Long-term surgical outcome and impact on daily life activities of strabismus surgery in thyroid-associated ophthalmopathy with and without previous orbital decompression.

BACKGROUNDS: To report the long-term surgical outcomes and the impact on daily life activities of strabismus surgery in patients with Thyroid Associated Orbitopathy (TAO) with and without previous orbital decompression. METHODS: Patients who underwent strabismus surgery for TAO were retrospectively reviewed. The primary outcome was to evaluate the influence of orbital decompression on the outcomes of TAO related strabismus surgery. Surgical success was defined by the resolution of diplopia and a post-operative deviation < 10 prism diopters (PD). The secondary outcomes were the clinical features, surgical approaches, and impact on daily life activities. RESULTS: A total of 45 patients were included in the study. The decompression surgery group (DS) included 21 patients (46.7%), whereas the non-decompression surgery group (NDS) patients were 24 (53.3%). The mean follow-up time from the last strabismus surgery was 2,8 years (range 8-200 months). Successful surgical outcome was achieved in 57,1% of patients in the DS, and 75% of patients in the NDS (p = 0,226). DS patients required almost twice the number of surgical interventions for strabismus compared to the NDS (1,95 vs. 1,16 respectively, p = 0,006), a higher number of extraocular muscles recessed in the first surgery (2,67 vs. 1,08 respectively, p < 0.001), and a lower rate of unidirectional surgery compared to NDS (23% vs. 95%, p < 0,001). At the pre-operative assessment, 71.4% of DS patients had eso-hypotropia, while no patients had this type of strabismus in the NDS group (p < 0.001). On the other hand, the hypotropia rate was 79.2% in NDS patients and only 4.8% in DS patients (p < 0.001). Moreover, 21,8% of NDS patients used prism lenses in daily life activities, compared to 42.9% of patients that used prism lenses to reduce the impairment in their daily life activities (p = 0.016). CONCLUSIONS: The results of our study showed that DS patients required almost twice the number of strabismus surgical procedures, a higher number of extraocular muscles recessed in the first surgery, and an increased need for prism lenses to correct the residual deviation compared to the NDS, but with similar long-term surgical outcomes.

Epidemiology, clinical features, and surgical outcomes of acute acquired concomitant esotropia associated with myopia.

PURPOSE: To analyze epidemiology, clinical features, and surgical outcomes of type III acute acquired concomitant esotropia (Bielschowsky esotropia (BE)). METHODS: The medical charts of patients diagnosed with acquired concomitant esotropia between 2013 and 2021 were reviewed. Assessed data were age, gender, age at diplopia onset, age at the diagnosis, refraction, visual acuity, neuroimaging, diplopia onset, angle of deviation, stereopsis, surgical procedure, amount of surgery, and relapse of diplopia after surgery. Moreover, we investigated the correlation between the use of electronic devices and the onset of diplopia. RESULTS: One hundred seventeen patients (mean age 35.07 ± 15.81 years) were included in the study. The mean delay to the diagnosis was 3.29 ± 3.62 years. Myopia range was 0 to 17 diopters spherical equivalent. 66,3% spent more than 4 hours a day using laptops, tablets, or smartphones at the onset of diplopia, and 90,6% presented a subacute onset. None showed neurologic signs or symptoms. Patients who underwent surgery were ninety-three, with a rate of surgical success of 93.6%, and a relapse rate of 17.2%. A negative correlation resulted between pre-operative deviation and age at diagnosis (ρ = -0.261; p<0.05), whereas factors associated with surgical failure were older age at diplopia onset (p = 0.042) and longer delay between onset and diagnosis (p = 0.002). CONCLUSION: We registered an outstanding increase in prevalence of BE, which could be related to the exponential increase in the use of electronic devices for professional, educational, and recreational purposes. A prompt diagnosis and an augmented dose of surgery allows good motor and sensory results.

Case report: Cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL) as a risk factor for central serous chorioretinopathy.

