Epiretinal membrane development after Ex-Press glaucoma filtration device implant: 2-year results of a case control study.

BACKGROUND: The most common retinal complications after glaucoma surgery are choroidal detachment, hypotony maculopathy, malignant glaucoma, vitreous hemorrhage, endophthalmitis and retinal detachment. However, if glaucoma surgery is a risk factor for the ERM development needs to be clarified. This study aims to assess the incidence of epiretinal membrane (ERM) in 2 years of follow-up in patients with primary open-angle glaucoma (POAG) treated with Ex-Press shunt implant. METHODS: A prospective, consecutive, single-center, case-control study. We enrolled patients affected by POAG and scheduled for Ex-Press device implant with or without concomitant cataract surgery. The control group was the contralateral eyes which continues anti-glaucomatous eyedrops. Complete ophthalmologic evaluation and spectral-domain optical coherence tomography were performed before surgery, at 6 months and 24 months of follow-up. RESULTS: Eighty-two eyes of 41 consecutive patients, 18 males and 23 females with a mean age of 70, 29 ± 8,45, were analyzed at 24 months. 39.1% of eyes developed ERM: 29.3% were cellophane macular reflex (CMR) and 9.8% were pre-macular fibrosis (PMF). In the control group, 19.5% of eyes developed ERM: 17.1% were CMR and 2.4% were PMF. No statistically significant difference was reported (p = 0.121) between treated and control group. ERM development did not affect significantly the central foveal thickness (260.13 ± 35.01 µm at baseline, 265.03 ± 34.90 µm at 6 months and 275.18 ± 33.31 µm at 24 months) and macular volume (7.75 ± 0.43 mm3 at baseline, 7.77 ± 0.48 mm3 at 6 months and 7.77 ± 0.46 mm3 at 24 months), remained comparable to reported average measures in healthy individuals during the follow-up. Concomitant cataract surgery did not increase the ERM incidence. CONCLUSION: Ex-Press implant may increase the ERM incidence regardless concomitant cataract surgery, accelerating or inducing a posterior vitreous detachment, such as other ocular surgical procedure. Nevertheless, the vast majority of ERM are CMR, not affecting the macular profile.

Short-term results of a pulsed therapy with hydrocortisone eye drops to treat moderate to severe dry eye in primary Sjögren syndrome patients.

BACKGROUND: We investigated the safety and efficacy of short-term treatment with topical low-dose hydrocortisone sodium phosphate 0.335% (PFH) in patients with moderate to severe primary Sjögren syndrome (SS)-related dry eye disease (DED). METHODS: A retrospective single-centre interventional study. All patients received PFH for 6 days with a pulsed posology: three times daily for 2 days, twice daily for 2 days, and once daily for 2 days. This scheme was repeated for 3 consecutive months and then alternated for 3 months. Data were collected at baseline, 3 months, and 6 months of follow-up. RESULTS: A total of 40 SS patients were enrolled. Conjunctival hyperaemia and corneal-conjunctival stain significantly improved (p < 0.001). Ocular Surface Disease Index score reduced significantly between baseline and 3 months and between baseline and 6 months (p < 0.001). The tear film osmolarity lowered significantly in each eye from baseline to 3 months and from baseline to 6 months (p = 0.002 and p = 0.037, respectively). Comparing results at 3 and 6 months, the Ocular Surface Disease Index score (p = 1.000), the frequency of lacrimal substitutes installation (p = 0.632), and tear film osmolarity (right eye p = 0.518, left eye p = 1.000) did not change significantly. Intraocular pressure did not change during the study period. CONCLUSION: PFH eye drops with a pulsed posology improve signs and symptoms, not affecting the intraocular pressure in SS-related DED. Therefore, this pulsed treatment is safe and efficacious.

Ocular siderosis: a misdiagnosed cause of visual loss due to ferrous intraocular foreign bodies-epidemiology, pathogenesis, clinical signs, imaging and available treatment options.

