Clinical Experience of Using a Combination of Dexamethasone and Levofloxacin After Cataract Surgery.

Background: Where routine prophylactic antibiotics have been adopted following cataract surgery, rates of endophthalmitis have been decreasing. Intracameral and topical antibiotics are currently used to prevent endophthalmitis after cataract surgery. When applying topical antibiotics, there are different recommendations on the frequency and duration of therapy. The development of bacterial resistance to the excessive and long-term use of antibiotics is a growing problem worldwide. The goal is to achieve a good antibiotic effect with the shortest possible use of antibiotics. Objective: The aim of this study was to compare the effectiveness of a new combination therapy of dexamethasone and levofloxacin for seven days after cataract surgery with the previous regimen of dexamethasone, neomycin sulfate, and polymyxin B, which was given for 21 days. Methods: A retrospective analysis of medical records and administered a questionnaire was conducted to assess the effectiveness of postoperative therapy in our cataract surgery patients. The study involved 52 patients who underwent surgery within the last year, performed by a single surgeon at our institution. The findings can help us improve the quality of care we provide and optimize our patients' overall quality of life. Results: We conducted an in-depth study on 52 individuals who underwent cataract surgery at our institution. The prescribed therapeutic regimen for the participants included administering Ducressa solution four times daily for the first seven days and Maxidex solution three times daily for the subsequent 14 days. The study found that none of the participants experienced complications after surgery, and all found it easy to instill the medication. The prescribed regimen effectively managed the postoperative recovery of the participants, and the medication was well-tolerated. Conclusion: Our research found that a new combination of levofloxacin and dexamethasone, when used topically, may require a shorter treatment period, reducing the risk of antibiotic resistance and providing a safe alternative for endophthalmitis prevention.

Combined Cataract and Corneal Transplantation Surgery Without Viscosurgical Devices.

Background: The most common complications after performing the triple Descemet's stripping automated endothelial keratoplasty (DSAEK), which combines the cataract phacoemulsification, intraocular lens implantation and DSAEK procedure, are detachment or decentration of the donor lamella and postoperative interface haze. One reason for this is the retained viscoelastic used during surgery. Objective: This study aimed to describe triple DSAEK procedure without the usage of viscoelastic and to discuss its potential benefits on surgical outcomes. Methods: The surgical procedures and outcomes of patients with Fuchs' dystrophy and lens opacification who underwent the triple DSAEK were retrospectively reviewed. The surgical procedure was described, and postoperative complications were studied. Results: The study included 10 eyes of 10 patients. Capsulorhexis and IOL implantation performed in locally potentiated anesthesia compared to general anesthesia did not significantly differ (P > 0,05). The mean preoperative best-corrected visual acuity was 0.75 LogMar. The mean postoperative best-corrected visual acuity was 0.2 LogMar. The central graft thickness before surgery was 129.6 µm and 6 months after surgery was 114.2 µm. Successful attachment of the donor lamellae was observed in all 10 patients. None of the patients had postoperative interface haze or any other possible viscoelastic caused complication. Conclusion: Although viscoelastic can facilitate certain aspects of the triple DSAEK procedure, we conclude that this procedure can be performed completely without its use. If performed by a trained surgeon, the procedure can be feasible without the complications of donor lamella detachment, decentration, or interface haze.

Short-Term Effect of Conventional Versus Accelerated Corneal Cross-Linking Protocol on Corneal Geography and Stability.

Purpose: To determine the 6-month effect of conventional (CXL30) and accelerated cross-linking with a UVA intensity of 9 mW/cm2 (CXL10) on corneal stability and to investigate whether there was a difference in ABCD grading system parameters regarding the two different procedures. Methods: Twenty-eight eyes of 28 patients with a documented keratoconus (KN) progression were included. Patients were selected to undergo either epi off CXL30 or CXL10. At the baseline and the follow-up visits after one (V1), three (V2), and six months (V3), the patients underwent complete ophthalmic examination and corneal tomography. Results: In the CXL30 group, all the parameters from the ABCD grading system significantly changed from baseline to V3; parameter A decreased (p = 0.048), B and C increased (p = 0.010, p < 0.001), and D decreased (p < 0.001). In the CXL10 group, there were no changes in parameters A (p = 0.247) and B (p = 0.933), though parameter C increased (p = 0.001) and D decreased (p < 0.001). After an initial decline after one month, visual acuity (VA) recovered on V2 and V3 (p < 0.001), and median maximal keratometry (Kmax) decreased in both groups (p = 0.001, p = 0.035). In the CXL30 group, there were significant changes in other parameters; average pachymetric progression index (p < 0.001), Ambrósio relational thickness maximum (ARTmax) (p = 0.008), front and back mean keratometry (p < 0.001), pachymetry apex (PA) (p < 0.001), and front elevation (p = 0.042). However, in the CXL10 group, there were significant changes only in ARTmax (p = 0.019) and PA (p < 0.001). Conclusion: Both epi-off CXL protocols showed similar short-term efficacy in improving VA and Kmax, halting the progression of KN, and both similarly changed tomographic parameters. However, the conventional protocol modified the cornea more significantly.