Purpose: To describe an atypical case of central serous chorioretinopathy (CSC) in a patient with cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL). Methods: A retrospective case report. Results: A 43-year-old white man with a genetic diagnosis of CADASIL was referred to our hospital because of reduced visual acuity in his right eye (20/30). In the previous 2 months, he developed CSC with subretinal fluid (SRF) and damage to the retinal pigmented epithelium without pachychoroid and pachyvessels or known risk factors for CSC. The patient was treated with transfoveal subthreshold micropulse yellow laser (577 nm) therapy. One month later, there were no signs of SRF, and visual acuity improved to 20/20. Conclusions: Cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL) is a genetic condition that primarily affects vascular smooth cells in small cerebral vessels and retinal arterioles. However, we hypothesize that CADASIL could also be responsible for an alteration of the vascular smooth cells in the choroidal arterioles, leading to choriocapillaris ischemia and CSC, even in the absence of a pachychoroid spectrum.

Binocular treatment for amblyopia: A meta-analysis of randomized clinical trials.

BACKGROUND: To date, there is still no consensus regarding the effect of binocular treatment for amblyopia. The purpose of this systematic review and meta-analysis was to summarize the available evidence to determine whether binocular treatment is more effective than patching in children with amblyopia. METHODS: Four electronic databases (PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials) were searched for studies that compared binocular treatment and patching in children with amblyopia. The outcome measures were visual acuity and stereopsis. Pooled effects sizes were calculated with a random-effect model. The standardized difference in means (SDM) with 95% confidence intervals (CI) was calculated. Sensitivity analysis and assessment of publication bias were performed. RESULTS: Five randomized clinical trials were included. No significant difference in visual acuity between patients treated with binocular treatment and patching was observed (SDM = -0.12; 95% CI: -0.45-0.20; P = 0.464). No significant difference in stereopsis between patients treated with binocular treatment and patching was observed (SDM = -0.07; 95% CI: -0.61-0.48; P = 0.809). For both variables, the between-study heterogeneity was high (respectively, I2 = 61% and I2 = 57%). CONCLUSIONS: This meta-analysis found no convincing evidence supporting the efficacy of binocular treatment as an alternative to conventional patching. Therefore, the binocular treatment cannot fully replace traditional treatment but, to date, it can be considered a valid complementary therapy in peculiar cases. Further studies are required to determine whether more engaging therapies and new treatment protocols are more effective.

Augmented bimedial rectus muscles recession in acute acquired concomitant esotropia associated with myopia.

OBJECTIVE: To review the clinical features of acute acquired concomitant esotropia in myopia and the results of augmented bilateral symmetrical medial rectus recession. METHODS: The medical charts of 50 patients diagnosed with acute acquired concomitant esotropia associated with myopia between 2013 and 2018 were reviewed. The dose-response was calculated, and the relationship of sex, age, refraction, best-corrected visual acuity (BCVA), preoperative deviation angle, and stereopsis with surgical results were analysed. RESULTS: Forty-six patients (mean age 40.1 ± 18.1 years) were included in the study. Preoperative esotropia angle at near and distance were, respectively, 26.0 ± 7.5 PD and 25.2 ± 7.9 PD. Surgery amount was 12.1 ± 1.8 mm of recession, and surgical success was achieved in 38 patients (82.6%). No overcorrections were recorded. At 1-year follow-up, the mean deviation angle at distance and at near was 1.9 ± 2.4 and 1.7 ± 2.1 PD, and no recurrences were observed. The average dose-response was 1.8 ± 0.6 PD/mm and was positively correlated with preoperative angle of deviation (R2 = 0.799, p < 0.001) and negatively correlated with age (R2 = -0.365, p = 0.013). Conversely, there were no significant associations between dose-response and sex, refractive error, BCVA, or stereopsis (all p > 0.05). Factors associated with surgical failure were a lower amount of recession and absence of stereopsis. CONCLUSIONS: Augmented bilateral medial rectus recession allows good motor and sensory results in patients with acute acquired concomitant esotropia associated with myopia.

Gaze Trajectory Index (GTI): A novel metric to quantify saccade trajectory deviation using eye tracking.

