Comparison of visual outcomes, spectacles dependence and patient satisfaction of multifocal and accommodative intraocular lenses: innovative perspectives for maximal refractive-oriented cataract surgery.

BACKGROUND: The aim of this study was to evaluate visual outcomes for different working distances (far, 60 cm and 33 cm) and impact on vision quality of multifocal IOLs AcrySof ResTOR SN6AD1 and SN6AD3 (Alcon, Inc., Fort Worth, Texas, USA) as well as REVIEW FIL611PV multifocal and OPTOFLEX FIL618 accommodative IOLs (Soleko, Ltd., Rome, Italy) in patients undergoing bilateral phacoemulsification. METHODS: In this observational prospective study 63 patients undergoing binocular cataract surgery were divided into four groups for implantation of one of the IOLs under evaluation. Visual outcomes were evaluated at 1 day, 7 days, 1 month, 3 months and 6 months after surgery. Patients' satisfaction and spectacle independence were evaluated with questionnaires administered at the 6-months follow-up. RESULTS: Improvements in visual acuity for the three working distances were statistically significant in all cases compared to the preoperative status, especially after binocular implantation. The AcrySof ReSTOR SN6AD1 multifocal IOL provided the best visual acuity results and tolerability for all working distances. While performing worse than SN6AD1, FIL611PV and FIL618 provided better uncorrected visual acuity and spectacles independence for intermediate/close-up and far distances respectively, in comparison with the SN6AD3 group. CONCLUSIONS: SN6AD1 was confirmed the best choice for all working distances. However, FIL611PV IOL may represent a valid and more cost-effective alternative, especially if surgeons intend to prioritize spectacle independence and patient autonomy at intermediate and close-up distances, in accordance to specific needs and requests. TRIAL REGISTRATION: Trial retrospectively registered in ISRCTN Registry on 02/02/2017. TRN: ISRCTN14145737 .

Advantages of Double Running Sutures in Astigmatism After Penetrating Keratoplasty.

Background: The purpose of this prospective study is to evaluate the effects of different suturing techniques in perforating keratoplasty surgery, in order to identify the most effective in reducing post-operative astigmatism. Methods: We analysed data from patients who underwent penetrating keratoplasty for different indications. All interventions were performed by the same surgeon. Patients were subjected to a follow-up of at least 12 months after surgery, during which astigmatism (assessed by keratometry, topography and refraction) best-corrected visual acuity (BCVA) and complications were evaluated. A total of 100 eyes from 100 patients were included and were randomly assigned to five different groups, each one featuring a different suturing technique: interrupted (INT), single running (SRS), double running with two 10-0 sutures (DRS), double running antitorque with two 10-0 sutures (DRSa), double running with both 10-0 and 11-0 sutures (DRS with 11-0). Results: There is a statistically significant difference in astigmatism after surgery between the double running sutures groups and the others with different techniques. However, there is no statistically significant difference between the INT and the SRS group; moreover, there is no statistically significant difference between the different groups with double running sutures (DRS, DRSa, DRS with 11-0). There is no statistically significant difference in BCVA values among the five groups. The wound leak rate was 10% in the INT group, 5.3% in the SRS group and 0% in all groups with double running sutures. Conclusion: In penetrating keratoplasty surgery, the double running suture technique reduces postoperative astigmatism, provides faster visual rehabilitation and features lower complication rates when compared to techniques featuring single running and interrupted sutures. No significant difference in terms of postoperative astigmatism or complication rates was observed among patients receiving double running suture techniques.

Long-Term Effects of Iron Chelating Agents on Ocular Function in Patients with Thalassemia Major.