Pseudophakic Cystoid Macular Oedema (PCME) Prevention in Patients with Non-Proliferative Diabetic Retinopathy (NPDR)-Randomized Controlled Trial.

Background and Objectives: The purpose of this study was to compare the effect of topical bromfenac and dexamethasone on the intraocular concentration of interleukin 6 (IL-6) and incidence of pseudophakic cystoid macular oedema (PCME) after cataract surgery in patients with non-proliferative diabetic retinopathy (NPDR). Materials and Methods: Ninety eyes of patients with mild-to-moderate NPDR that underwent phacoemulsification cataract surgery were divided into three groups. A detailed description of the clinical study protocol is described later in paper. In short, Group 1 received topical bromfenac (0.9 mg/mL), Group 2 dexamethasone (1 mg/mL), and Group 3 placebo, both preoperatively and postoperatively. Additionally, all patients received combined topical steroid and antibiotic drops (dexamethasone, neomycin and polymyxin B) 3 weeks postoperatively. On the day of the surgery, aqueous humour samples (0.1-0.2 mL) were obtained and IL-6 concentrations were analysed. Central foveal subfield thickness (CFT) measured using spectral-domain optical coherence tomography (SD-OCT) was analysed preoperatively and postoperatively. Results: There was no significant difference in IL-6 concentrations between groups. Postoperative CFT was significantly lower in the dexamethasone group compared to the placebo group. In addition, the correlation between IL-6 and CFT was statistically significant in the dexamethasone group. No patient developed PCME in any of the three groups. No adverse events were reported during the study. Conclusion: Topical bromfenac and dexamethasone have no significant effect on intraocular IL-6 concentration in patients with NPDR. Topical bromfenac is not more effective than topical dexamethasone in reducing postoperative CFT in patients with NPDR.

LENS CARE COMPLIANCE RATES AND PERCEPTIONS AMONG RIGID GAS PERMEABLE CONTACT LENS WEARERS - A PILOT STUDY.

The aim was to estimate compliance rate among rigid gas permeable lens wearers (RGPLW) in lens system care, identify procedures in lens care process with poorest compliance levels, and assess concordance between participant reported practices and their subjectively perceived compliance. The study included outpatient RGPLW managed at Zagreb University Hospital Center in Zagreb, Croatia. They filled out a questionnaire that included demographic data, duration of lens wear, self-evaluation compliance grade, and 14 lens care procedures and wearing habits indicative of compliance. There were 50 patients (mean age 34.6 years, 68% female). Full compliance was found in a single patient. The mean number of non-compliant procedures was 5.48, with 32% of participants non-compliant in more than 50% of the compliance criteria. Critical procedures of the lens care process were infrequent lens case exchange (74%), using tap water for lens (70%), and improper case cleaning (68%). The mean lens case replacement time was 9.8 months (SD 6.76), with only 26% of patients replacing lens case at least once in 3 months. Excessive daily lens wear was associated with greater total number of non-compliant procedures (p<0.0008). RGPLW were aware of their inappropriate lens care only when achieved non-compliance in almost 50% of the procedures. In conclusion, lens wearers were not aware of their extremely low compliance rate in several aspects of lens and lens case maintenance. Study results indicated the key procedures the practitioners should focus on when evaluating subjective and objective compliance and reinforcing care and hygiene education of RGPLW.

Influence of Donor Thickness on Visual Acuity in Descemet's Stripping Automated Endothelial Keratoplasty.

Purpose: Conventional Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK) is a corneal transplantation procedure where the patient's inner dysfunctional layer is replaced with donor lamella. The data currently present in the literature about the correlation between lamellar thickness and visual acuity is sometimes contradictory and lacks clarity. Methods: Study included 55 eyes that underwent the conventional DSAEK procedure. Patients had no other comorbidities that could affect visual acuity. Data about lamellar thickness and visual acuity were measured six months after surgery with anterior segment optical coherent tomography (A5-OCT). Results: The results show that visual acuity before surgery improved from 0.82 to 0.25 logMAR after surgery. Better visual acuity of 0.20 logMAR was achieved with postoperative lamellas thinner than 124 µm, while statistically significantly lower visual acuity of 0.29 logMAR was gained with postoperative lamellas thicker than 124 µm. Conclusion: Our results suggest that the goal after conventional DSAEK is to have postoperative lamellas thinner than 124 µm in the eye, as this will result in better postoperative visual acuity. This value represents the optimal thickness for conventional DSAEK surgery that could minimize tissue loss for eye banks and surgeons may experience fewer problems during surgery, while obtaining good final visual acuity.