BACKGROUND: Many different indexes have been proposed to quantify saccade curvature based on geometric properties of the saccade trajectory projected on the 2D plane. We introduce the Gaze Trajectory Index (GTI), a novel metric to quantify saccade trajectory deviation based on calculation of the rotational eye movements performed in 3D space while following a 2D saccade trajectory recorded with eye tracking (ET). METHODS: We provided a description of GTI calculation. In 13 subjects with normal binocular vision we assessed GTI in single-target tests, then we evaluated GTI against previously proposed metrics (Maximum Deviation,MD; Area Curvature,AC; Quadratic Curvature,QC; Initial Direction,ID) using a distractor paradigm that elicited two types of saccade deviations, i.e."inner-curved" and "outer-curved" saccades. RESULTS: In single-target tests GTI showed that saccade curvature was significantly higher for oblique than for vertical saccades (0.86°±0.32 vs 0.55°±0.60,p < 0.05) and higher for vertical than for horizontal saccades (0.55°±0.60 vs 0.23°±0.17,p < 0.05), in accordance with previous studies. In distractor-based tests, for inner-curved saccades, GTI strongly correlated with MD (r = 0.965,p < 0.01), AC (r = 0.940,p < 0.01), QC (r = 0.866,p < 0.01), and Principal Component Analysis (PCA) confirmed that all these metrics reflect the same underlying phenomenon. For outer-curved trajectories, GTI showed poor correlation with MD and AC (r = 0.291 and 0.416,p < 0.01), however PCA included the three metrics in the same first component group. For outer-curved trajectories, GTI was the only metric showing strong correlation (r = 0.950,p < 0.05) with the overshoot degree of the trajectory. CONCLUSION: The novel GTI seems to have adjunctive potential, particularly for outer-curved trajectories, in the estimation of the absolute amount of saccade trajectory deviation.

Photorefractive keratectomy influences the angle of ocular deviation in strabismus patients with hyperopia.

PURPOSE: To evaluate refractive, binocular vision and ocular alignment outcomes of photorefractive keratectomy (PRK) for the treatment of hyperopia in esotropic patients. METHODS: Medical charts of hyperopic patients with full or partial accommodative esotropia (FAE or PAE) or consecutive exotropia (CE) undergone PRK from 2011 to 2014 were reviewed. The primary outcome was to assess the efficacy of PRK in improving ocular alignment. The secondary outcomes were the assessments of uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), spherical equivalent (SE) and stereoacuity. RESULTS: Sixty-four eyes of 32 hyperopic patients were included. Three patients were affected by FAE, 24 by PAE and 5 by CE. All FAE patients and 4 PAE patients underwent only PRK; the remaining 25 patients underwent PRK plus strabismus surgery. After PRK, the mean corrected esodeviation decreased significantly in the overall esotropic population [7.15 ± 9.42 prism diopters (PD) vs. 5.04 ± 8.83 PD; p = 0.03] and in particular in the group with small-angle esodeviation (< 20 PD). Conversely, the only 2 patients with an angle of strabismus ≥ 20 PD as well as all CE patients did not show any postoperative variation of the deviation angle. Mean preoperative BCVA did not differ from postoperative UCVA (p = 0.19), while the mean postoperative SE decreased significantly after PRK (p < 0.0001). CONCLUSIONS: Our study confirmed that PRK eliminates the accommodative component of the deviation. In addition, this procedure seems to reduce or eliminate also the non-accommodative component of esodeviation (especially in small-angle deviation), thus suggesting to postpone strabismus surgery after PRK when esotropia and hyperopia coexist.

Quantitative Approach for the Analysis of Fusional Convergence Using Eye-Tracking and SacLab Toolbox.

Fusional vergence is a disjunctive movement of the eyes that is made in order to obtain single vision. The aim of the study was to provide a quantitative and objective approach for analyzing the fusional convergence response using eye tracking (ET) technology and automatic data analysis provided by the intuitive SacLab toolbox previously developed by our group. We evaluated the proposed approach in a population of 26 subjects with normal binocular vision, who were tested with base-out prisms (magnitudes 4Δ, 6Δ, and 10Δ) in order to elicit fusional convergence response. Eye movements were recorded using the Viewpoint ET and analyzed using SacLab. Parameters describing both the vergence and the version components of the fusional response (convergence duration, CD; peak convergence velocity, PCV; number of intrusive saccades, NS; and mean saccadic amplitude, MSA) were automatically calculated and provided to clinicians for an objective evaluation. Results showed that the number of subjects achieving fusional convergence decreased with prism magnitude. For subjects achieving fusion CD and PCV increased significantly (p < 0.05) when increasing the prism magnitude. For NS and MSA, there were no significant changes when passing to 6Δ, but a significant increase resulted when passing to 10Δ (p < 0.05). Noninvasive ET associated with the intuitive SacLab toolbox may represent a valid option to objectively characterize the fusional vergence response in clinical setting. The analysis may be extended to patients with vergence disorders.