BACKGROUND: The aim of this study is to evaluate eye structures and function in patients receiving iron chelating therapy and to assess whether a correlation exists between the onset of ocular alterations and the intake of iron chelating drugs. METHODS: A prospective cohort study was performed. Eighty-eight patients, composed of children and adults with thalassemia major (TM) who are taking or had taken iron chelating drugs (deferoxamine, deferiprone or deferasirox), have been initially enrolled in the study. The final sample featured 80 patients, including 18 children and 62 adults. These subjects received an eye examination to evaluate intraocular pressure (IOP), best corrected visual acuity (BCVA), the presence of refractive defects, cornea, anterior chamber, lens, fundus oculi, visual field and mean retinal nerve fiber layer (RNFL) thickness. Logistic regression model analysis was performed in order to assess any correlation. In addition, a literature search regarding the relation between iron chelating drugs and ocular adverse events was carried out to compare the results obtained with the evidence in the literature. RESULTS: Logistic regression did not report a significant correlation between the intake of iron chelating drugs and the onset of anterior ocular segment alterations, lens opacities, retinal diseases, optical neuropathies, astigmatism, visual field and RNFL thickness defects. Logistic regression returned a statistically significant correlation between myopia and iron chelation therapy (p-value 0.04; OR 1.05) and also between presbyopia and total duration of therapy with deferoxamine (p-value 0.03; OR 1.21). Although intraocular pressure levels remained within the normal range, a significant correlation with the length of deferoxamine therapy has been found (p-value 0.002; association coefficient -0.12). A negative correlation between deferiprone and presbyopia has also been observed. CONCLUSION: Iron chelation therapy is not associated with severe visual function alterations. Limitation of deferoxamine treatment can help prevent ocular complications. Deferiprone and/or deferasirox may be preferable, especially in patients over age 40 years.

Choroidal vascularization and adrenergic innervation qualitative findings obtained with induced fluorescence preparations and optical coherence tomography angiography: possible correlations and perspectives.

BACKGROUND: Recent advances in optical coherence tomography (OCT) technology allow a more accurate choroidal visualization. The aim of this study is to provide histochemical analysis with induced fluorescence images of the choroidal stromal, vascular and nerve network, highlighting possible correspondences with OCT and OCT angiography (OCT-A) analysis. METHODS: The material examined with a histochemical process of induced fluorescence through condensation of biologically active monoamines with glyoxylic acid was obtained from 6 eyes enucleated for malignant melanoma and ciliary body neoplasia. The resulting images have been qualitatively compared with OCT and OCT-A choroidal images obtained from 10 volunteers, in order to identify possible relationships. Choriocapillary segmentation was performed automatically through the embedded analysis software, while segmentation of Sattler's and Haller's layers was performed through a manual method. RESULTS: Histochemical analysis provided accurate visualization of choroidal adrenergic innervation across all layers and its relationships with blood vessels and melanocytes. The above structures were not visualized at OCT and OCT-A which provided good visualization of blood vessels in Sattler's and Haller's layers as well-delimited hyporeflective areas. Decorrelation signal was not detected in OCT-A analysis due to low blood flow velocity in external choroidal layers. CONCLUSIONS: The choroid is an extremely dynamic structure which deserves to be analyzed in vivo since it is involved in the pathogenesis of several ocular conditions. Direct evaluation of the activity of choroidal nerves and melanocytes is still not possible with OCT and OCT-A, even if they are capable of providing a satisfactory representation of choroidal vascularization.

The Pupil Diameter as a Possible Indicator of Neurodegenerative Diseases and Response to Acetylcholinesterase Inhibitors Therapy: In-Depth Measurements Following Topical Administration of Tropicamide and Pilocarpine.

BACKGROUND: The aim of this study is to assess whether pupillary modifications following ocular anticholinergic and cholinergic drugs can identify subjects with neurodegenerative diseases from early stages. METHODS: 51 subjects were divided into 3 groups, according to different neurodegenerative diseases, and compared with a control group of 10 patients. Pupil diameter has been measured at different times after topical administration of tropicamide 0.01% in the right eye. Then, topical administration of pilocarpine 0.06% has been performed, followed by pupillary constriction measurement. Pupillary response rates were stratified according to acetylcholinesterase inhibitors intake. RESULTS: Observed mydriasis and pupillary constriction was similar in all study groups at all evaluation times. Patients without acetylcholinesterase inhibitors intake presented greater mydriasis. CONCLUSIONS: Although it was not possible to observe significant differences among groups in terms of pupillary response, the analysis of pupillary features may become an useful tool to detect efficacy of acetylcholinesterase inhibitors.

Perspectives of Autologous Mesenchymal Stem-Cell Transplantation in Macular Hole Surgery: A Review of Current Findings.

