Donor Characteristics in Graft Detachment after Posterior Lamellar Keratoplasty for Fuchs Endothelial Dystrophy and Bullous Keratopathy.

Background: Descemet Membrane Endothelial Keratoplasty (DMEK) has been widely adopted to treat Fuchs endothelial dystrophy (FED) and Bullous keratopathy (BK). Graft detachment (GD) is one of the common earliest post-operatory complications, and it is usually recovered by Air Rebubbling (ARB). Methods: Retrospectively, we investigated predictive factors related to GD between January 2016 and March 2020, a pre-COVID era, in 72 patients, 72 eyes, and their donors' lamellar characteristics, focusing on donor's cause of death. The patients were divided according to the posterior lamellar keratoplasty technique adopted. Results: GD and consequent ARB were most common but not significantly prevalent in DMEK (p = 0.11). It was more common in FED for both surgical approaches. Only in BK treated with DSAEK were host steeper mean astigmatism (p = 0.03) and donors with smaller graft pre-cut diameters (p = 0.02) less likely to be related to GD. Regarding donor's cause of death, only cardiovascular accident could be related to GD in BK treated with DMEK (p = 0.04). Conclusions: Our study shows that the conventional match between pathology and corneal lenticule is not sufficient to prevent ARB. Donor's cause of death can impair graft and host attachment. In particular, cardiovascular death may impair the efficiency of donors' endothelial cells, inducing GD after DMEK in BK.

Scedosporium apiospermum contact lens-related keratitis: a case report and literature review.

Background: Scedosporium apiospermum (SA) is commonly present in temperate climates. It can induce cutaneous and subcutaneous tissue infections as well as disseminated infections in immunocompromised or immunocompetent hosts. The eye is rarely involved. Keratomycosis is usually caused by plant-related injuries. Here, we describe a patient with a severe and sight-threatening corneal abscess caused by SA, which was associated with contact lens wear and was successfully treated with a combination of surgical and medical therapies. Case Presentation: An otherwise healthy 22-year-old woman, with history of contact lens wearing, was referred to the Ophthalmic Department of Bari University, Bari, Italy for evaluation of a corneal abscess and hypopyon in her left eye. Intensive topical and systemic antibiotic therapy was initiated after obtaining con- junctival swabs. Within 2 days, her ophthalmic condition had worsened, and her best-corrected visual acuity (BCVA) dropped to counting fingers. She underwent penetrating keratoplasty, after which her ophthalmic condition improved. Microbiological culture, obtained from the explanted cornea, revealed SA infection. This was addressed with specific topical and systemic therapy using voriconazole. Two weeks later, the con- dition of her left eye was stable, with mild corneal edema and no sign of acute graft rejection. Her BCVA improved to 20/25, and all medications were discontinued, except for the steroid eye drop. The patient was scheduled for a 1-month follow-up. Conclusions: Prompt identification of the etiological agent is mandatory to perform appropriate therapy in cases of keratomycosis. Surgery to remove the infected cornea is helpful in patients with deteriorating condition, in whom the initial medical therapy has failed. Topical and systemic antimycotic therapy, based on microbiological culture, is recommended as an adjunctive therapy for the surgical management of severe corneal mycotic abscesses.

Graft Detachment After Descemet's Stripping Automated Endothelial Keratoplasty in Bullous Keratopathy and Fuchs Dystrophy.