Trehalose/hyaluronate eyedrop effects on ocular surface inflammatory markers and mucin expression in dry eye patients.

AIM: To assess the ocular surface parameters, inflammatory marker level in tears, and mucin expression in conjunctival epithelium before and after treatment with trehalose/hyaluronate tear substitute in dry eye (DE) patients. PATIENTS AND METHODS: Fifteen DE patients were evaluated in an open-label, pilot study at enrollment, after 2 days of washout (baseline) and after 1 and 2 months (endpoint) of treatment with a trehalose/hyaluronate tear substitute (one drop/eye/three times daily). Data for symptoms of discomfort (Ocular Surface Disease Index and Visual Analogue Scale pain score), tear film (Schirmer test I, tear film breakup time), ocular surface damage (corneal National Eye Institute) and conjunctival van Bijsterveld scores, impression cytology scored by Nelson's grade and goblet cells (GCs) number/mm2 analysis, and MUC4 immunostaining, and inflammation (interleukin [IL]-1ß, IL-6, and IL-8 levels) were measured. RESULTS: Significant changes at endpoint as compared to baseline were found for Ocular Surface Disease Index score (respectively, mean±SD, 22.2±2.9 vs 38.7±12.7), Visual Analogue Scale score (3.4±1.3 vs 6.6±1.4), tear film breakup time (8.6±1.28 vs 6.17±1.9 seconds), corneal staining (National Eye Institute grade 1.23±0.64 vs 3.37±0.49), conjunctival staining (1.73±1.14 vs 4.17±0.91), impression cytology (Nelson grade 1.10±0.20 vs 1.63±0.54), and GC density (139.9±22.0 vs 107.8±16.2 GC/mm2). IL-1ß, IL-6, and IL-8 tear levels showed a significant decrease at endpoint as compared to baseline (respectively, pg/mL tears: 12.3±6.9, 26.6±25.2, 743.5±477.7 vs 33.6±17.3, 112.0±24.3, 1,139.2±671.7). CONCLUSIONS: A decrease in ocular discomfort symptoms, surface damage, and tear cytokine levels was shown after 2 months' treatment with trehalose/hyaluronate tear substitute in DE patients, along with a significant GC density recovery. These results may be associated with the synergic action of both trehalose and hyaluronic acid in targeting different entries of the DE vicious loop.

Steroid intra-trochlear injection for the treatment of acquired Brown syndrome secondary to trochleitis.

PURPOSE: To evaluate the outcomes of early intra-trochlear steroid injections in patients with acquired Brown syndrome secondary to trochleitis (ABSST). METHODS: Retrospective analysis from medical charts of patients diagnosed as affected by unilateral ABSST from January 2008 to June 2015, and treated according to our Institution protocol: intra-trochlear injection of 1ml of triamcinolone acetonide 40 mg/ml is performed under sterile conditions. In cases of no resolution/improvement within 1 month, further monthly injections are performed up to a maximum number of three. Non-responder patients after three injections undergo recession of the superior oblique muscle. RESULTS: Thirteen patients were diagnosed as affected by unilateral ABSST, and were included in the analysis (seven F, six M; median age at diagnosis 30.38 ± 25.56 years). The mean time interval from ABSST diagnosis to the first steroid injection was 7.84 ± 5.40 days (range 2-17). After a median number of 1.30 injections per patient, 11 patients (84.6% of the total) showed complete remission of symptoms and signs within 22.45 ± 13.85 days after the first injection. None of these responder patients referred to diplopia in primary gaze after injections. The remaining two non-responder patients after three injections underwent superior oblique muscle recession of 8.0 mm. CONCLUSIONS: Early intra-trochlear steroid injections are effective in patients with acquired Brown syndrome secondary to trochleitis, leading to a complete recovery of signs and symptoms in the majority of treated patients. Surgical treatment should be limited only to patients non-responding to serial steroid injections.

Efficacy of 2-Month Treatment With Cord Blood Serum Eye Drops in Ocular Surface Disease: An In Vivo Confocal Microscopy Study.

