CAPSULaser - a new modality in the portfolio of cataract surgeons.

To assess the efficiency and safety of capsulorhexis with CAPSULaser in comparison with standard capsulorhexis performed manually by emerging and established surgeons. Specialized Eye Hospital-Varna Bulgaria. Prospective, randomized, non-masked study. Patients were randomized to the M group (manual CCC), L group (laser CCC), and 2 surgeons. The manual CCC was targeted at 5.5 mm. The laser CCC was sized at 5.3 mm and measured with the same caliper device during photomicroscopy. The inclusion criteria were otherwise healthy eyes with cortical, nuclear, or subcapsular cataracts of any maturity with a biomicroscopically deep anterior chamber and preoperative pupil wider than 6.5 mm. The surgical time was measured for the entire procedure and only for capsulotomy. Sixty eyes of 60 patients, aged 65.8 ±â€…11 years, were prospectively recruited. Two surgeons (one with 3 years and one with 30 years of experience) performed the same types and number of procedures. The experienced surgeon was 2 times faster when performing manual capsulorhexis, but the time for CAPSULaser was almost the same. The size of the "laser" CCC was planned to be 5.3 and ended up with a minimum of 5.4 in 4 weeks; however, no lens prolapse from the CCC was observed. Utilization of the CAPSULaser in cataract surgery is easy and achievable for surgeons at any stage of their careers and provides controlled, well-centered capsulorhexis with no more adverse events than conventional surgery. The limitations are the requirement for a minimal pupil size of 6 mm, a deep anterior chamber, and a transparent cornea.

Damage of the ocular surface from indoor suntanning-Insights from in vivo confocal microscopy.

PURPOSE: To evaluate the ocular surface at the microstructural level of adults who habitually undertake indoor-suntanning utilising in vivo confocal microscopy. METHODS: Participants were prospectively recruited and enrolled into either а study group (n = 75) with a history UV indoor tanning, or a control group (n = 75) with no prior history of artificial tanning. The study group participated in voluntary tanning sessions performed with standard equipment and maintained their usual routine for eye protection. Slit lamp biomicroscopy and in vivo confocal microscopy were performed at baseline before undertaking a series of suntanning sessions (10 sessions of 10 min duration over a 15 day period), within three days after the last session, and four weeks after the last session. Control group participants were examined at baseline and 8 weeks later and did not participate in tanning sessions. RESULTS: All participants were female with a mean age of 25 ± 4 years and 24 ± 4 years in the study and control groups, respectively. No clinically significant changes were observed in either group over time using slit lamp biomicroscopy (all p ≥ 0.05), however, statistically significant differences were observed between the study and the control group for all corneal layers imaged using confocal microscopy (all p ≤ 0.03). Characteristic cystic conjunctival lesions with dark centres and bright borders were observed in 95% of the study group before and in 100% after the suntanning sessions. CONCLUSION: Indoor suntanning resulted in statistically significant microstructural changes in the cornea and the bulbar conjunctiva that are undetectable with slit lamp biomicroscopy.

UV damage of the anterior ocular surface - microstructural evidence by in vivo confocal microscopy.

PURPOSE: To evaluate and describe the microstructural changes at the ocular surface in response to habitual ocular sun exposure, correlate them with the UV protection habits and follow their dynamics using in vivo confocal microscopy(ICM). METHODS: For a period of minimum 4 months 200 subjects (400 eyes), aged 28 ±â€¯7.3 years, were recruited with the agreement that they will spend their summer exclusively in the region of the Black Sea coast at 43 °N latitude and will be examined before and after the summer. All subjects filled in a questionnaire about habitual UV protection and were examined clinically and by ICM. RESULTS: Questionnaire results demonstrated that 83.5% (167 participants) of the subjects considered the sun dangerous for their eyes, but 78% (156 subjects) believed that there is danger exclusively during the summer period. Although no clinical changes were detected, microstructural analysis of the cornea demonstrated statistically significant (p = 0.021) decrease of the basal epithelial density - from 6167 ±â€¯151 cells/mm2 before to 5829 ±â€¯168 cells/mm2 after the summer period. Microstructural assessment of the conjunctiva demonstrated characteristic cystic lesions with dark centres and bright borders encountered in only 25 eyes(6%) before, and affecting 118 eyes(29.5%) after the summer. The total area of the cysts after the summer increased fivefold. Spearman analysis proved negative correlation between sun protection habits and number of cysts. CONCLUSION: Summer sun exposure for one season leads to clinically undetectable, microstructural changes affecting the cornea, bulbar and palpebral conjunctiva with transient, but possibly cumulative nature.