The main treatment available for idiopathic macular holes is represented by pars plana vitrectomy with internal limiting membrane peeling. However, late-stage macular holes are affected by a higher risk of surgical failure. Although adjuvant techniques can be employed, a satisfactory functional recovery is difficult to achieve in refractory macular holes. Given their neuroprotective and antiapoptotic properties, mesenchymal stem cells (MSCs) may represent an appealing approach to treat these extreme cases. The purpose of this review is to highlight the findings regarding healing mechanisms exerted by mesenchymal stem cells and preliminary application in cases of refractory macular holes. When compared with MSCs, MSC-derived exosomes may represent a feasible alternative, given their reduced risk of undesired proliferation and easiness of use.

How to minimize pterygium recurrence rates: clinical perspectives.

The main treatment for pterygium is surgical removal. However, pterygium surgery is concerned with high rates of postoperative recurrence. Predicting factors of recurrence are not fully understood, yet, but they probably depend on a multitude of patient-related, clinical, and/or surgical factors. Several adjuvant treatments have been proposed to reduce postoperative pterygium recurrence, including different antimetabolites, antiangiogenetic factors, and radiation therapy. The purpose of this review is to collect the current evidence regarding application and limits of different therapeutic approaches for preventing postoperative recurrence of pterygium, giving insights and perspectives for better management of this disease. In the light of the current evidence, pterygium surgery cannot disregard wound coverage with conjunctival autografting or rotational flap combined with adjuvant treatments. The rotational flap technique is associated with shorter surgical time rates and prevents graft displacement and necrosis, given its vascular pedicle. Amniotic membrane may still be reserved in case of great conjunctival defects or insufficient conjunctiva. Repeated subconjunctival antivascular endothelial growth factor injections can be considered as an effective and safe adjuvant treatment. Moreover, management of postoperative pain is crucial. Innovative treatment strategies will probably target different molecular pathways, considering recent findings regarding pterygium pathogenesis, to improve better understanding and develop universally shared guidelines. Great importance shall be dedicated to the identification of novel molecular biomarkers and favoring factors of recurrence, in order to achieve a customized surgical treatment for each patient and obtain maximal reduction of postoperative recurrence.

From DMEK to Corneal Endothelial Cell Therapy: Technical and Biological Aspects.

The main treatment available for restoration of the corneal endothelium is keratoplasty and DMEK provides faster visual recovery and better postoperative visual acuity when compared to DSAEK. However, the technical challenges related to this technique and the steep technical learning curve seem to prevent the overcoming of DSAEK in favor of DMEK. Furthermore, the outcome of lamellar keratoplasty techniques is influenced by problems related to corneal grafting tissue availability, management, and quality. On the other hand, improvements in the field of cell engineering have opened the way for the use of stem cells-derived corneal endothelial cells with regenerative intent. In this overview, latest findings in endothelial cell engineering are reported, and perspectives of clinical application of mesenchymal stem cells for corneal endothelial replacement and regeneration are evaluated.

Best Prophylactic Strategy in Groups at Risk of Intraoperative Floppy Iris Syndrome Development: Comparison Between Atropine Instillation and Adrenaline Intracameral Injection.

BACKGROUND: Intraoperative Floppy Iris Syndrome (IFIS) is an important cause of surgical complications and iris defects in patients undergoing phacoemulsification that were treated with selective subtype α1A receptor antagonists for a long period of time. To date, no definitive preventive strategy has emerged, yet. The need of prophylaxis is dictated by the high prevalence of males affected by benign prostatic hyperplasia undergoing cataract surgery. OBJECTIVE: To identify the best prophylactic strategy in groups at risk of IFIS development by comparing two mydriatic treatments in course of phacoemulsification surgery. METHODS: 81 eyes of 81 patients in treatment with Tamsulosin were enrolled in the study. 43 eyes were treated with atropine sulfate 1% while 38 eyes received an injection of mydriatic solution containing epinephrine in the anterior chamber. All phacoemulsifications were videotaped in order to assess the occurrence of IFIS and the severity of the syndrome. RESULTS: The treatment group showed a statistically significant reduction (p = 0.0115) of floppy iris syndrome incidence, from 86.05% (37/43) of the atropine group to 60.53% (23/38). The analysis showed a reduction of IFIS mild form only, whereas the incidence of severe forms remained unchanged. CONCLUSIONS: We believe that IFIS may arise through two different mechanisms: pharmacological antagonism and anatomical modifications. Patients suffering from mild forms of the disease showed a statistically significant reduction of IFIS incidence after intraoperative prophylaxis due to epinephrine's ability to displace Tamsulosin, resulting in the increase of iris tone when the disease is caused mainly by receptorial antagonism. On the contrary, prophylaxis does not deliver any valuable result in case of severe forms where the anatomical variations play a major role.