PURPOSE: To investigate the morphological changes of corneal epithelium and subbasal nerves by in vivo confocal microscopy in patients with ocular surface disease (OSD) treated with cord blood serum (CBS) eye drops. METHODS: Twenty patients with OSD (mean age 61.1 ± 12.6 years) were included in this prospective 1-arm study and treated with CBS eye drops for 2 months. Corneal sensitivity, Schirmer test score, breakup time, subjective symptoms [Ocular Surface Disease Index (OSDI) and Visual Analogue Scale (VAS)], and corneal staining were evaluated before (T0) and after (T1) treatment. In vivo confocal microscopy analyzed giant epithelial cells, subbasal nerve number and tortuosity, neuromas, beading, and dendritic cells (DCs) in the central cornea. RESULTS: OSDI, Visual Analogue Scale, and Oxford grading values significantly decreased at T1 versus T0 (respectively, 44.1 ± 18.9 vs. 74.2 ± 13.9; 3.7 ± 1.5 vs. 8.9 ± 0.9; and 2.4 ± 1.1 vs. 3.3 ± 1.3; P < 0.0001), whereas corneal sensitivity, Schirmer test score, and breakup time significantly increased (respectively, 49.5 ± 2.6 vs. 47.9 ± 2.9; 3.2 ± 2.0 vs. 2.4 ± 2.2; 4.6 ± 3.1 vs. 3.8 ± 2.1; P < 0.0001). Corneal nerve morphology improved at T1 versus T0 with a higher total nerve number (3.4 ± 1.6 vs. 2.5 ± 1.6 per frame) and lower tortuosity (3.0 ± 0.7 vs. 3.5 ± 0.6) (P < 0.01). The number of patients presenting with giant epithelial cells, beading, and neuromas decreased at T1. DC density did not change after treatment. The detection of neuromas and higher DC density at T0 were associated with greater OSDI reduction at T1 (P < 0.001). CONCLUSIONS: CBS eye drops significantly improved corneal nerve morphology and subjective symptoms in patients with severe OSD. The presence of neuromas and higher dendritic cell density at baseline were associated with greater reduction of discomfort symptoms after treatment.

Hydroxychloroquine for treatment of rheumatoid arthritis: multifocal electroretinogram and laser flare-cell photometry study.

PURPOSE: To evaluate early changes in multifocal electroretinogram (mfERG) and subclinical aqueous humor flare and cellularity in patients receiving hydroxychloroquine (HCQ) as treatment for rheumatoid arthritis. METHODS: Ten patients receiving treatment with HCQ and no ophthalmic symptoms were enrolled. After complete ocular examination, mfERG and laser flare-cell photometry were performed. Patients were also divided into two subgroups with HCQ cumulative dose (CD) higher or lower than 500 g. Results obtained were compared with a control group of ten healthy subjects and statistical analysis was performed. RESULTS: In patients receiving HCQ treatment, mfERG P1-wave in ring 2 showed a significant reduction in amplitude and a significant increase in latency compared to healthy control subjects, respectively resulting in 1.143 µV vs 1.316 µV (P=0.040) and 38.611 ms vs 36.334 ms (P=0.024). These changes are highly related to CD. Furthermore, when using the laser flare-cell photometry, a significant increase in aqueous humor flare and cellularity was shown in patients with CD higher than 500 g, resulting in a mean value of 14.4 ph/ms compared to 8.1 ph/ms in patients with CD lower than 500 g (P=0.0029). These reports appear highly related to CD (P=0.001). Receiver operating characteristic curve analysis showed mfERG P1-wave amplitude in ring 2 as the most sensitive value in detecting early HCQ-related retinopathy. CONCLUSION: MfERG was shown to be a very sensitive test in detecting early retinal toxicity and should be used for the screening of patients receiving HCQ treatment. Although less sensitive, laser flare-cell photometry can provide further information to evaluate early toxic retinal cell damage.

SacLab: A toolbox for saccade analysis to increase usability of eye tracking systems in clinical ophthalmology practice.