In vivo confocal microstructural analysis of corneas presenting Kayser-Fleischer rings in patients with Wilson's disease / Análise microestrutural confocal in vivo de córneas apresentando anel de Kayser-Fleischer em pacientes com doença de Wilson

ABSTRACT Purpose: To evaluate microstructural differences between corneas with and without Kayser-Fleischer rings in age-matched subjects with Wilson's disease with neurological symptoms, using confocal laser scanning microscopy. Methods: The study included 12 subjects with Wilson's disease with neurological symptoms. Twelve corneas presented clinically with classic Kayser-Fleischer rings, visible on slit lamp examination; the other 12 served as controls. The subjects underwent a comprehensive clinical examination. Microstructural analysis using confocal laser scanning microscopy evaluated increased corneal thickness, decreased number of cells, increased debris or specific deposits, and unusual microstructures. Results: Clinically, the subjects with Kayser-Fleischer rings had similar corneal findings and normal intraocular pressure; two had typical sunflower cataracts and decreased visual acuity. The control eyes all presented normal visual acuity, intraocular pressure, and corneal appearance. The microstructural analysis demonstrated similar findings in all the affected corneas. Compared with the control corneas, there were fewer keratocytes in the anterior stroma (17.380 vs. 22.380/mm3). Round, "hollow" dark areas were observed between the keratocytes; these were universal and similar in appearance in all affected corneas and all cornea layers. In the peripheral posterior stroma, there were dust-like, bright, granular deposits that tended to increase in number and density toward Descemet's membrane, masking the peripheral endothelium. The control corneas presented a normal microstructure apart from dust-like granular deposits in the periphery. Conclusions: In vivo confocal microscopy is a useful tool for evaluating the corneal microstructure when a Kayser-Fleischer ring is clinically present. The ring consists of granular, bright particles that increase in density toward Descemet's membrane, and is associated with a decreased number of keratocytes and peculiar dark, round areas in all stromal layers, probably a sign of corneal damage. When the ring is not visible in subjects with Wilson's disease, changes to the corneal microstructure are insignificant.

RESUMO Objetivo: Avaliar, ao nível microestrutural, através de microscopia confocal in vivo a lazer, 12 córneas com anel de Kayser-Fleischer visível ao exame da lâmpada de fenda e compará-las com 12 córneas clinicamente normais de indivíduos com idades correspondentes aos pacientes com doença de Wilson e sintomas neurológicos. Métodos: O estudo incluiu 12 indivíduos com doença de Wilson e sintomas neurológicos (24 córneas). Doze córneas apresentavam clinicamente o anel clássico de Kayser-Fleischer e as outras 12 serviram como controle. Todos os pacientes foram submetidos a um exame clínico abrangente e a uma análise microestrutural subsequente utilizando microscopia confocal in vivo de varredura a laser. Os principais resultados observados foram: aumento da espessura da córnea, diminuição do número de células, aumento de resíduos/depósitos específicos e microestrutura atípica. Resultados: Clinicamente, todos os indivíduos com anel de Kayser-Fleischer (12 olhos) apresentaram achados similares da córnea e pressão intraocular normal. Dois indivíduos também apresentaram uma catarata de girassol típica e diminuição da acuidade visual. Todos os olhos do grupo controle apresentaram acuidade visual, pressão intraocular e aparência corneana normais. A microscopia confocal in vivo com varredura a laser revelou achados semelhantes em todas as córneas afetadas. O número de ceratócitos no estroma anterior era menor, 17.380/mm3 (22.380/mm3 no grupo controle), e entre eles foram identificadas áreas escuras arredondadas "vazias". Essas zonas escuras eram generalizadas e similares em todas as córneas examinadas e em todas as camadas da córnea. No estroma posterior periférico, havia presença de depósitos granulares brilhantes e com aparência de pó que tendiam a aumentar em número e densidade no sentido da membrana de Descemet, mascarando o endotélio periférico. As córneas controle apresentaram estrutura normal, com exceção de depósitos granulares com aparência de pó na periferia. Conclusões: A microscopia confocal in vivo é uma ferramenta útil para a avaliação da microestrutura da córnea quando o anel de Kayser-Fleischer está clinicamente presente. O anel é constituído de partículas granulares brilhantes com densidade aumentada no sentido da membrana de Descemet. Sua presença está associada com uma diminuição do número de ceratócitos e com áreas circulares escuras "peculiares" em todas as camadas estromais, que representam, provavelmente, um sinal de dano da córnea. Quando o anel não está clinicamente visível, a estrutura da córnea in vivo encontra-se insignificantemente alterada.

