflectivity were highest, 7 days postoperative showing progressive decrease over time. CONCLUSIONS: The DSEK procedure represents a promising alternative to conventional penetrating keratoplasty for patients with Fuchs endothelial dystrophy. Confocal microscopy is able to detect interface morphological characteristics, to improve therapeutic choice, and to understand the pathophysiology of visual recovery.

Scleral buckling technique without retinopexy for treatment of rhegmatogeneous: a pilot study.

PURPOSE: To evaluate the role of retinopexy in the surgical management of primary rhegmatogenous retinal detachment (RD) without proliferative vitreoretinopathy. The primary outcome was retinal attachment, and secondary outcomes were visual acuity results and complications. METHODS: A randomized controlled trial including 60 patients with RD caused by a break or a group of breaks no larger than one clock hour. Thirty eyes received no retinopexy (group 1), and 30 eyes received transscleral cryotherapy (group 2). An encircling buckle was placed in all eyes. In eyes with posterior breaks, segmental buckles were also added. In some eyes, subretinal fluid drainage or anterior chamber paracentesis and/or intravitreal air bubble injection was performed. RESULTS: No differences were found between the groups in terms of the preoperative clinical variables evaluated: age; sex; axial length; lens status; type, number, and location of breaks; extension of detachment; and macula status. There were no differences in the surgical procedures performed. The reattachment rate in group 1 was 90%, and in group 2, it was 87% (a difference that was not significant [P = 1.00]). Final visual acuity improved by two lines or more in 22 patients in group 1 and in 20 patients in group 2 (P = 0.317). CONCLUSIONS: Our results indicate that primary rhegmatogenous RD can be successfully treated with scleral buckling without retinopexy.