Pigment dispersion syndrome and pigmentary glaucoma: a review and update.

INTRODUCTION: Pigment dispersion syndrome (PDS) is a condition where anomalous iridozonular contact leads to pigment dispersion throughout the anterior segment and the released pigment is abnormally deposited on various ocular structures. CLINICAL PRESENTATION: The clinical presentation of PDS is defined by the presence of pigmented cells on the corneal endothelium, an increase of pigmentation of the trabecular meshwork, and mid-periphery transillumination defects of the iris. This syndrome, more common in myopes, is usually bilateral and can be associated with ocular hypertension or glaucoma. Secondary open-angle pigmentary glaucoma (PG) can develop due to reduction of the outflow of aqueous humour and consequent increase in intraocular pressure leading to glaucomatous optic neuropathy. Diagnosis of PG is commonly between 40 and 50 years of age, occurring more frequently in men. The advent of ultrasound biomicroscopy and anterior segment optical coherence tomography has contributed to enhancing our knowledge on the condition. Typical alterations of the anterior segment are the posterior insertion of the iris and iris concavity. Treatment of PG should be initiated early to hinder disease progression, glaucomatous damage, and vision loss. Management is based on medical therapy, laser iridotomy, selective laser trabeculoplasty, and filtration procedures. CONCLUSIONS: The differential diagnosis of PDS with other disorders can be challenging and awareness of the condition together with meticulous ophthalmologic examination allows early diagnosis followed by appropriate management strategies. The present review is a comprehensive report on the clinical characteristics, pathogenesis, current management, and status quo of PDS and PG.

Correction to: Pigment dispersion syndrome and pigmentary glaucoma: a review and update.

In the original publication, introduction section under Abstract was published incorrectly. The correct version is given below.

The Relationships Between Vitamin K and Cognition: A Review of Current Evidence.

Vitamin K is a fat-soluble nutrient discovered in 1935 and its role in blood coagulation has been thoroughly explored. In recent years, studies conducted in vitro and on animals highlighted vitamin K involvement in brain cells development and survival. In particular, vitamin K seems to have an antiapoptotic and anti-inflammatory effect mediated by the activation of Growth Arrest Specific Gene 6 and Protein S. Moreover, this vitamin is involved in sphingolipids metabolism, a class of lipids that participate in the proliferation, differentiation, and survival of brain cells. An altered expression in sphingolipids profile has been related to neuroinflammation and neurodegeneration. This review stems from a growing interest in the role of vitamin K in brain functions, especially in cognition, also in view of an expected increase of prevalence of Alzheimer's disease and other forms of dementia. It collects recent researches that show interesting, even though not definitive, evidence of a direct correlation between vitamin K levels and cognitive performance. Moreover, vitamin K antagonists, used worldwide as oral anticoagulants, according to recent studies may have a negative influence on cognitive domains such as visual memory, verbal fluency and brain volume. The aim of this review is to analyze the evidence of clinical studies carried out up to date on the relationship between vitamin K intake and cognitive performances. The involvement of vitamin K antagonists (VKAs) in declining cognitive performances is also addressed separately.

Intracameral lidocaine as supplement to classic topical anesthesia for relieving ocular pain in cataract surgery.

AIM: To evaluate safety, efficacy, and patient adherence of intracameral lidocaine as supplement of classic topical anesthetic drops in cataract surgery. METHODS: A prospective and controlled trial including a large cohort of 1650 individuals suffering with bilateral cataract not complicated, in program by phacoemulsification surgery, were randomly assigned to 2 different groups for the type of anesthesia received, 0.4% oxybuprocaine hydrochloride (INN) drops, and INN drops associated to intracameral 1% lidocaine hydrochloride monohydrate. At the end of surgery, tables were assigned to each patient indicating the degree of pain (0-3) felt during the operation. RESULTS: Thirty-two percent of patients in group 1 declared to have not felt any pain against the 77% of patients in group 2. Fifty-nine percent of patients in group 1 complained about only a slight discomfort against 20% of group 2 patients. Only a small percentage of patients in group 1 (5%) admitted severe pain, while no patient in group 2 admitted severe pain. Four patients of group 2 reported an episode of transient amaurosis, lasting several hours after surgery. CONCLUSION: Intracameral administration of lidocaine is a simple and secure method able to increase the analgesia during the cataract surgery, eliminating the discomfort and increasing also the cooperation of the patients during the steps of manipulation.