Exclusion of known corneal dystrophy genes in an autosomal dominant pedigree of a unique anterior membrane corneal dystrophy.

PURPOSE: With advances in phenotyping tools and availability of molecular characterization, an increasing number of phenotypically and genotypically diverse inherited corneal dystrophies are described. We aimed to determine the underlying causative genetic mechanism in a three-generation pedigree affected with a unique anterior membrane corneal dystrophy characterized by early onset recurrent corneal erosions, small discrete focal opacities at the level of Bowman layer and anterior stroma, anterior stromal flecks, and prominent corneal nerves. METHODS: Twenty affected and unaffected members of a three-generation family were examined and extensively clinically characterized including corneal topography and in vivo confocal microscopy, and biological specimens were collected for DNA extraction. Mutational analysis of two corneal genes (TGFBI [Transforming Growth factor-beta induced] and ZEB1 [zinc finger E box-binding homeobox 1]) was undertaken, in addition to testing with the Asper Corneal Dystrophy gene chip (Asper Ophthalmics, Tartu, Estonia). Subsequent Genotyping To 11 Known Corneal Gene Loci (COL8A2 [Collagen, Type VIII, Alpha-2], TACSTD2 [Tumor-Associated Calcium Signal Transducer 2], PIP5K3 [Phosphatidylinositol-3-Phosphate 5-Kinase, Type III], GSN [Gelsolin], KERA [Keratocan], VSX1 [Visual System Homeobox Gene 1], COL6A1 [Collagen, Type VI, Alpha-1], MMP9 [Matrix Metalloproteinase 9], KRT3 [Keratin 3]), and two putative loci, 3p14-q13 and 15q22.33-24) was undertaken using polymorphic markers, and haplotypes constructed. Multipoint linkage analysis was performed to generate LOD scores and produce LOD plots across the candidate intervals. RESULTS: No pathogenic sequence variations were detected in TGFBI or ZEB1 of the proband nor on the Asper Corneal Dystrophy gene chip (302 mutations in 12 genes). Multipoint linkage analysis of 11 known corneal genes and loci generated negative LOD plots and was able to exclude all genes tested including PIP5K3. CONCLUSIONS: Exclusion of linkage to candidate corneal loci combined with an absence of pathogenic mutations in known corneal genes in this pedigree suggest a different genetic causative mechanism in this dystrophy than the previously documented corneal genes. This unique phenotype of an anterior membrane dystrophy may therefore provide an opportunity to identify a new gene responsible for corneal disease.

Imaging the microstructural abnormalities of meesmann corneal dystrophy by in vivo confocal microscopy.

PURPOSE: To delineate the microstructural features of Meesmann corneal dystrophy using in vivo confocal microscopy. METHOD: Three subjects with clinically diagnosed Meesmann corneal dystrophy were examined by slit-lamp biomicroscopy and slit-scanning in vivo confocal microscopy. RESULTS: On slit-lamp biomicroscopy, all subjects demonstrated large bilateral multiple epithelial cystic lesions extending to the midperiphery. On in vivo confocal microscopy, these lesions appeared as hyporeflective areas in the basal epithelial layer. The majority were circular, oval or teardrop shaped and ranged between 48 mum and 145 mum in diameter. Large elongated intraepithelial clefts were also seen. Reflective spots were visible within most of the lesions and these may represent the fibrillogranular material (termed peculiar substance) and tonofilament bundles observed in electron microscopy studies. An additional finding was the fragmented appearance of the subbasal nerve plexus. CONCLUSION: We present the first case series of Meesmann corneal dystrophy imaged by in vivo confocal microscopy and describe the associated microstructural features. Delineation of these features facilitates the use of the confocal microscope to aid diagnosis and management of corneal dystrophies.

Surgical detachment of Descemet's membrane and endothelium imaged over time by in vivo confocal microscopy.