PURPOSE: The purpose of this paper is to provide a meaningful literature review about the epidemiology, pathogenesis, clinical signs, imaging and treatment of ocular siderosis (OS). METHODS: A computerized search from inception up to March 2020 of the online electronic database PubMed was performed using the following search strings: "ocular siderosis" and "siderosis bulbi". The reference list in each article was analysed for additional relevant publications. RESULTS: OS is an uncommon cause of visual loss due to a retained ferrous intraocular foreign body (IOFB). It may develop from 18 days to years after a penetrating trauma that usually occurs during hammering. On average, patients are 22-25 years old, and the vast majority are male. The most common cause of OS development is delayed presentation by the patient or missed diagnosis of IOFB after trauma. The pathophysiology is not fully understood; nevertheless, iron deposition causes hydroxyl radical formation, which damages photoreceptors and retinal pigment epithelium. Moreover, iron damages retinal vessels with consequent inner retinal layers degeneration. The most frequent signs are iris heterochromia, pupillary mydriasis, cataract development and retinal arteriolar narrowing with pigmentary retinal degeneration. Electroretinogram signs, in particular, b-wave amplitude reduction, arise earlier than clinical signs. Orbital CT scans and ultrasonography play an essential role in detecting IOFBs. Treatment depends on the IOFB location and OS development. However, it is crucial to remove the IOFB after OS development because visual acuity and clinical signs may improve. Anterior segment IOFBs can be dislodged using an intraocular magnet (IOM) or forceps through limbal paracentesis. In contrast, posterior segment IOFBs require a pars plana vitrectomy and IOM or forceps to be removed through an enlarged sclerotomy or the limbus. CONCLUSION: Recommending the usage of protective glasses and spreading knowledge about OS may further benefit patient care.

Secondary epiretinal membrane after Ex-Press glaucoma filtration device implant.

PURPOSE: To estimate the frequency of epiretinal membrane (ERM) in eyes with primary open-angle glaucoma (POAG) treated with Ex-Press shunt implant. Secondarily, we aimed to assess the role of concomitant cataract surgery and the impact of the ERM on central foveal thickness and macular volume. METHODS: In this prospective, consecutive, case-control study, we enrolled 54 patients affected by PAOG and scheduled for Ex-Press device implant with or without contemporary phacoemulsification. Contralateral eyes affected by POAG and receiving anti-glaucomatous eyedrops constituted the control group. Complete ophthalmologic evaluation and spectral-domain optical coherence tomography (OCT) were performed before and 1, 3 and 6 months after surgery. RESULTS: Twenty-six eyes received the Ex-Press implant alone, and 28 eyes underwent the combined procedure. Six months postoperatively, we observed 18 (33%) cases of ERM: 15 (28%) of cellophane macular reflex (CMR) and 3 (6%) of pre-macular fibrosis (PMF). In the control group, 9 (17%) eyes developed an ERM: 8 (15%) were CMR, and 1 (2%) was PMF. The frequency of ERM statistically differs between treated and contralateral eyes (P = 0.032, χ2 test). The ERM frequency did not statically differ between eyes subjected to simple or combined surgery (P = 0.846, χ2 test). Mean central foveal thickness and mean macular volume did not significantly differ between groups. CONCLUSION: The Ex-Press glaucoma shunt may increase the risk of ERM onset regardless of the concomitant cataract surgery; however, most cases were cellophane macular reflex with limited functional and anatomical impact.

Pachychoroid neovasculopathy: a type-1 choroidal neovascularization belonging to the pachychoroid spectrum-pathogenesis, imaging and available treatment options.

PURPOSE: The purpose of this paper is to provide a meaningful literature review about the epidemiology, pathogenesis, imaging and treatment of pachychoroid neovasculopathy (PNV). METHODS: A computerized search from inception up to December 2019 of the online electronic database PubMed was performed using the following search string: "pachychoroid neovasculopathy". The reference list in each article was scanned for additional relevant publications. RESULTS: PNV is a type-1 choroidal neovascularization, overlying focal areas of choroidal thickening and dilated choroidal vessels. It can develop in patients affected by pachychoroid pigment epitheliopathy or chronic central serous chorioretinopathy. The absence of drusen, the presence of pachydrusen, younger age of onset and choroidal thickening distinguish it from neovascular age-related macular degeneration (AMD). PNV incidence and prevalence data are lacking. Its pathophysiology is not fully understood, but angiogenic mechanisms involved in neovascular AMD may be different from those in PNV. Due to optical coherence tomography (OCT) improvements, PNV can be diagnosed more easily than before. In particular, PNV shows a shallow pigment epithelium detachment with an undulating retinal pigment epithelium over a subfoveal choroidal thickening, associated with vein enlargement in Haller's layer (named pachyvessels) and choriocapillaris thinning. On OCT angiography, PNV reveals tangled hyper-reflective filamentous neovessels in the choriocapillaris itself. The current first-line PNV treatment is intravitreal anti-VEGF (vascular endothelial growth factor) injections with a treat-and-extend regimen. In particular, aflibercept shows a higher rate of fluid absorption than others. In the case of fluid recurrence or persistence, photodynamic therapy is a valid alternative. CONCLUSION: Ongoing research into pathophysiology and imaging improvements may be helpful in defining prognostic criteria and stratifying patient risk, allowing responsible monitoring and management of PNV.