Effectiveness of 0.1% topical salicylic acid on blepharoconjunctivitis affecting glaucoma patients treated with topical prostaglandin analogues: a prospective randomized trial.

AIM: To evaluate the efficacy of 0.1% topical salicylic acid (TSA) to treat iatrogenic chronic blepharoconjunctivitis in patients with primary open angle glaucoma (POAG), treated with topical prostaglandin analogues (TPAs). METHODS: Totally 60 patients were randomly distributed into 3 equal size groups, two of which treated with 0.1% TSA (OMKASA®) and 0.1% topical clobetasone butyrate (TCB; VISUCLOBEN®) respectively, and one consisting of untreated controls. The parameters taken into account at baseline (T0) and after 30d (T1) of therapy were: conjunctival hyperemia, lacrimal function tests [Schirmer I test and break up time (BUT)] and intraocular pressure (IOP). RESULTS: Conjunctival hyperemia showed a substantial improvement in both treated groups (P<0.001) but not among controls. Similarly, lacrimal function tests displayed an improvement of Schirmer I test in both treated groups (P<0.05) and an extension of BUT only in the group treated with 0.1% TSA (P<0.05). The IOP increase was statistically significant only in those patients treated with 0.1% TCB (P<0.001). CONCLUSION: The 0.1% TSA has proved to be an effective anti-inflammatory treatment of blepharoconjunctivitis affecting glaucoma patients on therapy with TPAs, leading to a sizeable decrease of inflammation as well as both quantitative and qualitative improvement of tear film. Furthermore, differently from 0.1% TCB, it does not induce any significant IOP increase.

Sturge-Weber Syndrome Associated with Monolateral Ocular Melanocytosis, Iris Mammillations, and Diffuse Choroidal Haemangioma.

We present the case of a 12-year-old boy with Sturge-Weber syndrome and ocular melanocytosis who presented with bilateral naevus flammeus of the face and hyperpigmentation of the right iris associated with ipsilateral iris mammillations. The patient had glaucoma and a diffuse choroidal haemangioma of the right eye. Optical coherence tomography of the anterior segment confirmed iris hyper-pigmentation and did not show abnormalities of the chamber angle structures. B-scan ultrasonography and enhanced depth imaging optical coherence tomography were performed and showed a marked difference in thickness and reflectance between the right and left choroid. Visual field examinations with perimetry showed early defects in the right eye. Peripapillary optical coherence imaging showed borderline values of retinal nerve fibre layer thickness reduction in the right eye. Sturge-Weber syndrome associated with ocular melanocytosis and iris mammillations is an extremely rare condition. This paper highlights the role of multi-imaging methods in the enhanced evaluation of rare diseases towards choosing the most appropriate management strategies and improving the follow-up of patients over time.

Neuroprotection in Glaucoma: Old and New Promising Treatments.

Glaucoma is a major global cause of blindness, but the molecular mechanisms responsible for the neurodegenerative damage are not clear. Undoubtedly, the high intraocular pressure (IOP) and the secondary ischemic and mechanical damage of the optic nerve have a crucial role in retinal ganglion cell (RGC) death. Several studies specifically analyzed the events that lead to nerve fiber layer thinning, showing the importance of both intra- and extracellular factors. In parallel, many neuroprotective substances have been tested for their efficacy and safety in hindering the negative effects that lead to RGC death. New formulations of these compounds, also suitable for chronic oral administration, are likely to be used in clinical practice in the future along with conventional therapies, in order to control the progression of the visual impairment due to primary open-angle glaucoma (POAG). This review illustrates some of these old and new promising agents for the adjuvant treatment of POAG, with particular emphasis on forskolin and melatonin.

