A novel approach to remove retained lens material: Suction-assisted elevation and anterior chamber phacoemulsification.

PURPOSE: To describe and evaluate the feasibility of a novel pars plana vitrectomy (PPV) technique for the removal of retained lens material (RLM), which obviates the need for either 20-gauge intravitreal fragmentation or perfluorocarbon-assisted elevation. METHODS: Interventional case series. After thorough 23-gauge PPV, the hard lens material is engaged and held adherent to the vitreous cutter using aspiration, then raised into the anterior chamber. There, a standard phacoemulsification probe, inserted through a corneal incision, is used to fragment and remove the material. RESULTS: Three eyes of 3 patients were operated on. In all eyes, RLM could be removed completely. Postoperatively, 2 of 3 eyes (67%) achieved 20/20 best-corrected visual acuity. No complications such as glaucoma, cystoid macular edema, corneal edema, or retinal detachments were recorded. Intraoperatively, retinal tears were detected in 2 of 3 (67%) eyes and treated with endolaser retinopexy and fluid-air exchange. One eye subsequently developed macular hole requiring further surgery. CONCLUSION: Suction-assisted lens elevation may be a viable and convenient technique to remove RLM during PPV. Although the comparison with other methods is beyond the scope of this preliminary study, visual outcomes and complication rates were encouraging and should be validated in a larger group of patients.

Microscope-Integrated Intraoperative Optical Coherence Tomography-Guided Big-Bubble Deep Anterior Lamellar Keratoplasty.

PURPOSE: The purpose of this study was to evaluate the feasibility of microscope-integrated intraoperative optical coherence tomography (OCT) for real-time quantitative analysis of surgical planes in big-bubble deep anterior lamellar keratoplasty (DALK). METHODS: In this interventional case series, intraoperative OCT-guided big-bubble DALK was performed in 16 consecutive eyes of 16 patients with keratoconus. Trephination depth was measured using the intraoperative OCT caliper tool. Aiming for a depth within 150 µm from the endothelial surface, the trephination groove was extended to a deeper plane using a 15-degree blade. Repeat OCT scans were taken to measure residual stromal thickness before insertion of the DALK probe from the bottom of the extended trephination. Caliper measurements, success rate of pneumatic dissection, and complications were recorded. RESULTS: After trephination, residual stromal thickness exceeded 150 µm in all eyes and averaged 257.1 ± 42.5 µm. In each case, the initial trephination groove was extended to a depth within 150 µm from the endothelial surface (118.9 ± 27.1 µm). Big-bubble formation was achieved in 12 eyes (75%). Type 1 bubble was obtained in 11 eyes. Perforation requiring conversion to penetrating keratoplasty occurred in 4 eyes during insertion of the cannula into a residual stromal bed of <100 µm (n = 2; 63 and 75 µm) or layer-by-layer dissection (n = 2). CONCLUSIONS: Quantitative analysis of intraoperative OCT scans can be used to assist decision-making on whether to proceed with pneumatic dissection or extend the trephination groove, thereby facilitating insertion of the injection cannula at the desired stromal depth.

Efficacy and safety of Ab interno XEN gel implant after a failed filtering surgery.

Purpose: To evaluate the efficacy and safety of Ab interno XEN gel stent in patients with open angle glaucoma who underwent a previous failed filtering surgery. Methods: A retrospective, observational, multi-centered and descriptive cohort study was conducted from January 2019 to February 2020 on patients with primary open angle glaucoma (POAG) who underwent XEN gel stent implant after a failed filtering surgical procedure. Main parameters evaluated were: changes in IOP measured with Goldmann applanation tonometer, number of anti-glaucomatous eye drops, postoperative complications, and necessity of further surgical procedures. The quantification of quality of life was obtained from the VFQ-25 questionnaire. A descriptive analysis based on pre- post- and intra-operative data was carried out. Results: In all patients included in the study (6 patients for a total of 7 eyes), IOP dropped during the follow up time. We found a mean percentage reduction of -41.5% at 9 months compared to the preoperative data (baseline). IOP lowered from 21.71 ± 4.64 mmHg to 9 ± 3,21 mmHg 1 day after the operation, 11 ± 3.21 at 1 week, 11.42 ± 1.81 mmHg at 1 month, 12.42 ± 3.10 mmHg at 3 months, 13.57 ± 3.45 at 6 months, 12.71 ± 1.79 at 9 months. In 71.4%, the procedure turned out to be complication free and only one case required needling of the bleb in order to achieve optimal intraocular pressure control. A total of 71.4% patients reached a medication free regimen with a percentage of reduction in the mean number of drugs needed of -88.9%. Conclusion: In our experience, XEN gel stent implant performed in Caucasian patients with POAG and a history of failed filtrating surgery, showed to be an effective and safe procedure.