Ponte Osteotomies in the Surgical Treatment of Adolescent Idiopathic Scoliosis: A Systematic Review of the Literature and Meta-Analysis of Comparative Studies.

The purpose of the present paper is to assess if Ponte osteotomies (POs) allow for a better correction in adolescent idiopathic scoliosis (AIS) surgery and to investigate their safety profile. A systematic search of electronic databases was conducted. Inclusion criteria: comparative studies that reported the outcomes of AIS patients who underwent surgical correction through posterior-only approach with and without POs. Clinical and radiographic outcomes were extracted and summarized. Meta-analyses were performed to estimate the differences between patients treated with and without POs. p < 0.05 was considered significant. In total, 9 studies were included. No significant difference in thoracic kyphosis (TK) change between patients treated with and without POs was found (+3.8°; p = 0.06). Considering only hypokyphotic patients, a significant difference in TK change resulted in POs patients (+6.6°; p < 0.01), while a non-significant TK change resulted in normokyphotic patients (+0.2°; p = 0.96). No significant difference in coronal correction (2.5°; p = 0.10) was recorded. Significant estimated blood loss (EBL) (142.5 mL; p = 0.04) and surgical time (21.5 min; p = 0.04) differences were found with POs. Regarding complications rate, the meta-analysis showed a non-significant log odds ratio of 1.1 (p = 0.08) with POs. In conclusion, POs allow for the restoration of TK in hypokyphotic AIS, without a significantly greater TK change in normokyphotic patients, nor a significantly better coronal correction. Considering the significantly greater EBL and the trend toward a higher complications rate, the correct indication for POs is crucial.

Endothelial cell density change in fully dislocated XEN Gel IMPLANT after trabeculectomy: A case report.

PURPOSE: To report a case of fully dislocated XEN Gel Implant device into the anterior chamber, 18 months after its implantation and its impact on endothelial cell density. RESULT: A 75-year-old man with a history of multiple glaucoma surgeries during the last three years presented with an entirely dislocated XEN Gel implant into the anterior chamber. An endothelial cell density reduction was observed over 18 months. Thus, the implant was removed. In the short-term after surgery, the endothelial cell loss rate reduced. CONCLUSION: XEN Gel Implant can dislocate into the anterior chamber, increasing endothelial cell loss in an eye already underwent multiple surgical procedures with subsequent adverse events. Therefore, if the implant seems displaced, the endothelial cell density should be monitored, and the length of the free-tube segment within the anterior chamber should be measured, during the patient's follow-up.

Surgical technique for removing vitreous cortex remnants using a diamond-dusted membrane scraper.

PURPOSE: The purpose of this paper is to present a new surgical technique to remove vitreous cortex remnants. METHODS: Non-consecutive retrospective interventional case series. RESULTS: When the posterior vitreous is split, its outermost layer may remain attached to the retina, developing vitreoschisis-induced vitreous cortex remnants (VCR). Their role in macular pathology etiopathogenesis has been well documented; however, recently, it has been proposed that VCR also play a crucial role in proliferative vitreoretinopathy and consequent retinal redetachment. The prevalence of VCR is underestimated because triamcinolone acetonide is not routinely used for vitreous staining. Vitreous cortex remnants (VCR) removal is challenging, and several surgical techniques have been proposed. However, they require sclerotomy enlargement, material that may not be readily available, and manual fashioning. Alternatively, a diamond-dusted membrane scraper (DDMS), already widely used in macular pathology treatment, can follow the contour of the retina, as it is a silicone tube, and remove VCR with its abrasive tip. A DDMS may also be introduced in the vitreous cavity through a standard trocar. Finally, the use of a DDMS provides predictable feedback, making the learning curve short. In this case series, 34 eyes affected by primary rhegmatogenous retinal detachment were enrolled. The retinal redetachment rate was 2.9% at six months of follow-up, below the average literature value of 21%. No adverse events were reported. CONCLUSION: A DDMS can be suitable for use in VCR removal, although further studies are warranted to understand the indications and extent of this surgical technique for improving the management of rhegmatogenous retinal detachment.

