Pulsed vs continuous light accelerated corneal collagen crosslinking: in vivo qualitative investigation by confocal microscopy and corneal OCT.

PURPOSE: To assess qualitative corneal changes and penetration of pulsed and continuous light accelerated crosslinking by in vivo confocal microscopy and corneal OCT. METHODS: A total of 20 patients affected from progressive keratoconus were enrolled in the study. Ten eyes of 10 patients underwent an epithelium-off pulsed-light accelerated corneal collagen crosslinking (PL-ACXL) by the KXL UV-A source (Avedro Inc.) with 8 min (1 s on/1 s off) of UV-A exposure at 30 mW/cm(2) and energy dose of 7.2 J/cm(2); 10 eyes of 10 patients underwent an epithelium-off continuous-light accelerated corneal collagen crosslinking (CL-ACXL) at 30 mW/cm(2) for 4 min. Riboflavin 0.1% dextran-free plus hydroxyl-propyl-methylcellulose solution (VibeX Rapid, Avedro Inc.) was used for a 10-min corneal soaking. Treated eyes were examined by in vivo scanning laser confocal analysis and spectral anterior segment OCT at 1, 3, and 6 months. RESULTS: Epithelial stratification and nerves regeneration improved in time, being complete at month 6 in both groups without endothelial damage. Keratocyte apoptosis in PL-ACXL was estimated at a mean depth of ∼200 µm, whereas an uneven demarcation line was detectable by confocal microscopy at a mean depth of 160 µm in CL-ACXL. CONCLUSION: In vivo confocal microscopy and corneal OCT allowed a precise qualitative analysis of the cornea after epithelium-off PL-ACXL and CL-ACXL treatments. Apoptotic effect was higher in pulsed than in continuous light treatments, exceeding 200 µm in corneal stroma. According to different morphological data, the clinical efficacy of ACXL needs to be determined in a long-term follow-up and large cohort of patients.

Videourodynamics in patients with neurogenic bladder due to multiple sclerosis: our experience.

PURPOSE: The aims of this study were to: (a) analyse the most frequent morphofunctional features of the lower urinary tract observed during videourodynamic examination in patients with neurogenic bladder due to multiple sclerosis; (b) investigate the role of the videourodynamic examination in the clinical management of these patients; and (c) demonstrate the relationship between morphological and functional variables. MATERIALS AND METHODS: We performed videourodynamic examinations in 75 patients affected by neurogenic bladder secondary to multiple sclerosis. RESULTS: The introduction of pharmacological therapy, based on clinical and functional evaluation of the lower urinary tract, is correlated with satisfactory morphofunctional outcomes, reducing moderate-to-severe postvoid residual (PVR; p < 0.1) and compliance (p < 0.05) at the price of reduced bladder sensation. Clinical management of these patients based on morphological evaluation of the lower urinary tract decreased the occurrence of detrusor-sphincter dyssynergy (DSD) and detrusor overactivity incontinence at the following examination. CONCLUSIONS: Our study confirmed a relationship between detrusor overactivity and hypertonic bladder, bladder diverticula, vesicoureteral reflux, between detrusor underactivity and PVR and between DSD and bladder diverticula. Our data show how the videourodynamic examination may improve evaluation and urological management of these patients.

In vivo confocal microscopy in bilateral herpetic keratitis: a case report.

PURPOSE: Bilateral herpetic keratitis is a rare infection of the cornea. Ocular herpes in atopic patients is more often bilateral, with more frequent recurrences. The authors report a case of bilateral herpes simplex virus (HSV) keratitis during the active phase studied by in vivo confocal microscopy. METHODS: A 28-year-old man with 5 years history of unilateral HSV keratitis and atopic dermatitis was referred to the authors for a clinical and diagnostic evaluation.RESULTS. The corneas showed the typical features of dendritic HSV keratitis in both eyes. Examination by in vivo confocal microscopy demonstrated similar lesions in both eyes: a distortion of the superficial and basal epithelium and the presence of irregular hyperreflective structures and dendritic particles near the epithelial cells. The subbasal nerve plexus presented a tortuous appearance with hyperreflective areas and beadlike formations along the fibers. After a week of antiviral treatment, in vivo confocal microscopy examination demonstrated an irregular epithelium with highly reflective deposits and reflective areas. A reduction of nerve fiber bundles with a large number of beadlike formations and abnormal tortuosity was also noted. CONCLUSIONS: In vivo confocal microscopy enables a noninvasive evaluation of the ocular surface at a high magnification level. It could be useful for the early and differential diagnosis of corneal infections and when HSV keratitis recurrence is suspected.