Descemet's stripping automated endothelial keratoplasty (DSAEK) is a surgical technique for corneal transplantation in case of corneal decompensation. One of the main complications is graft detachment (GD) recoverable with Air Re-bubbling (ARB). The aim of this retrospective, interventional case series was to identify factors related to this complication in eyes operated for bullous keratopathy (BK) and Fuchs dystrophy (FD). We considered one-hundred patients who underwent DSAEK for BK or FD between January 2016 and October 2017 at Department of Ophthalmology, Policlinico Universitario of Bari, Italy. Studied parameters included physiological and pathological anamnesis of both donors and recipients and properties of donor's lenticules and of the recipient's corneas. Data was analyzed using One-way ANOVA with Tukey post hoc test and Chi-square test with Odds Ratio (OR) calculation. We grouped patients according to diagnosis. GD occurred in 9 eyes affected by BK and 19 by FD (p=0.003, OR = 0.25, 95% CI, 0.098-0.62). It was recovered with ARB. In BK, ARB correlated to complicated cataract extraction (p=0.04, OR = 7.83, 95% CI, 1.28 - 47.98) and aphakia (p=0.026, OR = 54.38, 95% CI, 2.51 - 11.76). In FD, ARB was associated to donor's death for neoplasia (p=0.06, OR= 4.04, 95% CI, 1.06 - 15.37). No other differences were found. In conclusion, we could hypothesize that in FD patients, donor's cancer therapy may play a role on altered corneal fibroblast metabolism, activating a synergetic effect between chemotherapy and genetic alteration of FD, which may lead to an altered adhesion of donor's lenticule on recipient's stroma. In BK patients, complicated cataract extraction and aphakic status of recipients' eye may contribute to altered adhesion of donor's lenticule post-DSAEK.

Topical nonsteroidal anti-inflammatory drugs as adjuvant therapy in the prevention of macular edema after cataract surgery.

PURPOSE: The purpose of the study was to assess adjuvant treatment with topical nonsteroidal anti-inflammatory drugs (NSAIDs) (0.9 % bromfenac, 0.1 % nepafenac, 0.5 % indomethacin, or 0.1 % diclofenac) in addition to topical steroidal treatment with 0.1 % dexamethasone and 0.3 % netilmicin for prevention of cystoid macular edema (CME) after uneventful small incision cataract extraction with foldable intraocular lens (IOL) implantation. SETTING: Institute of Ophthalmology, Department of Scienze Mediche di Base, Neuroscienze ed Organi di Senso, Aldo Moro University, Policlinico Consorziale di Bari, Bari, Italy. DESIGN: A retrospective 6-month single center study. METHODS: Patients were divided into groups according to treatment with topical drugs for 2 weeks, after phacoemulsification with foldable IOL implantation. CME incidence was evaluated by assessing retinal foveal thickness changes using spectral domain optical coherence tomography. All patients were treated with a fixed combination of dexamethasone and netilmicin, and some patients were additionally treated with NSAIDs (bromfenac, nepafenac, indomethacin, or diclofenac). RESULTS: Fourteen patients were treated with bromfenac, 15 with nepafenac, 12 with indomethacin, and 14 with diclofenac; ten patients were treated with dexamethasone and netilmicin alone. At the end of the follow-up, macular thickness, evaluated at 1-week post-surgery, was reduced only in the group treated with nepafenac (-1.3 %, p = 0.048), was increased in the group treated with dexamethasone and netilmicin alone (+4.3 %, p = 0.04), and did not change in the groups treated with bromfenac (-1.1 %, p = 0.3), indomethacin (+0.1 %, p = 0.19), or diclofenac (+1.2 %, p = 0.74). There were no side effects in any group. CONCLUSIONS: Topical treatment with nepafenac, bromfenac, and indomethacin enhanced the efficacy of steroids to reduce postoperative macular edema. Diclofenac did not improve steroids efficacy.

Ex-Press Mini-Implant in the Management of Ocular Hypertension Secondary to Silicone Oil Tamponed.

This study was designed to compare the success of patients with ocular hypertension, secondary to pars plana vitrectomy and silicone oil tamponade, who received an Ex-PRESS Glaucoma Filtration Device P50 (Alcon Laboratories, Inc. Fort Worth, Texas, USA) to those who had conventional trabeculectomy. The records of 10 eyes of 10 consecutive subjects who had Ex-press implants and 9 eyes of 9 consecutive controls who had trabeculectomy procedures were reviewed. Success was defined as the reduction of intraocular pressure (IOP) in patients who did not require further glaucoma surgery in the eye of note during the entire follow-up. IOP was reduced by 10.3 ± 9.7 mmHg (range -31 to 3) in the Ex-PRESS group and by 13.9 ± 11.4 mmHg (range -35 to -4) in the trabeculectomy group. The difference in the percentage of IOP reduction between the standard trabeculectomy group (42.7%) and the Ex-PRESS group (35.9%) was not statistically significant (P = 0.72). The Ex-PRESS device seems to be at least as effective as the standard trabeculectomy in lowering the IOP of patients with hypertension secondary to pars plana vitrectomy and silicone oil tamponade. Even though the data suggested that the Ex-PRESS device did not result in an overall greater reduction in IOP than trabeculectomy, this does not reach statistical significance.