Topical preservative-free ophthalmic treatments: an unmet clinical need.

Introduction: The main role of preservatives in eyedrops is to ensure sterility and microbiological integrity of the drug, and to facilitate the penetration of active compounds into the eye. However, several studies documented significant toxic effects induced by preservatives, especially on the ocular surface. Consequently, most of the ophthalmic medications became progressively available in preservative-free (PF) formulations.Areas covered: We analyzed pre-clinical and clinical studies on PF eyedrops with particular attention to common chronic diseases such as dry eye and glaucoma. We discussed about the pros and cons of using PF eyedrops, in terms of efficacy, safety, and social-economic aspects.Expert opinion: There are still unresolved issues that make hard for PF medications to definitively conquer the drug market. Despite robust pre-clinical evidences of less toxicity, the low number of randomized clinical trials does not permit to state that PF eyedrops have, in clinical practice, a similar efficacy or a higher safety compared to preserved forms. These aspects limit their use to chronic diseases requiring long-term therapies with multiple daily instillations, especially in the presence of concomitant ophthalmic diseases that expose to a risk of ocular surface worsening.

Localized versus 360° intraoperative laser retinopexy in cases of rhegmatogenous retinal detachment with mild-to-moderate grade proliferative vitreoretinopathy.

BACKGROUND/OBJECTIVES: To compare the efficacy of intraoperative localized and 360° laser retinopexy in cases of rhegmatogenous retinal detachment (RRD) treated with pars plana vitrectomy and air tamponade. SUBJECTS/METHODS: In this interventional, prospective, randomized, comparative study, 93 consecutive cases of RRD were enroled. After randomization 48 eyes received circumferential, while 45 underwent localized intraoperative laser retinopexy. Number and position of the retinal breaks, presence of proliferative vitreoretinopathy and/or lattice degeneration were recorded. Anatomical and visual outcome of the two groups were compared at 6 months postoperatively. RESULTS: Baseline characteristics did not significantly differ between groups. The single-operation reattachment rate was 86.66% in localized group and 89.58% in 360° group. The difference was not significant. (P = 0.46, χ2 test). At 6 months postoperatively, visual acuity (logMAR) was 0.06 ± 0.05 in localized group and 0.05 ± 0.03 in 360° group. The difference was not statistically significant (P = 0.673, t-test). CONCLUSIONS: Localized laser resulted to be as effective as 360° laser application; this may lead some advantages in term of lower invasiveness, reduction risk of complications and time saving.

Bullous Central Serous Chorioretinopathy: A Rare and Atypical Form of Central Serous Chorioretinopathy. A Systematic Review.

Bullous central serous chorioretinopathy (bCSCR) is a rare variant of the central serous chorioretinopathy, complicated by an exudative retinal detachment with shifting fluid. This systematic review aims to present the epidemiology, the pathogenesis, the clinical presentation, the imaging, the differential diagnosis, and the latest treatments of this disease. A total of 60 studies were identified following a literature search adhering to PRISMA guidelines. After full-text evaluation, 34 studies about bCSCR were included. bCSCR usually affects middle-aged men, and the principal risk factor is corticosteroid medications. Pathogenesis is related to an increased choroidal vessel and choriocapillaris permeability, with subsequent subretinal fluid accumulation, rich in fibrin, which may provoke the exudative retinal detachment. Clinical presentation and imaging are fundamental to distinguish bCSCR from other pathologies, avoiding unappropriated treatment. Corticosteroid withdraws (if assumed) and laser photocoagulation of leakage sites seen at angiography may speed up retinal reattachment. Verteporfin photodynamic therapy, transpupillary thermal therapy, oral eplerenone and scleral thinning surgery are other therapeutic options. An early diagnosis might prevent disease progression due to harmful medications as well as unnecessary surgery.