Air-guided manual deep anterior lamellar keratoplasty: long-term results and confocal microscopic findings.

PURPOSE: To evaluate the long-term results of air-guided manual deep anterior lamellar keratoplasty (DALK) and to perform confocal microscopy on postoperative DALK corneas. METHODS: Seven postoperative consecutive DALK corneas were evaluated 1 year after suture removal. All patients underwent a complete ophthalmologic examination evaluating visual acuity, astigmatism, corneal thickness, and endothelial cell count. Confocal microscopy was performed to examine the corneas of the seven eyes and to obtain the measured interface depth. RESULTS: Eighteen months after surgery, the mean postoperative uncorrected visual acuity was 20/38 and the mean best-corrected visual acuity was 20/23. Postoperative mean value of residual recipient stroma thickness was 65.57 microm +/- 28.74. CONCLUSIONS: Maximum depth DALK can lead to significant advantages for quality of vision when compared to other types of anterior lamellar keratoplasty. Still, it remains a challenging procedure. These results show that a deep dissection without baring Descemet membrane makes good visual results possible, preventing corneal perforation and conversion to penetrating graft.

Unilateral corneal endothelial dystrophy and anterior keratoconus.

PURPOSE: To describe a case of keratoconus and Fuchs' corneal endothelial dystrophy in the left eye with no corneal disease in the right eye. METHODS: A 64-year-old woman presented with visual impairment in her left eye; computer-assisted topographic analysis and specular microscopy were performed in both eyes and left cornea was histopathologically examined. RESULTS: Keratoconus was diagnosed by slit-lamp examination, keratometry, and computer-assisted topographic analysis. Corneal endothelial dystrophy was diagnosed on the basis of clinical examination and specular microscopy. Histopathologic examination revealed a stromal degeneration typical of keratoconus and a non-guttae form of endothelial dystrophy. CONCLUSIONS: This is a rare case of unilateral corneal endothelial dystrophy and keratoconus.

Keratoconus associated with corneal macular dystrophy: in vivo confocal microscopic evaluation.

PURPOSE: The authors present a case, studied through in vivo confocal microscopy, of concomitant keratoconus and macular corneal dystrophy (MCD). METHODS: A 29-year-old man underwent a penetrating keratoplasty in the right eye in May 2005. Confocal microscopy was performed to examine the cornea of the right eye. RESULTS: A diagnosis of concomitant keratoconus and MCD was suspected, due to the simultaneous findings of corneal ectasia and stromal opacities. CONCLUSIONS: In this case, using in vivo confocal microscopy, morphologic changes were detected in many corneal layers and compared with the histopathologic findings. The morphologic alterations were found mainly in the area of the cornea apex.

Conservative treatment of keratoconus by riboflavin-uva-induced cross-linking of corneal collagen: qualitative investigation.

PURPOSE: To assess corneal tissue modifications after riboflavin-UVA-induced cross-linking of corneal collagen in patients with progressive keratoconus as well as regeneration of epithelium and subepithelial nerve plexus by in vivo HRT II system confocal microscopy in humans. METHODS: Ten patients with progressive keratoconus were treated by riboflavin-UVA-induced cross-linking of corneal collagen, involving assessment of ultrastructural modifications of the corneal epithelium and subepithelial nerve plexus by HRT II system confocal microscopy. Treatment included instillation of 0.1% riboflavin-20% dextrane solution 5 minutes before UVA irradiation and every 5 minutes for a total of 30 minutes. Radiant energy was 3 mW/cm 2 or 5.4 Joule/cm 2 and the source was dual UVA (370 nm) light-emitting LED. The protocol included the operation followed by antibiotic medication and eye dressing with a soft therapeutic contact lens. Changes in epithelium and subepithelial and stromal nerve plexus were assessed by HRT II system confocal microscopy in vivo. RESULTS: After 5 days of soft contact lens wearing, corneal epithelium has a regular morphology and density. Disappearance of subepithelial stromal nerve fibers was observed in the central irradiated area where, 1 month after the operation, initial reinnervation was microscopically observed. No changes in nerve fibers were observed in the peripheral untreated with a clear lateral transition between the two areas. Six months after the operation, the anterior subepithelial stroma was recolonized by nerve fibers with restoration of corneal sensitivity. CONCLUSIONS: HRT II system confocal microscopy confirms corneal epithelium restore and re-innervation after riboflavin-UVA-induced collagen cross-linking directly in vivo in humans.