PURPOSE: Many open source software packages have been recently developed to expand the usability of eye tracking systems to study oculomotor behavior, but none of these is specifically designed to encompass all the main functions required for creating eye tracking tests and for providing the automatic analysis of saccadic eye movements. The aim of this study is to introduce SacLab, an intuitive, freely-available MATLAB toolbox based on Graphical User Interfaces (GUIs) that we have developed to increase the usability of the ViewPoint EyeTracker (Arrington Research, Scottsdale, AZ, USA) in clinical ophthalmology practice. METHODS: SacLab consists of four processing modules that enable the user to easily create visual stimuli tests (Test Designer), record saccadic eye movements (Data Recorder), analyze the recorded data to automatically extract saccadic parameters of clinical interest (Data Analyzer) and provide an aggregate analysis from multiple eye movements recordings (Saccade Analyzer), without requiring any programming effort by the user. RESULTS: A demo application of SacLab to carry out eye tracking tests for the analysis of horizontal saccades was reported. We tested the usability of SacLab toolbox with three ophthalmologists who had no programming experience; the ophthalmologists were briefly trained in the use of SacLab GUIs and were asked to perform the demo application. The toolbox gained an enthusiastic feedback from all the clinicians in terms of intuitiveness, ease of use and flexibility. Test creation and data processing were accomplished in 52±21s and 46±19s, respectively, using the SacLab GUIs. CONCLUSIONS: SacLab may represent a useful tool to ease the application of the ViewPoint EyeTracker system in clinical routine in ophthalmology.

Horner Syndrome Following Thyroid Surgery: The Clinical and Pharmacological Presentations.

PURPOSE: To report the clinical and pharmacological findings of a patient with iatrogenic Horner syndrome (HS) which occurred after thyroid surgery. CASE REPORT: A 29-year-old man was referred to our emergency ward due to anisocoria and unilateral eyelid ptosis reported by the patient immediately after a recent thyroidectomy for a papillary carcinoma. Ophthalmologic examination revealed 3 mm ptosis of the right eyelid. In dim illumination, the right and left pupil size was measured 3 and 6 mm, respectively. In bright illumination, the amount of anisocoria decreased; the near pupillary reaction was intact. Brain and neck magnetic resonance imaging and chest radiography were normal. Pharmacological tests with 10% cocaine, 1% hydroxyamphetamine and 1% phenylephrine localized the interruption of the oculosympathetic pathway with postganglionic third-order neuron involvement. After 6 months of follow-up, no sign of recovery was recorded. CONCLUSION: Despite HS could appear to be a rare complication of thyroid surgery, it is of importance for the neck surgeons to be aware that oculosympathetic pathway (OSP) is a potentially vulnerable structure with close anatomical relationship with the thyroid gland, and for the ophthalmologists that HS may occur secondary to neck surgery and taking an accurate history is mandatory.

Accommodative spasm might influence surgical planning and outcomes in acute acquired distance esotropia in myopia.

INTRODUCTION: Acute acquired distance esotropia (AADE) is a poorly understood moderate-angle strabismus, affecting young adult myopes and determining bothersome diplopia. Symptoms can be intermittent in the early stages, becoming constant in long-lasting disease. Symptomatic therapy includes prism correction, while surgery is the only curative treatment. However, the latter is affected by high rate of symptoms recurrence with the frequent need for reoperation. HYPOTHESIS: We hypothesize that AADE could be caused by the increase of the accommodative demand, often secondary to a myopic overcorrection. This condition could determine an increase in induced hyperopia at near, dominated by an excess of accommodation and therefore of convergence. The latter cannot be relaxed at distance and diplopia develops. We speculate that early-stage AADE could be successfully treated by cycloplegic eye drops slowly tapered within three months. On the other hand, surgery remains the only option in long-lasting AADE. In these cases, we propose a new pre-operative assessment of esotropia by asking the patient to fix alternatively a stimulus at near and at distance in order to stimulate the accommodative convergence. This technique allows to unmask the total amount of the angle of deviation and to plan a wider bilateral medial rectus muscle recession avoiding long-term residual esotropia. DISCUSSION: Currently, AADE curative therapy is surgical regardless of onset time but it is usually affected by poor outcomes. If our hypothesis was to be confirmed, pharmacological treatment could solve early-stage AADE, avoiding any surgery. Furthermore, a wide bilateral medial rectus muscle recession, quantified on the basis of the above mentioned test for measuring the total amount of the strabismus angle, could improve outcomes eliminating the need for reoperation in long-lasting AADE.

Ocular-surface temperature modification by cataract surgery.