What Is the Impact of Intraoperative Microscope-Integrated OCT in Ophthalmic Surgery? Relevant Applications and Outcomes. A Systematic Review.

BACKGROUND: Optical coherence tomography (OCT) has recently been introduced in the operating theatre. The aim of this review is to present the actual role of microscope-integrated optical coherence tomography (MI-OCT) in ophthalmology. METHOD: A total of 314 studies were identified, following a literature search adhering to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. After full-text evaluation, 81 studies discussing MI-OCT applications in ophthalmology were included. RESULTS: At present, three microscope-integrated optical coherence tomography systems are commercially available. MI-OCT can help anterior and posterior segment surgeons in the decision-making process, providing direct visualization of anatomic planes before and after surgical manoeuvres, assisting in complex cases, and detecting or confirming intraoperative complications. Applications range from corneal transplant to macular surgery, including cataract surgery, glaucoma surgery, paediatric examination, proliferative diabetic retinopathy surgery, and retinal detachment surgery. CONCLUSION: The use of MI-OCT in ophthalmic surgery is becoming increasingly prevalent and has been applied in almost all procedures. However, there are still limitations to be overcome and the technology involved remains difficult to access and use.

Non-resolving, recurrent and chronic central serous chorioretinopathy: available treatment options.

Central serous chorioretinopathy is one of the most frequent causes of vision reduction among middle-aged men. This disease usually has a self-limiting course, but sometimes it lasts more than 4-6 months or a second episode follows a complete resolution of the first one. Nevertheless, to date no consensus exists about the duration threshold and therapy protocols for these non-resolving central serous chorioretinopathy. Treatment as half-dose and half-fluence photodynamic therapy, subthreshold micropulse laser treatment, mineralocorticoid receptor antagonists, intravitreal anti-angiogenic drugs, transpupillary thermal therapy, anti-androgenic drugs, methotrexate, Rifampicin and melatonin are described in this review. Complications are very uncommon but end-point results like central macular thickness reduction and best-corrected visual acuity improvement are difficult to compare among different therapeutic modalities due to different duration of follow-up and lack of homogeneity in patient recruitment. The aim of this review is focusing on treatment modalities for these chronic forms with comprehensive recent management updates according to latest clinical trial results.

Traumatic submacular hemorrhage: available treatment options and synthesis of the literature.

Sub-macular hemorrhage (SMH) is a hematic collection between the neurosensory retina and the retinal pigment epithelium; one of its causes is ocular blunt trauma, that usually affects young patients. Persisting SMH leads to a damage of photoreceptors mediated by three main mechanisms: iron-related toxicity, impairment of diffusion of oxygen and nutriment, mechanical damage due to clot contraction. Since early photoreceptors' damage has been reported within 24 h, it is suggested to provide an early treatment, although there are no guidelines or consensus between authors regarding treatment strategies. The aim of this review was to present and compare available treatment options, like intravitreal tissue plasminogen activator (tPA) associated with pneumatic displacement, pneumatic displacement alone, subretinal tPA injection with pneumatic displacement, and intravitreal anti-vascular endothelial growth factor (VEGF) injection. All procedures obtained consistent results, though the most effective seemed to be pars plana vitrectomy, subretinal tPA and gas tamponade, probably due to a quicker liquefaction and displacement of the clot. Limitations concern the greater invasiveness and the higher incidence of complications. Alternatively, intravitreal injection of tPA and gas may represent a less invasive option with fewer complications. Intravitreal injection of gas and prone position could be preferred in young patients without coexisting ocular pathology, being a minimally invasive treatment, with lower risk of complications and a good visual recovery. Anti-VEGF agent have found, to date, limited employment in cases of traumatic SMH even though they may be useful as alternative or adjuvant therapy. Most of the published literature consists of small studies and case reports, therefore further investigations and larger clinical trials are required to fully understand safety and efficacy of the procedures. A preoperative comprehensive evaluation may be helpful to realize a surgical plan tailored on patient.