Surgical reposition of a dislocated Ex-PRESS miniature device.

PURPOSE: To present a technique of surgical reposition of the Ex-PRESS miniature glaucoma device when dislocated in corneal limbus. METHODS: A 54-year-old woman diagnosed with glaucoma, with a 3-month history of Ex-PRESS miniature implant, was referred to our department because of progressive intraocular pressure (IOP) rise. Slit-lamp biomicroscopy showed the posterior flange of the implant located in the corneal limbus; IOP was 34 mmHg. Surgical technique consisted of reopening of the conjunctiva and the scleral flap, excision of the corneal tissue covering the flange, and stitching the implant to the sclera with polyprolene suture. RESULTS: Postoperatively, IOP rapidly reduced to 5 mmHg and was balanced to 10 mmHg in the follow-up. CONCLUSIONS: Corneal dislocation of the Ex-PRESS implant, when associated with ocular hypertension, needs surgical treatment. Before considering a trabeculectomy, it could be valuable to attempt an implant reposition.

Masquerade syndrome of multicentre primary central nervous system lymphoma.

Purpose. In Italy we say that the most unlucky things can happen to physicians when they get sick, despite the attention of colleagues. To confirm this rumor, we report the sad story of a surgeon with bilateral vitreitis and glaucoma unresponsive to traditional therapies. Methods/Design. Case report. Results. After one year of steroidal and immunosuppressive therapy, a vitrectomy, and a trabeculectomy for unresponsive bilateral vitreitis and glaucoma, MRI showed a multicentre primary central nervous system lymphoma, which was the underlying cause of the masquerade syndrome. Conclusions. All ophthalmologists and clinicians must be aware of masquerade syndromes, in order to avoid delays in diagnosis.

Hemorrhagic Macular Infarction After Intravitreal Bevacizumab for Central Retinal Vein Occlusion.

Intravitreal bevacizumab for macular edema secondary to central retinal vein occlusion may induce resolution of macular edema. However, the possibility of a rebound macular edema thicker than at the initial presentation after intravitreal bevacizumab injections has been reported. A case of dramatic deterioration of central retinal vein condition with hemorrhagic macular infarction 3 weeks after intravitreal injection of bevacizumab is presented.

Combined cataract extraction and intravitreal bevacizumab in eyes with choroidal neovascularization resulting from age-related macular degeneration.

PURPOSE: To evaluate the safety and efficacy of phacoemulsification, intraocular lens (IOL) implantation, and a single intravitreal injection of bevacizumab in patients with coexisting visually significant cataract and subfoveal neovascularization due to age-related macular degeneration. SETTING: Department of Ophthalmology, University of Bari, Bari, Italy. METHODS: Eyes with predominantly classic subfoveal neovascularization and cataract had phacoemulsification, IOL implantation, and a 1.25 mg intravitreal injection of bevacizumab. One month after combined surgery, corrected distance visual acuity (CDVA), anterior chamber reaction, and intraocular pressure were evaluated and central foveal thickness was measured by optical coherence tomography. RESULTS: Twenty eyes of 20 patients were evaluated. One month postoperatively, the mean CDVA improved significantly, from 20/100 (range 20/160 to 20/80) at baseline to 20/63 (range 20/125 to 20/50) (P<.0001). The mean central foveal thickness decreased significantly, from 353.75 microm +/- 12.50 (SD) (range 334 to 375 microm) at baseline to 275.7 +/- 17.3 microm (range 255 to 323 microm) at 1 month (P<.0001). Intraocular pressure did not change significantly, and anterior chamber reaction was absent. No ocular or systemic adverse events were observed. CONCLUSION: Combined phacoemulsification, IOL implantation, and intravitreal bevacizumab was a safe and efficacious treatment in patients with visually significant cataract and active subfoveal neovascularization.