POSTOPERATIVE THINNING OF LAMELLAR DONOR GRAFT AFTER CONVENTIONAL DESCEMET'S STRIPPING AUTOMATED ENDOTHELIAL KERATOPLASTY.

- The purpose of this study was to evaluate postoperative deturgescence of lamellar donor graft after conventional Descemet's stripping automated endothelial keratoplasty (DSAEK). It was a prospective study that included 55 eyes of patients (mean age 70.9±9.4 years; female 61.8%, male 38.2%). Preoperative thickness of lamella was compared with postoperative thickness six months after surgery. Central lamellar graft thickness decreased from 142±27 µm preoperatively to 124±20 µm 6 months postoperatively (p<0.01). After performing conventional DSAEK corneal transplantation, surgeons should expect deturgescence of corneal graft and reduction in thickness of lamellae by about 12% of initial thickness according to our results. We found this information important for better planning of surgical procedures and knowing what to expect after surgery, as well as for better cooperation with eye banks when ordering pre-cut corneal tissue.

Posterior Capsule Opacification and Nd:YAG Rates with Two Acrylic Intraocular Lenses after Age-Related Cataract Treatment: Three-year Results.

OBJECTIVE: To compare the incidence and intensity of posterior capsule opacification (PCO) between two intraocular lenses (IOLs) over three years. METHODS: Eighty-three patients underwent cataract surgery with implantation of Acreos Adapt AO or Acrysof SA60AT. PCO values were assessed using a photographic image analysis system (EPCO 2000) and the amount of PCO at the slit lamp. RESULTS: Mean PCO score was 2.78 ± 1.55 for the Acreos Adapt AO and 2.32 ± 1.20 for the Acrysof SA60AT (P=.229). There were no significant differences in the median EPCO values in the entire IOL optics area (0.60 ± 0.26 vs 0.58 ± 0.23; P=.745) and in the central 3-mm zone (0.28 ± 0.13 vs 0.27 ± 0.12; P=.638). Neodymium:YAG capsulotomy was performed in 28% of eyes with Acreos Adapt AO and 23.33% with Acrysof SA60AT (P=.692). CONCLUSION: Both IOLs had comparable PCO and Nd:YAG rates three years postoperatively.

Progression of conjunctival primary acquired melanosis (PAM) to widely spreaded malignant melanoma.

Primary acquired melanosis (PAM) is an acquired pigmentation of the conjunctival epithelium, a preinvasive pigmented lesion. When it is associated with cellular atypia it can lead to the developement of melanoma. We report a case report of malignant melanoma of the conjuntiva, which arrised from the conjuntival PAM. The disease was too extensive for ocular conservation, therefore exenteration was performed. This case highlights the need for regular follow-up of patients with melanocytic lesions of the ocular adnexa, and particular attention to the surgical technique, and careful follow-up to detect further disease activity.

Effect of the against the rule myopic astigmatism on the near vision of the elderly.

In the two groups of patients with myopic astigmatism the uncorrected near vision was tested after catatract surgery. Each group with 20 patients ages 60-80. All patients enrolled in study have uncorrected far vision 0.5 or better on Snellen tables. In the first group patients were with the rule after surgery myopic astigmatism (1-1.50 Diopter), and in the second group were patients with against the rule after surgery myopic astigmatism (1-1.50 Diopter). Patients in the second group with against the rule astigmatism achieved significantly (p<0.01) better uncorrected near vision.

Comparative study of antibacterial and antifungal effects of rigid gas permeable contact lens disinfecting solutions.

The aim of this study was to compare antimicrobial efficacy of rigid contact lens disinfecting solutions. We tested five commercially available solutions: Unique pH (Alcon Laboratories), Boston Advance (Polymer Technology Corp.), Nitilens Conditioner GP (Avizor), Total Care (AMO), Boston Simplus (Bausch&Lomb). Their efficacy to disinfect saline solution experimentally contaminated with American Type Culture Collection (ATCC): Staphylococcus aureus (ATCC 25923), Escherichia coli (ATCC 25922), Pseudomonas aeruginosa (ATCC 27853), Candida albicans (ATCC 90028) and Staphylococcus epidermidis (isolated from our laboratory) was tested. All tested solutions reduced concentrations of bacteria and fungi below 1000 CFU/mL (Colony forming unit; reduction by 3 log and 1 log, respectively) after the 8 hours period. Overall, all contact lens care solutions showed good disinfecting activity against tested bacteria and fungi, with more variation in their antifungal than in antibacterial efficacy. Results of our study might be valuable when selecting appropriate solutions for non-compliant contact lens wearers.

A case of lacrimal gland dirofilariasis.