A 90-year-old woman developed a large circular capsulorhexis-like defect in Descemet's membrane as a complication of small incision cataract surgery. Nine months post-surgery, in vivo confocal microscopic examination of the temporal mid-peripheral cornea revealed an endothelial cell density of 934 +/- 69 cells/mm2 (normal range 1566-3088 cells/mm2). Endothelial pigmented deposits were visible as scattered hyper-reflective areas on the posterior endothelial surface. Descemet's folds were also noted. In vivo confocal microscopy performed 3 years later showed the temporal mid-peripheral corneal endothelial density (in the region of the break) was 948 +/- 66 cells/mm2. A reduction of endothelial polymegathism and pleomorphism was observed. Imaging in the region of the temporal portion of the original Descemet's defect showed well-defined linear structures with hyper-reflective edges. Compared to 3 years previously, the cornea at the level of Descemet's membrane appeared to have greater reflectivity. This case demonstrates how microstructural changes in the cornea can be described and analysed over time with the assistance of in vivo confocal microscopy.

Keratoglobus and posterior subcapsular cataract: surgical considerations and in vivo microstructural analysis.

We report sporadic, bilateral keratoglobus associated with posterior subcapsular cataract in a 43-year-old man. Slitlamp biomicroscopy showed symmetric arcus senilis-like deposits, a polygonal appearance resembling crocodile shagreen, an unusual endothelial appearance, and posterior subcapsular cataract. Orbscan II pachymetry maps (Bausch & Lomb) demonstrated bilateral diffuse corneal thinning (359.53 microm +/- 21.15 [SD] in the right eye and 379.61 +/- 11.49 microm in the left eye). These thickness values were confirmed by ultrasound pachymetry. In vivo confocal microscopy showed multiple criss-crossing dark lines and no identifiable cellular elements within the stroma. There were mild to moderate, guttata-like endothelial changes surrounded by pleomorphic cells. Phacoemulsification was performed in the left eye after careful consideration of the presenting features and modification of the surgical technique. Minimal structural alteration was observed during microstructural analysis 7 months after surgery. The endothelial morphology postoperatively was similar to that at baseline.

In vivo confocal microstructural analysis and surgical management of Brown-Mclean syndrome associated with spontaneous crystalline lens luxation.

We report 3 members of an extended family who presented with bilateral peripheral corneal edema consistent with Brown-McLean syndrome. On clinical examination, all eyes demonstrated normal central corneas and marked peripheral edema. In vivo confocal microscopy of the peripheral cornea highlighted similar observations in the 6 eyes including endothelial pigmentation, masked stromal structure due to edema, prominent nerves, and localized basal epithelial edema. In the central cornea, in vivo confocal microscopic observations highlighted large cellular structures with prominent nuclei in groups consisting of several cells of similar appearance. In vivo confocal microscopy may enhance the diagnosis of Brown-McLean syndrome and may be used for dynamic evaluation and postoperative follow-up of the structural corneal changes.

Analyzing small-incision cataract surgery by Orbscan II fourth-dimensional pachymetry mapping.

PURPOSE: To assess the changes in pachymetry after routine corneal and scleral tunnel phacoemulsification. SETTING: Discipline of Ophthalmology, University of Auckland, Auckland, New Zealand. METHOD: This prospective study comprised 174 eyes of 174 consecutive patients having uneventful, small-incision, sutureless, phacoemulsification cataract surgery; 124 patients had a clear corneal incision and 50, a superior scleral tunnel incision. Difference pachymetry maps were derived from Orbscan II elevation topography data obtained before and 4 weeks after surgery. Corneal thickness changes at 12 midperipheral areas located in 12 meridians were derived from difference (subtraction) maps. The mean corneal thickness within a single area corresponding to the center of the surgical incision was compared to the mean pachymetry readings of all 12 midperipheral measurements. RESULTS: The overall mean midperipheral corneal thickness (12 samples per cornea) increased by a mean of 5.89 microm +/- 16.09 (SD) in the clear corneal incision group and 6.89 +/- 14.50 microm in the scleral tunnel group. The mean central corneal thickness increased by 7.28 +/- 20.98 microm and 7.74 +/- 21.34 microm, respectively. The corneal thickness in the meridian closest to the incision was significantly higher than the mean value of the 12 meridians measured in both groups, with means of 14.95 +/- 26.86 microm in the clear corneal group (P =.001) and 16.22 +/- 21.23 microm in the scleral tunnel group (P =.002). There were no statistically significant postoperative differences in the central, midperipheral, or incision-site corneal thickness measurements between the 2 surgical techniques (P =.77). CONCLUSIONS: Time-dependent (fourth-dimensional) pachymetry subtraction maps are useful for following corneal dynamics over time. This study found that small-incision phacoemulsification techniques--scleral and corneal tunnel--had a minor but similar effect on corneal thickness 4 weeks after surgery.