Biomolecular Modulation of Neurodegenerative Events during Ageing.

The objective is to assess the modulation of retinal and optic nerve degenerative events induced by the combination of α-lipoic acid (ALA) and superoxide dismutase (SOD) in an animal model of ageing. For this study, 24 male Wistar-Harlan strain rats were left to age for up to 24 months. One group of rats was subjected to a diet supplemented with ALA and SOD for 8 weeks, while another group was used as a positive control and not subjected to any dietary treatment. To assess the cytoprotective effects of the antioxidants, a morphological analysis was carried out on sections of retina and optic nerve head, stained with haematoxylin-eosin, followed by an analysis of the modifications to nuclear DNA detected by the TUNEL technique. The lipid peroxidation assay was used to assess the damage induced by oxidative stress at cell membrane level. The molecules involved in apoptosis mediated by oxidative stress, such as caspase-3 and inducible nitric oxide synthase, were also assayed by immunolocalization and western blot. ALA and SOD are able to counteract senile neurodegenerative deterioration to the retina and optic nerve. Indeed, the combination of these antioxidant molecules can reduce oxidative stress levels and thus prevent both nuclear degradation and subsequent cell death.

Nd: Yag laser iridotomy in Shaffer-Etienne grade 1 and 2: angle widening in our case studies.

AIM: To obtain widening of a potentially occludable angle, in according to Kanski's indications, through preventive Nd:Yag laser iridotomy. The observational study was performed by using gonioscopy for the selection and follow-up of 1165 treated eyes and exploiting Shaffer-Etienne gonioscopic classification as a quality/quantity test of the angle recession. METHODS: Between September 2000 and July 2012, 586 patients were selected at the Outpatients' Ophthalmological Clinic of the Policlinico Umberto I of Rome in order to undergo Nd: Yag laser iridotomy. A Goldmann type contact lens, Q-switched mode, 2-3 defocus, and 7-9 mJ intensity with 2-3 impulse discharges were used for surgery. RESULTS: From as early as the first week, a whole 360° angle widening were evident in the patients, thus showing the success of Nd:Yag laser iridotomy in solving relative pupil block. The angle remained narrow by 270° in 14 eyes only, despite repetitions of further treatment with laser iridotomy in a different part of the iris, twice in 10 eyes and three times in 4 eyes. CONCLUSION: Nd:Yag laser iridotomy revealed itself as being a safe and effective treatment in widening those critical Shaffer-Etienne grade 1 and 2 potentially occludable angles.

Irritable eye syndrome: neuroimmune mechanisms and benefits of selected nutrients.

Previous studies showed comorbidity of some ocular, enteral, and affective symptoms comprising irritable eye syndrome. Aims of the present study were to learn more about the pathogenic mechanisms of this syndrome and to evaluate benefits of food supplements on these disorders. In in vitro assay, Lactobacillus acidophilus lysate inhibited interleukin (IL)-1ß and tumor necrosis factor (TNF)-α generation of lipopolysaccharide (LPS)-stimulated macrophages in dose- and size-dependent manner. For a prospective, open-label phase I/II controlled clinical trial, 40 subjects affected by ocular dysesthesia and hyperesthesia and comorbid enteral and anxiety-depression symptoms were randomly assigned either into the treated group, which received a composition containing probiotic lysate, vitamins A, B, and D and omega 3 fatty acids, or into the control group, which received vitamins and omega 3 fatty acids. For reference, 20 age- and sex-matched healthy subjects were also selected. White blood count (WBC) and lymphocyte and monocyte counts, as well as IL-6 and TNF-α levels, were significantly above the reference levels in both treated and control groups. After 8 weeks, WBC and lymphocyte and monocyte counts, and cytokine levels significantly decreased, and ocular, enteral, and anxiety-depression symptoms significantly improved in the treated group as compared to the control group. This proof-of-concept study suggested that subclinical inflammation may be a common mechanism connecting ocular, enteral, and anxiety/depression symptoms, and supplements affecting dysbiosis may be a new approach to treating this syndrome.