Novel 'heavy' dyes for retinal membrane staining during macular surgery: multicenter clinical assessment.

PURPOSE: To evaluate the feasibility of two novel 'heavy' dye solutions for staining the internal limiting membrane (ILM) and epiretinal membranes (ERMs), without the need for a prior fluid-air exchange, during macular surgery. METHODS: In this prospective nonrandomized multicenter cohort study, the high molecular weight dyes ILM-Blue™ [0.025% brilliant blue G, 4% polyethylene glycol (PEG)] and MembraneBlue-Dual™ (0.15% trypan blue, 0.025% brilliant blue G, 4% PEG) were randomly used in vitrectomy surgeries for macular disease in 127 eyes of 127 patients. Dye enhanced membrane visualization of the ILM and ERMs, 'ease of membrane peeling', visually detectable perioperative retinal damage, postoperative best-corrected visual acuity (BCVA), dye remnants and other unexpected clinical events were documented by 21 surgeons. RESULTS: All surgeries were uneventful, and a clear bluish staining, facilitating the identification, delineation and removal of the ILM and ERMs, was reported in all but five cases. None of the surgeries required a fluid-air exchange to assist the dye application. BCVA at 1 month after surgery improved in 83% of the eyes in the MembraneBlue-Dual™ group and in 88% in the ILM-Blue™ group. No dye remnants were detected by ophthalmoscopy, and no retinal adverse effects related to the surgery or use of the dyes were observed. CONCLUSION: The 'heavy' dye solutions ILM-Blue™ and MembraneBlue-Dual™ can be injected into a fluid-filled vitreous cavity and may facilitate staining and removal of the ILM and/or ERMs in macular surgery without an additional fluid-air exchange.

Spectral domain optical coherence tomography findings in patients with acute syphilitic posterior placoid chorioretinopathy.

PURPOSE: To describe the appearance of acute syphilitic posterior placoid chorioretinitis, a rare ocular manifestation of syphilis, on spectral domain optical coherence tomography (SD OCT) both before and after treatment. METHODS: Ophthalmic examination and imaging studies of 30 eyes of 19 confirmed cases were analyzed both at the time of presentation and at each follow-up visit. Patients with SD OCT and fluorescein angiography at the time of presentation, and at least three documented follow-up visits after initiation of therapy, were included in the study. Standard treatment of neurosyphilis was given to each patient, including 4 million units of penicillin G administered intravenously every 4 hours for 14 days. RESULTS: Fundus examination and imaging studies were consistent with previous reports and confirmed the diagnosis of acute syphilitic posterior placoid chorioretinitis. In 13 eyes (43.3%), baseline SD OCT scans were performed within 1 to 2 days of presentation and revealed a small amount of subretinal fluid, disruption of the inner segment/outer segment junction, and hyperreflective thickening of the retinal pigment epithelium (RPE). All 30 eyes were again scanned between Days 7 and 9 after presentation and revealed loss of the inner segment/outer segment and OS/RPE bands, and irregular hyperreflectivity of the RPE with prominent nodular elevations but without subretinal fluid. Early disruption of the external limiting membrane and punctate choroidal hyperreflectivity were seen in 1 of the 30 eyes (3.3%) and 14 of the 30 eyes (46.6%), respectively. Vision improved and the outer retinal abnormalities normalized in 28 of the 30 eyes (93.3%) after the treatment of neurosyphilis. The external limiting membrane, inner segment/outer segment band, and/or linear outer segment/RPE junction remained substantially abnormal despite treatment in 2 eyes left with 20/200 vision. CONCLUSION: Patients with acute syphilitic posterior placoid chorioretinitis show characteristic outer retinal abnormalities on SD OCT imaging, including disruption of the inner segment/outer segment band, nodular thickening of the RPE with loss of the linear outer segment/RPE junction, and, in some cases, loss of the external limiting membrane, accumulation of subretinal fluid, and punctate hyperreflectivity in the choroid. Vision improved and these abnormalities reversed after treatment of neurosyphilis in most of the patients. Persistently, poor vision despite treatment was associated with long-term loss or disruption of outer retinal anatomy on SD OCT.