Treatment of recurrent retinal angiomatous proliferation with intravitreal triamcinolone acetonide followed by photodynamic therapy with verteporfin: A retrospective case series.

OBJECTIVE: The aim of this study was to report the effect on tolerability of combined treatment with intravitreal triamcinolone acetonide (IVT) and photodynamic therapy (PDT) with verteporfin in patients with stage II retinal angiomatous proliferation (RAP) who had been treated previously with PDT and presented with recurrent RAP (R-RAP). METHODS: This was a retrospective case series of patients with R-RAP after PDT (1-5 treatments) treated once with IVT followed 1 month later by PDT. A visual acuity test, fluorescein and indocyanine green angiography, and optical coherence tomography were performed at baseline and at 1, 3, and 6 months. RESULTS: Five patients (4 men, 1 woman; mean [SD] age, 76.8 [3.9] years) with 6 eyes diagnosed with stage II R-RAP who had previously been treated with PDT and who received an IVT injection and PDT within 1 month were included in the study. Best corrected visual acuity (BCVA) remained stable after IVT in 5 eyes (83%) and deteriorated in 1 eye (17%). After PDT, BCVA remained stable in 2 eyes (33%) and deteriorated in 4 eyes (67%). IVT treatment combined with PDT also reduced fluorescein leakage. Median lesion size increased 24% before PDT and 61% at 6 months after PDT. One eye had intraocular hypertension at 3 months, and 1 eye developed a pigment epithelial tear after PDT. CONCLUSION: The results were limited by the number of eyes and relatively short follow-up, but in this study, PDT after IVT did not appear to be as effective or well tolerated in 5 patients who had already been treated with PDT and presented with R-RAP.

Intravitreal bevacizumab for treatment-naïve subfoveal occult choroidal neovascularization in age-related macular degeneration.

PURPOSE: This study aimed to evaluate the efficacy of multiple injections of intravitreal bevacizumab for treatment-naïve subfoveal occult choroidal neovascularization (CNV) in age-related macular degeneration (AMD). METHODS: Twelve eyes of 12 patients (mean age 76 +/- 6 years) with mean best corrected visual acuity (BCVA) of 20/100 and occult subfoveal CNV at fluorescein angiography (FA), indocyanine-green (ICG) angiography and optical coherence tomography (OCT), showing intra- or subretinal fluid with or without retinal pigment epithelial detachment (PED), underwent multiple intravitreal injections (mean 2.4 +/- 0.7) of 1.25 mg (0.05 ml) bevacizumab. Visual acuity and OCT findings were assessed at the end of follow-up. RESULTS: After a mean follow-up of 5.7 +/- 2 months, BCVA improved from 20/100 (range 20/50-20/303) to 20/60 (range 20/28-20/200) (p = 0.038). Five eyes (42%) increased BCVA by > or = 3 lines, six eyes (50%) increased BCVA by < 3 lines and one eye (8%) remained stable. Macular thickness decreased from 298 +/- 71 microm to 223 +/- 72 microm (p = 0.017). No ocular or systemic side-effects were observed. CONCLUSIONS: Short-term results suggest that multiple intravitreal injections of 1.25 mg bevacizumab are well tolerated and associated with significant improvements in BCVA and decreased retinal thickness by OCT in most patients with treatment-naïve occult CNV. Further evaluation of intravitreal bevacizumab for the treatment of occult CNV is warranted.

In vivo evidence of hypotrophic ciliary body in ocular ischemic syndrome by ultrasound biomicroscopy.

In ocular ischemic syndrome, the ischemic condition is due to markedly reduced blood flow and increased vascular resistance of retrobulbar circulation, as in the central retina and posterior ciliary arteries. Chronic hypoxia affects even the iris and ciliary body. The hypoperfusion of the ciliary body leads to a relative hypotony, presumably related to decreased aqueous humor production. Histopathologic study has demonstrated ciliary body atrophy on an ischemic basis. The authors used ultrasound biomicroscopy to demonstrate in vivo the hypotrophic condition of the ciliary body in ocular ischemic syndrome.