PURPOSE: To analyze ocular-surface temperature changes after microincision cataract surgery and to correlate them with surgical, clinical, and laboratory parameters. SETTING: Ophthalmology Unit, Saint Orsola-Malpighi Hospital, Bologna, Italy. DESIGN: Prospective case series. METHODS: Patients affected by monolateral senile cataract were examined preoperatively and 7 days and 28 days postoperatively. Infrared thermography was used to measure the temperature soon after eye opening, the temperature after 10 seconds of sustained eye opening, and the difference between these 2 values in the central cornea, nasal limbus, and temporal limbus. The Ocular Surface Disease Index (OSDI), Schirmer test, vital staining, tear breakup time (TBUT), conjunctival scraping cytology, exudated tear-serum albumin, and laser flare-cell meter examinations were performed. RESULTS: The study comprised 26 patients (10 men, 16 women). The temperature changed significantly after surgery. The temperature soon after eye opening showed cooling in the central cornea and nasal limbus and heating in the temporal limbus. The temperature after 10 seconds of sustained eye opening minus the temperature soon after eye opening increased in all regions. The temperature after 10 seconds of sustained eye opening minus the temperature soon after eye opening in the central cornea was inversely related to the OSDI and directly related to TBUT. The temperature soon after eye opening increased in the temporal limbus and was directly related to inflammatory indices. CONCLUSIONS: The ocular-surface temperature changed after cataract surgery depending on the region analyzed. The cooling in the central cornea could be related to the increased tear-film instability. The heating in the temporal limbus could be related to postoperative inflammation. FINANCIAL DISCLOSURE: None of the authors has a financial or proprietary interest in any material or method mentioned.

Long-lasting corneal endothelial graft rejection successfully reversed after dexamethasone intravitreal implant.

Graft rejection is the most significant complication corneal transplantation and the leading indication for overall corneal transplantation. Corticosteroid therapy represents the mainstay of graft rejection treatment; however, the optimal route of administration of corticosteroid remains uncertain. We report herein for the first time the multimodal imaging of a case of long-lasting corneal endothelial graft rejection successfully reversed 3 months after dexamethasone intravitreal implant. A 29-year-old Asian female presented with a long-lasting corneal endothelial graft rejection in her left phakic eye. She underwent penetrating keratoplasty for advanced keratoconus 24 months before presentation. Hourly dexamethasone eyedrops, daily intravenous methylprednisolone, and one parabulbar injection of methylprednisolone acetate were administered during the 5 days of hospitalization. However, the clinical picture remained approximately unchanged despite therapy. By mutual agreement, we opted for the off-label injection of dexamethasone 0.7 mg intravitreal implant in order to provide therapeutic concentrations of steroid for a period of ~6 months. No other concomitant therapies were prescribed to the patient. Visual acuity measurement, slit lamp biomicroscopy, anterior segment photography, confocal microscopy, anterior segment optical coherence tomography, laser cell flare meter, intraocular pressure measurement, and ophthalmoscopy were performed monthly for the first postoperative 6 months. Three months after injection, both clinical and subclinical signs of rejection disappeared with a full recovery of visual acuity to 20/30 as before the episode. Currently, at the 12-month follow-up visit, the clinical picture remains stable without any sign of rejection, recurrence, or graft failure. Dexamethasone intravitreal implant seems to be a new potential effective treatment for corneal graft rejection, particularly in case of poor compliance or lack of response to conventional treatment. In addition, it could be especially useful in diabetic patients unable to receive systemic steroids.

Intolerant contact lens wearers exhibit ocular surface impairment despite 3 months wear discontinuation.

PURPOSE: To evaluate ocular surface (OS) parameters recovery in intolerant contact lens (CL) wearers after a period of discontinuation. METHODS: This is a retrospective analysis of data from 87 intolerant CL wearers who had discontinued their use for an average period of 12 weeks because of associated discomfort and failure to successfully refit. Data were collected from clinical charts. Data from 50 matched healthy volunteers served as controls. Clinical tests included subjective discomfort symptoms questionnaire (Ocular Surface Disease Index, OSDI), Schirmer test, break-up time (BUT), corneal esthesiometry and corneo-conjunctival staining. Laboratory tests included scraping and imprint cytology. Tear protein analysis included dosage of total tear protein (TP), lysozyme-C (LYS-C), lactoferrin (LACTO), zinc-α2-glycoprotein (ZAG-2), IgA heavy chain bands (Ig-A), and serum albumin (ALB). Data were correlated to wear parameters. RESULTS: All values were significantly worse in intolerant CL wearers group (p always <0.001). In particular, lower values compared to controls were found for BUT, corneal esthesiometry, goblet cell density, LYS-C, LACTO, ZAG-2, and TP. On the contrary, higher values compared to controls were found for OSDI, staining, imprint cytology, scraping cytology, ALB, IgA-heavy chain. The IgA/LYS-C ratio calculated as an index of the increased activity of the IgA-producing cell was found significantly higher in the intolerant group and in correlation with discomfort symptoms. CONCLUSIONS: Ocular surface parameters were altered in intolerant CL wearers, even after a prolonged discontinuation period. Our data suggest that OS recovery necessary to successfully refit lenses may need a discontinuation time longer than 3 months.