Glaucoma: Biological Trabecular and Neuroretinal Pathology with Perspectives of Therapy Innovation and Preventive Diagnosis.

Glaucoma is a common degenerative disease affecting retinal ganglion cells (RGC) and optic nerve axons, with progressive and chronic course. It is one of the most important reasons of social blindness in industrialized countries. Glaucoma can lead to the development of irreversible visual field loss, if not treated. Diagnosis may be difficult due to lack of symptoms in early stages of disease. In many cases, when patients arrive at clinical evaluation, a severe neuronal damage may have already occurred. In recent years, newer perspective in glaucoma treatment have emerged. The current research is focusing on finding newer drugs and associations or better delivery systems in order to improve the pharmacological treatment and patient compliance. Moreover, the application of various stem cell types with restorative and neuroprotective intent may be found appealing (intravitreal autologous cellular therapy). Advances are made also in terms of parasurgical treatment, characterized by various laser types and techniques. Moreover, recent research has led to the development of central and peripheral retinal rehabilitation (featuring residing cells reactivation and replacement of defective elements), as well as innovations in diagnosis through more specific and refined methods and inexpensive tests.

Efficacy of Subconjunctival Bevacizumab Injections before and after Surgical Excision in Preventing Pterygium Recurrence.

PURPOSE: To evaluate the efficacy of subconjunctival bevacizumab injections, before and after surgical excision with bare sclera technique, in preventing postoperative pterygium recurrence. MATERIAL AND METHODS: 83 eyes of 83 patients affected with primary pterygia underwent surgical excision. 42 eyes received two subconjunctival bevacizumab injections, at the dosage of 2.5 mg/0.1 ml, one week prior surgery and one week after intervention. Recurrence rate was evaluated among the two groups. Moreover, modifications of pterygium size and grade one week after the first injection were evaluated. RESULTS: At 6 months after surgery, the recurrence rate was 7.14% in the bevacizumab group and 24.39% in the control group. Significant changes of pterygium size and grade were reported after the first injection. No important complications related to bevacizumab subconjunctival injections were registered. CONCLUSIONS: The application of subconjunctival bevacizumab injections, at the dosage of 2.5 mg/0.1 ml, before and after surgical pterygium excision, may be useful in preventing lesion recurrence after bare scleral procedures. Furthermore, bevacizumab subconjunctival administration is well tolerated and may represent a safer alternative if compared with other surgical techniques and adjunctive drugs. This trial is retrospectively registered with ISRCTN Registry on 18 April 2017, TRN: ISRCTN11424742.

Implantation of a Multifocal Toric Intraocular Lens after Radial Keratotomy and Cross-Linking with Hyperopia and Astigmatism Residues: A Case Report.

Radial keratotomy is a refractive surgical technique, widely used in the 80s and early 90s to correct myopia and astigmatism, but now overcome by more recent laser techniques. Important consequences, often in patients with more than 45 years of age, are progressive hyperopic shift and/or an increase in corneal astigmatism, whose main cause seems to be an increase in the curvature radius of the central portion of the cornea. This seems to be due to radial keratotomy incisions - with the consequent need for cross-linking - intraocular pressure, and corneal biomechanical parameters. The authors propose phacoemulsification with a customized multifocal toric intraocular lens implantation to correct the induced shift and hyperopic astigmatism. A decent postoperative visual acuity was observed with good patient satisfaction. A specific protocol must be applied to optimize the correct diagnosis, presurgical evaluation and postsurgical outcomes that are to be maintained over time, without regressions.

Ocular Complications in Laparoscopic Surgery: Review of Existing Literature and Possible Prevention and Treatment.