The pediatric vision screening program performed in Bolzano in 2010: significance of the orthoptic re-examination.

AIM: To analyze results of the vision screening program performed in the Bolzano District and to evaluate the significance of orthoptic re-screening in children with unreliable results. METHODS: In 2010, 7772 children, aged 7 months, 3 years, or 5 years, were invited for orthoptic vision screening. Children with unreliable screening findings were re-invited for a second test. In this retrospective study we examined the charts of all children who underwent screening and reported the outcome. RESULTS: A total of 6126 children were examined; 1646 (21.2%) did not attend screening. Of the children tested, 562 (9.2%) showed positive screening results and were referred for ophthalmologic examination. There were 427 (7.0%) children with unreliable results who were re-examined after 3 to 6 months; among them, 307 (71.9%) showed a negative final result and 120 (28.1% of re-examined subgroup, 1.96% of the total) were positive. CONCLUSIONS: The large number of unreliable results at the first screening test could be caused by lack of collaboration. The orthoptic re-examination of children with unreliable results may be useful in reducing the amount of false positives.

Vasoproliferative retinal tumor treated with indocyanine green-mediated photothrombosis.

PURPOSE: To assess the efficacy of indocyanine green-mediated photothrombosis (ICGMP) in the treatment of large vascular lesions, and in particular of a 6-mm large, actively exudating vasoproliferative retinal tumor (VPRT). METHODS: Thirty minutes after the administration of a loading dose of 1 mg/kg of intravenous ICG multiple, confluent, 2 mm wide, infrared 810 nm diode laser spots were applied on the surface of the tumor. Duration of each spot was 60 seconds, and the power chosen was 400 mW. A subTenon injection of 40 mg triamcinolone suspension was administered immediately after treatment. RESULTS: No change in tumor aspect was observed after treatment. ICG late images were taken, showing no perfusion of the lesion. Two weeks after treatment the lesion was remarkably reduced in volume, but residual perfusion on ICG was observed. A second treatment with three laser spots on the diffusion site under the same modalities was performed. After the second treatment a complete obliteration of the lesion could be observed. In the original tumor site patchy retinal pigment epithelium atrophy and hyperplasia appeared. A diffuse, gradual, complete resolution of the exudates is now apparent at the fundus. Vision has slightly improved to 20/100. Follow-up has reached 2 years. CONCLUSION: In the presented case ICGMP achieved complete obliteration of a large VPRT. To our knowledge, this is the first VPRT successfully treated with ICGMP, and the largest retinal vascular lesion treated with laser technique reported in the literature. ICGMP is less invasive than cryotherapy and less expensive than recently proposed photodynamic therapy. It may deserve further study in the treatment of selected retinal vascular tumors.

Central serous chorioretinopathy in patients with keratoconus.

PURPOSE: To report the occurrence of central serous chorioretinopathy in patients with keratoconus and discuss the possible connection between these two conditions. METHODS: Observational case series. RESULTS: The authors identified three subjects with keratoconus and central serous chorioretinopathy. All patients underwent visual acuity measurement, fundus examination, digital fluorescein angiography, and optical coherence tomography. CONCLUSIONS: Keratoconus and central serous chorioretinopathy are two uncommon diseases, possibly due to dysfunction of epithelium and its basement membrane, which can occur together in some individuals. The authors discuss the possible connection between these two conditions.