Iatrogenic dry eye disease: an eledoisin/carnitine and osmolyte drops study.

BACKGROUND: To evaluate the effects of an eye drop containing eledoisin and carnitine in patients suffering from primary open-angle glaucoma (POAG) and ocular discomfort syndrome secondary to a chronically treated with eye drops containing benzalkonium chloride (BAK) as preservative. The dry eye disease was defined as a multifactorial drop disease concerning tears and ocular surface, which brings to discomfort symptoms and visual disorders with potential damage to the ocular surface. Several studies underlined the beneficial effects of secretagogues drugs, such as eledoisin. It is a neuro-peptide extracted from the salivary glands of some shellfishes. Recently, it has been also showed the protective role of carnitine in respect of the ocular surface exposed to the tear film hyperosmolarity. MATERIALS AND METHODS: This randomized double-blind pilot study has been evaluated by lubricant eye drop solutions containing eledoisin and carnitine in 40 patients with ocular discomfort syndrome secondary to POAG, since that the patients were chronically treated with eye drops which decrease eye pressure and contain BAK as preservative. The subjects filled out a questions form concerning the severity of the symptoms and their impact on daily activities. Subsequently Fluorescein Breakup Time (FBUT), Schirmer Test 1 (ST), and Ocular Protection Index (OPI) were measured at baseline and after 15days of treatment. RESULTS: At the end of therapy it was possible to match the beneficial effects of eye drops with carnitin, taurine, sodium hyaluronate and eledoisin. In fact, after 15days of treatment, patients of group 1 showed a decrease of approximately 50% concerning the severity of symptoms and a significant improvement of the tests valued. CONCLUSION: In summary, lubricant eye drops that restore physiological hosmolarity and stimulate tear production represent a promising strategy for dry eye syndrome.

Fixed topical combinations in glaucomatous patients and ocular discomfort.

OBJECTIVE: The purpose of this study was to verify the ocular comfort of a fixed topical combination of brinzolamide 1% plus timolol 0.5% suspension vs. dorzolamide 2% plus timolol 0.5% solution, both preserved with benzalkonium chloride (BAK), in patients with primary open-angle glaucoma (POAG) through subjective and objective methods. BAK is the most commonly used preservative in topical glaucoma medications. METHODS: 62 subjects were examined and included in the analysis. Each patient was asked to complete a questionnaire on symptoms (Ocular Surface Disease Index) and then underwent a series of examinations. The Ocular Protection Index evaluated the risk of damage to the ocular surface, and was expressed as the ratio between fluorescein breakup time and blinking interval. These and other analyses were repeated 30 days after instillation of the new eye drop treatment. RESULTS: The results demonstrated that patients enrolled with the preserved fixed combination of dorzolamide or brinzolamide represented a subgroup of patients in which the discomfort symptoms were supposedly justified by the presence of BAK used chronically in antihypertensive drops. Ocular discomfort scores were significantly higher with dorzolamide/timolol than brinzolamide/timolol (p < 0.0001). CONCLUSIONS: This work shows the better tolerability of brinzolamide 1% plus timolol 0.5% suspension, compared with dorzolamide 2% plus timolol 0.5% solution. Fortunately, some of the adverse reactions induced by preserved eye drop glaucoma medication are reversible after removing the preservatives. Both the potential for added benefit and patient compliance should be considered when selecting ocular hypotensive therapy.

Juxtafoveal choroidal neovascularization associated with retinitis pigmentosa treated with intravitreal bevacizumab.