Combined radial optic neurotomy, internal limiting membrane peeling, and intravitreal triamcinolone acetonide for central retinal vein occlusion.

To evaluate the efficacy of radial optic neurotomy, internal limiting membrane peeling, and intravitreal triamcinolone acetonide for central retinal vein occlusion. Eight consecutive eyes with central retinal vein occlusion with a duration of less than 6 months, cystoid macular edema, and best-corrected visual acuity (BCVA) of less than 20/200 were enrolled. BCVA, intraocular pressure, fluorescein angiography, and optical coherence tomography were evaluated. After 4.75 +/- 0.7 months, BCVA significantly improved, intraocular pressure was well controlled, and fluorescein angiography showed perfused state and reduction of the number of retinal hemorrhages in all eyes. Optical coherence tomography revealed significant reduction of macular thickness. Bleeding in the neurotomy site occurred in 3 cases. Radial optic neurotomy, internal limiting membrane peeling, and intravitreal triamcinolone acetonide may be useful in the management of central retinal vein occlusion with macular edema.

Phacoemulsification with transpupillary silicone oil removal and lens implantation through a corneal incision using topical anesthesia.

PURPOSE: To evaluate phacoemulsification combined with transpupillary silicone oil removal and foldable intraocular lens (IOL) implantation through a single corneal incision and planned posterior capsulorhexis after pars plana vitrectomy using topical anesthesia. SETTING: Department of Ophthalmology, University of Bari, Bari, Italy. METHODS: This noncomparative nonrandomized noncontrolled interventional case series comprised 34 consecutive patients (34 eyes). The mean age of the 25 men and 9 women was 54.4 years +/- 13.3 (SD). A mean of 8.2 +/- 9.4 months after silicone oil injection, patients had phacoemulsification with transpupillary silicone oil removal and foldable acrylic IOL implantation through a single corneal incision and a planned posterior capsulorhexis under topical anesthesia. Patients were operated on by the same surgeon. Visual acuity, the frequency of retinal redetachment, secondary cataract and vitreous hemorrhage formation, subjective pain and discomfort, the duration of surgery, and intraocular pressure (IOP) were noted. The mean follow-up was 9.4 +/- 5.1 months (range 4 to 21 months). RESULTS: Vision improved or stabilized in 88.2% of eyes. Retinal redetachment occurred in 4 eyes (11.8%) and transient vitreous hemorrhage in 1 (2.9%). All patients reported minimal discomfort during the procedure. The mean duration of surgery was 17 +/- 4 minutes. There was no significant intraoperative or postoperative IOP variation. CONCLUSIONS: Combined phacoemulsification, transpupillary silicone oil removal, and IOL implantation through a single corneal incision under topical anesthesia was safe and effective. In general, the visual outcomes were good with improvement in visual acuity.

Evaluation of corneal damage by combined phacoemulsification and passive efflux of silicone oil in vitrectomized eyes.

PURPOSE: To evaluate the effect on the corneal endothelium of phacoemulsification combined with passive silicone oil removal and intraocular lens (IOL) implantation under topical anesthesia after pars plana vitrectomy. SETTING: Department of Ophthalmology and Otolaryngology, University of Bari, Bari, Italy. METHODS: This retrospective study evaluated the corneal endothelium in 17 consecutive patients (17 eyes) who had phacoemulsification with transpupillary passive silicone oil washout (1300 centistokes) through a posterior capsulorhexis and single clear corneal incision and foldable acrylic IOL implantation. The findings were compared with those in a control group of 17 patients (17 eyes) who had phacoemulsification with acrylic IOL implantation through a single clear corneal incision. All procedures were performed by the same surgeon using topical anesthesia. The preoperative and postoperative endothelial cell densities, coefficient of variation (CV), and percentage of hexagonal cells at the corneal center and peripheral temporal position, evaluated by noncontact specular microscopy, were compared between the 2 groups. The central corneal thickness and occurrence of keratopathy were also noted. RESULTS: The mean phacoemulsification and total ultrasound times did not differ significantly between the 2 groups. At 6 months, the mean endothelial cell loss was 284.50 cell/mm(2) +/- 462.3 (SD) (11.2%) in the study group and 200.15 +/- 117.9 cell/mm(2) (8.3%) in the control group (P=.87, unpaired t test). There were no significant between-group differences in the increase in the mean CV and the percentage of hexagonal cells. The mean pachymetry remained at preoperative values, with no difference between groups. Keratopathy was not observed in any patient. CONCLUSIONS: Passive silicone oil efflux caused significant endothelial cell loss and changes in endothelial morphology. Nevertheless, these modifications were well tolerated and minimally different from the results of trauma caused by standard phacoemulsification with posterior chamber IOL implantation.