Dry Eye Disease Is Already Present in Hematological Patients Before Hematopoietic Stem Cell Transplantation.

PURPOSE: To analyze ocular surface parameters in patients before hematopoietic stem cell transplantation (HSCT) and to correlate them with hematological characteristics. METHODS: This is a retrospective analysis of prospectively collected data from 203 patients undergoing HSCT. Demographic data and hematological parameters (disorder type and stage) were collected from clinical charts. Ocular surface parameters (ocular surface disease index; Schirmer test I; tear film break-up time; corneal esthesiometry; and corneal and conjunctival staining) were analyzed the day before beginning the conditioning treatment for HSCT preparation. RESULTS: A high prevalence of dry eye (DE) was found: 116 patients (57.2%) were diagnosed as not suffering from DE, whereas 87 patients (42.8%) were diagnosed as having DE. Of these, 26 were classified as dry eye workshot (DEWS) severity score 1, 46 as DEWS score 2, and 15 as DEWS score 3. Tear film break-up time was found to be the only parameter statistically worse in the chronic lymphoproliferative disorder group compared with the stem cell malignancy group. Older age [odds ratio (OR) 1.03], female sex (OR 2.03), advanced stage of hematological disease (OR 1.4), and previous auto- or allo-HSCT (OR 1.9) showed a significant positive association in predicting DE onset before transplantation. CONCLUSIONS: DE was already present in a significant number of patients suffering from hematological disease before HSCT. Some hematological parameters seemed to influence this percentage. These results highlight the role of ocular surface examination by an ophthalmologist in hematological patients before HSCT, with the aim of diagnosing and, if necessary, treating DE patients early.

Targeting growth factor supply in keratopathy treatment: comparison between maternal peripheral blood and cord blood as sources for the preparation of topical eye drops.

BACKGROUND: Epitheliotrophic growth factors (GF) can be supplied topically to patients with severe keratopathy through a variety of blood-derived products. We compared GF content in adult peripheral blood serum (PB-S) and cord blood serum (CB-S) as potential sources of GF. To limit inter-individual variability the assessment was performed in maternal-child pairs at the time of delivery. MATERIAL AND METHODS: The amounts of epidermal GF (EGF), insulin-like GF (IGF), transforming GF-beta (TGF-ß), vascular endothelial GF (VEGF) in CB units collected from the umbilical vein and PB from mothers (each group n=30) were estimated by enzyme-linked immunosorbent assays. Obstetric characteristics and haematological data were recorded from the archives of the Emilia Romagna Cord Blood Bank. Statistical evaluations were performed by Wilcoxon's test and correlations between variables were determined using Spearman's (ρ) coefficient; p-values <0.05 were considered statistically significant. RESULTS: EGF, TGF-ß and VEGF levels were significantly higher in CB-S than in PB-S (median 1,254.4 vs 646.0 pg/mL, 51.3 vs 38.4 µg/mL and 686.8 vs 30 pg/mL, respectively; all p<0.0001) whereas IGF content was significantly higher in PB-S than in CB-S (159.9 vs 53.5 pg/mL, respectively; p<0.0001). In CB-S, the CD34(+) cell concentration appeared to be related to EGF, IGF and TGF-ß levels whereas white blood cell count appeared to be related to EGF and TGF-ß levels. VEGF levels showed no relation to the haematological parameters considered. Platelet counts were not related to GF level in either CB or PB. DISCUSSION: The GF content in the two blood sources was different, with CB containing larger amounts. Each GF selectively regulates cellular processes involved in corneal healing, so the use of PB or CB should be targeted to supply specific GF on the basis of the type and severity of the keratopathy.