PURPOSE: To describe a case of juxtafoveal choroidal neovascularization (CNV) occurring in a patient affected by retinitis pigmentosa (RP), treated with intravitreal bevacizumab over a 12-month follow-up. METHODS: A 66 year-old woman referred to our center for visual acuity deterioration was diagnosed as having classic juxtafoveal CNV associated with RP. The patient was treated with intravitreal bevacizumab, and was regularly monitored every month. RESULTS: At the end of the 12-month follow-up, best corrected visual acuity changed from 20/200 to 20/100 in the affected eye. Five intravitreal bevacizumab injections were required to obtain the stabilization of the CNV. CONCLUSIONS: Intravitreal bevacizumab is effective in producing juxtafoveal CNV stabilization and visual acuity improvement in a patient affected by RP, over a 12-month follow-up. Future studies are required to ascertain the best therapeutic approach for CNV complicating RP.

Differential activity and clinical utility of latanoprost in glaucoma and ocular hypertension.

BACKGROUND: The purpose of this study was to demonstrate the hypotensive efficacy and tolerability of latanoprost when used as monotherapy and as polytherapy associated with antiglaucomatous medication proven to be ineffective in keeping intraocular pressure under control. METHODS: Three hundred and thirty-seven patients (672 eyes) affected by primary open-angle glaucoma and intraocular hypertension were recruited over a period of 10 years from the Glaucoma Centre, Department of Ophthalmological Sciences, University of Rome "Sapienza", and treated, subject to informed consent, with latanoprost 0.005% alone or in combination with other ocular hypotensive drugs. The patients were followed during this period at regular intervals, with determination of visual field, fundus oculi, visual acuity, and eventual onset of local and systemic side effects. RESULTS: Latanoprost used as monotherapy and as polytherapy renders possible optimal and durable control of intraocular pressure in the form of one antiglaucomatous drug because it can substitute for one or more drugs and obtain the same hypotensive effect. CONCLUSION: Latanoprost can be described as the ideal hypotensive drug, not only because of its ideal compliance profile (only one daily dose in the evening), excellent hypotensive effect, and, above all, few systemic side effects.

Intravitreal bevacizumab for extrafoveal choroidal neovascularization after ocular trauma.

PURPOSE: To describe two cases of extrafoveal choroidal neovascularization (CNV) after ocular trauma successfully treated with intravitreal bevacizumab injection. METHODS: A 41-year-old man presented for progressive visual impairment in the left eye (LE). The patient had a positive history for pseudoxanthoma elasticum and suffered a blunt trauma in the LE 1 year before. Best-corrected visual acuity (BCVA) in the affected eye was 20/100. Fundus examination of the LE revealed angioid streaks and a choroidal rupture with retinal hemorrhages. Fluorescein angiography (FA) revealed an extrafoveal CNV and optical coherence tomography (OCT) findings demonstrated the presence of intraretinal fluid extending to the fovea. The second patient was a 61-year-old man complaining of blurred vision in the LE. Fundus examination of the LE revealed retinal pigment epithelium (RPE) changes, while FA showed the presence of an extrafoveal CNV close to the area of RPE attenuation. Intraretinal fluid extending to the fovea was detectable on OCT examination. An intravitreal injection of bevacizumab was proposed in both cases. RESULTS: In the first patient, treatment with one intravitreal bevacizumab injection was successful in contrasting CNV activity, as OCT findings showed a resolution of intraretinal fluid accumulation. BCVA remained unchanged (20/100) over the 12-month follow-up period, most probably due to permanent alteration of the photoreceptors. In the second case, BCVA improved from 20/40 to 20/20 with complete resolution of leakage on FA and fluid on OCT 1 month after a single intravitreal injection of bevacizumab. Visual function remained stable over the 14-month follow-up. CONCLUSIONS: Our results indicate that intravitreal bevacizumab is effective in the management of extrafoveal CNV secondary to ocular trauma.

Palmitoylethanolamide effects on intraocular pressure after Nd:YAG laser iridotomy: an experimental clinical study.