During laparoscopic surgery, ocular complications are possible, sometimes leading to devastating visual losses, hardly susceptible to recovery, although rare. Principal ocular adverse events are represented by corneal abrasions and the perioperative visual loss (POVL). POVL onset is related to intraocular pressure elevations (particularly after patient positioning in Trendelenburg or prone decubitus, depending on the surgical procedure), anesthesiologic factors and patients' characteristics. In the light of evidence from the existing literature, the authors suggest surgical and anesthesiologic measures to prevent and manage ocular complications in laparoscopic surgery. Apart from general recommendations, this article indicates practical guidelines specific for robot-assisted laparoscopic interventions and spinal surgery, as well as laparoscopic colorectal resection, radical prostatectomy, and gynecologic surgery. In conclusion, in order to better manage these complications, it is advisable to develop an interdisciplinary collaboration between surgeons, anesthesiologists, and ophthalmologists, on a procedural and medico-legal level, with the intent of mutual training.

Local and systemic complications after intravitreal administration of anti-vascular endothelial growth factor agents in the treatment of different ocular diseases: a five-year retrospective study.

PURPOSE: To observe the frequency of complications in patients undergoing intravitreal anti-VEGF injections for different ocular diseases in a five-year period. MATERIALS AND METHODS: Charts of patients receiving intravitreal anti-VEGF were retrospectively reviewed. Out of 1173 eyes, 762 were treated with bevacizumab, 382 with ranibizumab, and 29 with pegaptanib. Data recorded included demographic information, clinical findings, total injections received, and info about the onset of adverse effects. RESULTS: 12.86% of the eyes treated with bevacizumab presented side-effects, while ratings in the ranibizumab and pegaptanib groups were 15.97% and 20.69%, respectively. Odds ratios calculated comparing incidences after each anti-VEGF are 0.78 (bevacizumab versus ranibizumab, p = 0.152), 0.57 (bevacizumab versus pegaptanib, p = 0.227), and 0.73 (ranibizumab versus pegaptanib, p = 0.508). A total of 185 complications were detected (62.16% after bevacizumab). Ocular side-effects registered were 40 cases of sustained intraocular pression (IOP) elevation, one infectious uveitis, one retinal detachment, and one sub-retinal hemorrhage. Other cases were related to transient IOP elevation immediately after injection. Systemic complications registered were one case of nausea, one episode of chest pain with acute vision loss, and one case of acute blood hypertension. CONCLUSIONS: The majority of significant complications occurred in patients receiving multiple bevacizumab administrations. However, results may be affected by the difference in the utilization amount for each drug. AMD patients were the most represented, probably due to greater indication to treatment.

Correlation between fundus autofluorescence and central visual function in chronic central serous chorioretinopathy.

PURPOSE: To find possible correlations between the morphologic macular changes revealed by fundus autofluorescence (FAF) and the functional parameters such as visual acuity and retinal sensitivity in patients with chronic central serous chorioretinopathy (CSC). DESIGN: Prospective, cross-sectional study. METHODS: Forty-six eyes (39 consecutive patients) with chronic CSC were studied with FAF and microperimetry (MP). Retinal sensitivity value maps were exactly superimposed over FAF images. The following microperimetric parameters were applied: central 10-degree visual field, 4-2-1 strategy, 61 stimulation spots, white monochromatic background, stimulation time 200 ms, stimulation spot size Goldmann III. A possible relationship between MP and FAF was investigated. RESULTS: Mean best-corrected visual acuity (BCVA) was 20/32 (median 20/25, range 20/20-20/200). BCVA was significantly correlated with FAF findings (Mann-Whitney test; P < .0001). A positive concordance between FAF and MP evaluation was also found (total concordance of 0.720 with a kappa of Cohen of 0.456). The hypo-autofluorescent areas showed decreased retinal sensitivity, while adjacent areas of increased FAF could be associated to both normal and decreased retinal sensitivity. Absolute scotoma, defined as 0 dB retinal sensitivity, corresponded with absence of autofluorescence. CONCLUSIONS: Altered FAF in chronic CSC patients has a functional correlation quantified by microperimetry. This study confirms the impact of FAF changes on retinal sensitivity and their value to reflect the functional impairment in chronic CSC.