Triamcinolone-assisted pars plana vitrectomy for proliferative vitreoretinopathy.

PURPOSE: To determine whether triamcinolone acetonide (TAAC) staining facilitates posterior hyaloid and epiretinal membrane (ERM) removal in patients undergoing pars plana vitrectomy (PPV) for rhegmatogenous retinal detachment (RRD) with proliferative vitreoretinopathy (PVR). METHODS: Ten consecutive pseudophakic patients (10 eyes) underwent PPV for RRD with PVR. After a core PPV, a few drops of a commercially available TAAC aqueous suspension (40 mg/mL) with vehicle were injected into the mid vitreous cavity to visualize the posterior hyaloid, thus allowing a complete posterior hyaloidectomy. Next, 0.1 to 0.2 mL of TAAC was applied on the retinal surface to visualize and peel the ERMs. The tamponading agent was silicone oil (1,300 cs) in eight eyes and perfluropropane (C3F8 14%) in two eyes. The minimal follow-up period in all patients was 4 months. RESULTS: In all patients, intraoperative staining with TAAC consistently improved direct visualization and delineation of the posterior hyaloid and ERMs and facilitated their removal. No adverse reaction related to the use of TAAC was observed immediately postoperatively or 4 months after surgery. CONCLUSIONS: Intravitreal TAAC may be an important adjuvant tool in the delineation of posterior hyaloid and ERMs, allowing for a more complete and safer ERM removal in the surgical management of PVR complicating RRD. It is well tolerated with all its vehicle if used at low concentration and rapidly removed during surgery.

Frequency-doubling perimetry after photorefractive keratectomy.

PURPOSE: To evaluate the effect of photorefractive keratectomy (PRK) on frequency-doubling perimetry (FDP) patterns in myopic patients without glaucoma. SETTING: Department of Ophthalmology, University of Bari, Bari, Italy. METHODS: Sixteen myopic patients (16 eyes) with a spherical equivalent worse than -7.0 diopters were enrolled. The fellow eyes were used as controls. All patients had PRK for myopia. Using FDP, the mean defect (MD) and pattern standard deviation (PSD) were evaluated preoperatively and 2 weeks and 3 and 6 months after PRK. At the same examinations, the effect of the reprofiled cornea on the visual field was studied; the cornea was divided into 4 concentric zones (central, paracentral, lateral, and peripheral) and each median zone contrast sensitivity (MZCS) evaluated. RESULTS: There was no difference in PSD and MZCS between treated eyes and controls in any zone at any time (P >.05). Longitudinally, there was no variation in any perimetry zone (P >.05). In treated eyes, there was a significant relationship among ablation depth, MD, and MZCS in all zones until 2 weeks after laser surgery (P <.02). CONCLUSIONS: Frequency-doubling perimetry did not appear to be affected by corneal changes induced by PRK and can therefore be safely used in the early diagnosis of glaucoma.

Visual discomfort after acrylic intraocular lens implantation.

A 64-year-old man had phacoemulsification in both eyes. In January 1998, an Allergan SI-30NB silicone intraocular lens (IOL) with a 6.0 mm optic was implanted in the right eye. In April, an Alcon AcrySof MA60BN acrylic IOL with a 6.0 mm optic was implanted in the left eye. The following October, the patient experienced visual discomfort in the left eye. Two superior radial minikeratotomies were performed. The patient continued to have visual discomfort and the next month, a topographic ablation was performed in the same eye. In January 2000, the left IOL was replaced with a 5.5 mm Allergan SI-55NB silicone IOL. Visual impairment resolved 1 day after surgery.