PURPOSE: The purpose of this article was to evaluate whether the anti-inflammatory agent palmitoylethanolamide (PEA) can counteract the increase of intraocular pressure (IOP) that may occur after neodymium-doped: yttrium aluminum garnet (Nd:YAG) laser iridotomy. METHODS: Fifteen patients underwent bilateral laser iridotomy (Visulas YAG III Laser; Zeiss) for the prevention of primary closed-angle glaucoma. The IOP was measured at the beginning of the study (t-1), after 15 days of pretreatment with placebo or PEA (t0), and at 15, 30, and 120 min after the iridotomy (t1, t2, t3). The pretreatment consisted of 2 tablets of placebo or PEA per day for 15 days. RESULTS: The t-test did not show a significant difference between the preoperative mean values of IOP t-1 and t0 in both the pretreatments. Analysis of variance/Tukey's test pointed out a significant increase of the postoperative IOP values in placebo pretreated patients (P≤0.05), but not in those who were pretreated with PEA. The trend analysis confirmed the significant positive trend in placebo pretreatment. The parallelism test between the 2 regressions showed a significant difference for the slopes (P=0.022) and not for the intercepts (P=0.520). CONCLUSIONS: PEA can counteract the increase of IOP that occurs after iridotomy. It is likely that PEA controls the inflammatory process after iridotomy.

The Mozart effect in biofeedback visual rehabilitation: a case report.

PURPOSE: To evaluate the usefulness of acoustic biofeedback by means of Mozart's Sonata for Two Pianos in D Major K. 448 to maintain and/or restore visual performance in a patient with macular pucker and glaucoma. METHODS: A 74-year-old patient with open angle glaucoma in both eyes and macular pucker in the right eye (RE) underwent visual rehabilitation with acoustic biofeedback by means of the MAIA™ Vision Training Module (Centervue, Padova, Italy) 10 minutes each eye once a week for 5 weeks. The patient was asked to move his eyes according to a sound which changed into Mozart's Sonata for Two Pianos when the patient locked the fixation target. RESULTS: Best-corrected visual acuity improved in his right eye (RE) and was stable in the left eye (LE). Fixation stability improved in both eyes, and retinal sensitivity decreased in the RE and improved in the LE. The characteristic of the macular pucker did not change during the training as demonstrated with optical coherence tomography. The patient was very satisfied with the training, as demonstrated by a 25-item questionnaire (National Eye Institute - Visual Functioning Questionnaire, NEI-VFQ-25). The patient's reading speed and the character size which he was able to read improved in his RE. CONCLUSION: Music could enhance synaptic plasticity and affect neural learning and fixation training by means of MAIA vision training. Therefore it can improve visual performance in patients with macular pucker, postpone the surgical time, and assure a better quality of life for the patient.

New retinal imaging for the visualization and analysis of vitreoretinal interface (VRI) by short-wavelength scanning laser ophthalmoscope (swSLO).

BACKGROUND: The purpose of the study was to evaluate vitreoretinal interface (VRI) alteration with a short-wavelength scanning laser ophthalmoscope (swSLO), the Nidek F-10, and compare the results with those obtained by means of spectral-domain optical coherence tomography (SD-OCT). METHODS: Thirty-six eyes were studied (20 patients, mean age 68 ± 12.3 years). All patients underwent a complete ophthalmologic examination, which comprised SD-OCT and Nidek F-10 analysis with short-wavelength blue laser. Eyes were divided into four groups depending on the degree of VRI alteration observed with the swSLO and SD-OCT. Statistical analysis was performed using the Chi-square test. P values less than 0.05 were considered statistically significant. RESULTS: OCT ANALYSIS: eight eyes (22%) grade 0 (no abnormalities), 15 eyes (42%) grade 1 (preretinal cellophane); seven (19%) grade 2 (preretinal wrinkling); six (17%) grade 3 (macular pucker or hole). Nidek F-10 analysis: seven (19%) grade 0, 16 (45%) grade 1; seven (19%) grade 2; six (17%) grade 3. Chi-square = 0.099, P = 0.992. There was no statistically significant difference between the two instruments. CONCLUSION: Nidek F-10 allows both a quantitative and a qualitative evaluation of VRI and is equal to SD-OCT in detecting alteration of the inner portion of the retina, providing an easy way to evaluate and map differences in the inner vitreoretinal surface.