Microstructural analysis of Salzmann's nodular degeneration by in vivo confocal microscopy.

A 44-year-old man with symptoms of ocular irritation and corneal changes characteristic of Salzmann's nodular degeneration in the left eye was examined using in vivo confocal microscopy. In vivo confocal microscopy highlighted an irregularly shaped basal epithelium with foci of prominent nuclei, and disrupted anterior stromal architecture with increased reflectivity of extracellular matrix within the nodules. These observations were consistent with prior histopathological descriptions of Salzmann's nodular degeneration. In vivo confocal microscopy enhances the clinicopathological assessment of degenerative corneal diseases, such as Salzmann's nodular degeneration, without the need for biopsy.

Assessing the sub-basal nerve plexus of the living healthy human cornea by in vivo confocal microscopy.

The purpose of the study was to perform quantitative analysis of the sub-basal epithelial nerve plexus of healthy, living human cornea,using real time in vivo confocal microscopy and the analySIS software system. The study was based on in vivo confocalmicrostructural analysis of 50 eyes of 50 subjects, divided into two age groups: group 1 (n = 25)25 +/- 5 years of age, and group 2 (n = 25) 70 +/- 5 years of age. All subjects exhibited clinically healthy corneas. The overall nerve density was 632.35 +/- 287.57 microm/mm2 for group 1 and 582.39 +/- 327.13 microm/mm2 for group 2. The mean fibre dia-meter was measured at 0.52 +/- 0.23 microm for group 1 and at 0.56 +/- 0.27 microm for group 2. Beadings of the nerve fibres were recorded at a density of 213 +/- 123/mm for group 1 and 201 +/- 192/mm for group 2. Establishing standards for normal nerve density and morphology of the living human cornea at different ages may be beneficial, both in early detection and follow up of various corneal diseases and in post-surgical management following corneal surgery.

The Auckland cataract study: co-morbidity, surgical techniques, and clinical outcomes in a public hospital service.

AIM: To prospectively assess cataract surgery in a major New Zealand public hospital by defining presenting clinical parameters and surgical and clinical outcomes in a cohort of subjects just below threshold for treatment, based upon a points based prioritisation system. METHODS: The prospective observational study comprised 488 eyes of 480 subjects undergoing consecutive cataract operations at Auckland Hospital. All subjects underwent extensive ophthalmic examination before and after surgery. Details of the surgical procedure, including any intraoperative difficulties or complications, were documented. Postoperative review was performed at 1 day and 4 weeks after surgery. Demographic data, clinical outcomes, and adverse events were correlated by an independent assessor. RESULTS: The mean age at surgery was 74.9 (SD 9.6) years with a female predominance (62%). Significant systemic disease affected 80% of subjects, with 20% of the overall cohort exhibiting diabetes mellitus. 26% of eyes exhibited coexisting ocular disease and in 7.6% this affected best spectacle corrected visual acuity (BSCVA). A mean spherical equivalent of -0.49 (1.03) D and mean BSCVA of 0.9 (0.6) log MAR units (Snellen equivalent approximately 6/48) was noted preoperatively. Local anaesthesia was employed in 99.8% of subjects (94.9% sub-Tenon's). The majority of procedures (97.3%) were small incision phacoemulsification with foldable lens implant. Complications included: 4.9% posterior capsule tears, 3.8% cystoid macular oedema, and one case (0.2%) of endophthalmitis. Mean BSCVA after surgery was 0.1 (0.2) log MAR units (6/7.5 Snellen equivalent), with a mean spherical equivalent of -0.46 (0.89) D, and was 6/12 or better in 88% of all eyes. A drop in BSCVA, thought to be directly attributable to the surgical intervention, was recorded in a small percentage of eyes (1.5%) after surgery. CONCLUSION: This study provides a representative assessment of the management of cataract in the New Zealand public hospital system. A predominantly elderly, female population, frequently exhibiting significant systemic illness and coexisting ocular disease, relatively advanced cataracts, and poor BSCVA, presented for cataract surgery. The majority of subjects underwent small incision, phacoemulsification, day case surgery. While almost 90% achieved at least 6/12 BSCVA post-surgery, approximately 5% sustained an adverse intraoperative event and 1.5% of eyes exhibited a reduction in BSCVA postoperatively.