Manual deep lamellar keratoplasty: alternative methods and air-guided technique.

PURPOSE: To describe the techniques proposed for performing deep lamellar keratoplasty (DLK) and to evaluate the efficacy of a new, modified technique. METHODS: Fourteen eyes in 11 patients with keratoconus of moderate degree were included. All patients underwent a DLK with manual dissection from a limbal side port after an air bubble injection in the anterior chamber. All patients had complete ophthalmologic examination 6 months after the suture removal, evaluating best corrected visual acuity, corneal thickness, endothelial cell count, and topographic astigmatism. RESULTS: One case (7.1%) was converted to penetrating keratoplasty because of microperforation. In the 13 successful cases, 10 eyes (71.4%) achieved 20/30 or better 6 months after suture removal. Mean postoperative pachymetry was 628.39 micro (SD 57.34). Specular microscopy 6 months after suture removal revealed average endothelial cell count of 2261 (SD 287/mm(2)). CONCLUSIONS: Comparing this modified DLK technique with other methods proposed by several authors, air-guided DLK seems to be safe and effective and, after a short learning curve, can be performed with a low risk of conversion to penetrating keratoplasty.

[Intraoperative examination in neuropathology: proceedings evaluations]. / L'esame estemporaneo in neuropatologia: valutazione delle procedure tecniche.

INTRODUCTION: In the neuropathological intraoperative diagnostic is extremely important having guide lines to obtain a lot of information about the slide. In our study we have considered only the intraoperative the cases diagnosed within a month comparing the histological evaluation using the cryostat and the cytological examination of touch or smear preparation. MATERIALS AND METHODS: Our study includes 7 meningiomas, 2 metastatic carcinomas, 1 anaplastic astrocitoma, 1 mieloplaxis tumor, 1 anaplastic chordoma. For the cytological examination we have got ready 8 touch or smear preparations and we have executed 4 proceedings: stainings with Giemsa, toluidine blue and haematoxylin and eosin, after fixation with 95% alcohol and staining with haematoxylin and eosin after fixation with alcohol and a small quantity of acetic acid. For the histological examination we have got ready 8 preparations, using the cryostat. We have fixed the slides with 95% alcohol or 10% formalin and stained them with haematoxylin and eosin. In the 50% of the cases we have treated the sections with microwave at 400W. RESULTS: Two pathologists have examinated the 192 sections prepared, judging each slide considering the legibility: unsatisfactory, quite good, good and excellent. CONCLUSIONS: Considering the cytological examination, Giemsa and toluidine blue permit the best legibility of nuclear and cytoplasmatic morphological details. Legibility is worse in staining with haematoxylin and eosin. Addition of acetic acid makes variable results. In the histological slides the best result are obtained using 95% alcohol for fixing. Microwave use doesn't determine improvement.

Air-guided manual deep lamellar keratoplasty.

PURPOSE: To evaluate the efficacy of a new modified technique of deep lamellar keratoplasty (DLK). METHODS: Nine eyes of eight patients with keratoconus of moderate degree were included. All patients underwent DLK with manual dissection from a limbal side port after an air bubble injection in the anterior chamber. The patients underwent a complete ophthalmologic examination 6 months after the suture removal, evaluating best-corrected visual acuity, corneal thickness, endothelial cell count, and topographic astigmatism. RESULTS: One case (11.1%) was converted to penetrating keratoplasty because of microperforation. In the eight successful cases, 7 eyes (77.8%) achieved 20/30 or better visual acuity 6 months after suture removal. Mean postoperative pachymetry was 604.76 microm (SD 46.76). Specular microscopy 6 months after suture removal revealed average endothelial cell count of 2273/mm2 (SD 229). CONCLUSIONS: This modified DLK technique is a safe and effective procedure and could facilitate, after a short learning curve, this kind of surgery with a low risk of conversion to penetrating keratoplasty.

Closed-system and open-sky capsulorhexis for combined cataract extraction and corneal transplantation.

We describe a triple procedure combining corneal transplantation, cataract extraction, and intraocular lens implantation in which the continuous curvilinear capsulorhexis (CCC) is performed in a closed system when corneal transparency is sufficient or using an open-sky method when corneal transparency is poor. With the closed system, the CCC is performed first followed by trephination and hydroexpulsion of the nucleus. A Caporossi coaxial forceps is used to reduce the corneal incision to 1.2 mm, preventing the need for sutures. Tunnel formation, which could limit the size of trephination, is avoided. In addition, endothelial cell loss at the periphery of the recipient cornea is reduced. This technique was performed in 10 eyes without intraoperative complications. With the open-sky method, the CCC is created while counterpressure is applied to the center of the lens with a large spatula, reducing posterior pressure and thus the risk of capsule tear. This technique was performed in 9 eyes without intraoperative complications.

Regional lymph node dissection in the treatment of renal cell carcinoma: is it useful in patients with no suspected adenopathy before or during surgery?

OBJECTIVES: To evaluate the role of regional lymph node dissection (LND) in a series of patients with renal cell carcinoma (RCC) with no suspicion of nodal metastases before or during surgery. PATIENTS AND METHODS: A series of 167 patients with RCC, free from distant metastases at diagnosis, and who underwent radical nephrectomy at our hospital between January 1990 and October 1997, was reviewed. The mean (median, range) follow-up was 51 (45, 19-112) months. Of the 167 patients, 108 underwent radical nephrectomy alone and 59 had radical nephrectomy with regional LND limited to the anterior, posterior and lateral sides of the ipsilateral great vessel, from the level of the renal pedicle to the inferior mesenteric artery. Of these 59 patients, 49 had no evidence of nodal metastases before or during surgery. The probability of survival was estimated by the Kaplan-Meier method, using the log-rank test to estimate differences among levels of the analysed variables. RESULTS: The overall 5-year survival was 79%; the 5-year survival rate for the 108 patients who underwent radical nephrectomy alone was 79% and for the 49 who underwent LND was 78%. Of the 49 patients with no suspicion of lymph node metastases, one (2%) was found to have histologically confirmed positive nodes. CONCLUSION: These results suggest that there is no clinical benefit in terms of overall outcome in undertaking regional LND in the absence of enlarged nodes detected before or during surgery.

Evaluation of the 1997 tumour, nodes and metastases classification of renal cell carcinoma: experience in 172 patients.

OBJECTIVE: To compare the prognostic relevance of the 1987 and 1997 tumour, nodes and metastases (TNM) systems for staging renal cell carcinoma (RCC) in predicting patient outcome. PATIENTS AND METHODS: A series of 172 consecutive patients with RCC who underwent radical nephrectomy from January 1990 to October 1997 was evaluated comparatively according to the 1987 and 1997 TNM classifications. The median (range) follow-up of the patients was 50 (19-112) months. The probability of survival was estimated by the Kaplan-Meier method, using the log-rank test to estimate differences among levels of the analysed variables. RESULTS: Using the 1997 TNM classification resulted in a redistribution of 99 patients from stage pT2 on the 1987 TNM classification to stage pT1. As the staging criteria for pT3 and pT4 did not change, there was no re-classification of these patients. Kaplan-Meier survival curves showed a similar separation in 5-year survival between stage pT1 and pT2 using both systems; 100% vs 80% for the 1987 TNM and 86% vs 69% for the 1997 TNM systems. This difference in survival rates between patients with pT1 and pT2 disease was statistically significant only for the 1997 TNM staging system. However, when the 1987 TNM staging classification was applied, the separation in 5-year survival rates between pT2 and pT3 disease was greater. CONCLUSION: This study confirms the prognostic relevance of the 1987 TNM system, as established in the present patients. The 1997 TNM classification resulted in a better stratification of patients with pT1-pT2 disease, but had similar prognostic value for pT2 and pT3 disease.

[Fluoroangiography of various pathological pictures in unusual observations of the anterior segment]. / La fluorangiografia di alcuni quadri patologici di insolita osservazione del segmento anteriore.

Fluorangiography is a very important investigation in order to have a differential diagnosis in all pathological pattern of the conjunctiva of scleral corneal limbus of the sclera of the iris of the ciliary-body. We have in the literature two different patterns: A) Fluorescein negative pattern (cystic neoformations, benign tumors with or without pigment) B) Fluorescein positive pattern (inflammatory pseudotumors, malignant tumors). Authors agree more or less with this classification; they have, moreover, worked out some variations. In our case of a localised carcinoma, fluorescein positive, we did not observe less of fluorescein; in the iris melanoma, even this fluorescein positive, in all observed cases has shown only a small loss of fluorescein near his edges. In the other cases as in the leiomyoma and cystis we agree with the literature even with prudence.