A patient with a diagnosis of chronic and idiopathic unilateral dacryoadenitis was submitted to our clinic for diagnostic reasons from a regional hospital. Within a period of 1 year, this was the second onset of a swelling in the region of the lacrimal gland which - unlike the first time - showed resistance to antibiotic treatment. The patient's general and ophthalmic condition was good, and his only complaint was of cosmetic nature because of the disfiguring swelling in the lateral part of the left upper eyelid. Basic laboratory findings showed no abnormalities and radiographic imaging showed enlargement of the left lacrimal gland without bony destruction. Guided by epidemiological data for noninfectious dacryoadenitis we decided to perform excisional biopsy of the left lacrimal gland. To our surprise, the pathologist verified the presence of a worm of the genus Dirofilaria, which is, to the best of our knowledge, the second reported case of lacrimal gland dirofilariasis in the literature and the second reported case of such a disease in Croatia.

[Orbital-bony decompression in patients with dysthyroid orbitopathy--first Croatian experiences]. / Kostana orbitalna dekompresija u pacijenata s distireoidnom orbitopatijom--prva hrvatska iskustva.

INTRODUCTION: Dysthyroid orbitopathy or Graves's orbitopathy is an entity made of symptoms and signs found within ocular apparatus, orbit and adnexal tissue in patients with thyroid dysfunction. Orbital pathogenesis is based on organ-specific autoimmune reaction, resulting in extra ocular muscle dysfunction and retro bulbar tissue changes. These changes are characterized by different stages of orbital inflammation, swelling and passive congestion. No infiltrative or inactive stage of the disease is most commonly seen in younger population as mild, orbital inflammation, lid retraction, variable proptosis and retro bulbar discomfort. Infiltrative or active stage of the disease usually affects older people and is characterized by a broad spectrum of clinical symptoms such as moderate or severe orbital inflammation, retro bulbar pain, lid retraction, periocular edema, proptosis with corneal exposure, extra ocular muscle dysfunction, conjunctival and episcleral congestion and optic nerve compression with loss of visual acuity. The current treatment concept for dysthyroid orbitopathy is to achieve euthyroidism with antithyroid drugs, radioiodine and thyroidectomy. Subsequently, for the treatment of dysthyroid orbitopathy immunosuppressive drugs such as corticosteroids, cyclophosphamide, methotrexate, cyclosporine, octreotides, orbital radiotherapy and surgical decompression can be used. Indications for orbital decompression are differentiated as urgent and elective. Current opinion is that only severe proptosis with corneal exposure and damage and compressive optic neuropathy urge orbital bony decompression combined with aggressive medical treatment. Persistent, active orbitopathy, retro bulbar discomfort or pain and disfiguring proptosis are indications for elective orbital bony decompression. Orbital bony decompression is a surgical method based on principle of opening the confined orbital bony space and allowing herniation of orbital fat into paranasal sinuses, thus decreasing orbital pressure. PATIENTS, METHODS AND RESULTS: A series of patients surgically treated for dysthyroid orbitopathy from July 2004 till November 2005, were followed-up. The group included 8 patients previously treated for thyroid dysfunction. Five patients (10 eyes) were operated on by the "swinging eyelid" approach (group 1) and three patients (6 eyes) by "inferomedial approach" (group 2). In group 1 proptosis reduction occurred in all patients, varying from 4 to 6 mm within 6-10 months postoperatively; retrobulbar pain or discomfort decreased in all patients few days after the surgery; and 2 patients still felt numbness in the n. infraorbitalis innervation area at 10 months of follow up. In group 2, all patients had proptosis reduction by 3-4 mm within 6-10 months postoperatively; retro bulbar discomfort disappeared in all patients a few days after the surgery. In this group none of the patients complained of infraorbital numbness 6 months of the surgery. All patients filled out a brief questionnaire before and 4 months after the surgery, ranking their symptoms and complaints. CONCLUSION: Our patient series was rather small and selected, the data obtained are not representative of larger series. Based on these preliminary results and current literature data, we believe that orbital bony decompression is a highly effective, safe and quick procedure, easily adjustable to the surgeon as well as to the patient in achieving optimal results. We also believe that there is a need of better education of our patients considering the disease itself and treatment modalities through patient support groups or better physician-patient-nurse communication.

[Ocular findings in Fabry's disease]. / Fabryjeva bolest i promjene na ocima.

INTRODUCTION: Fabry's disease is a recessive X-linked disorder that results from a deficiency of the lysosomal hydrolase a-galactosidase A (alpha-Gal A). The absence of alpha-Gal A enzyme activity leads to accumulation of glycosphingolipid globotryaosyl ceramide (GL-3) in the lysosomes of a variety of cell types. Subsequently, angiokeratoma and ocular signs develop until, in most cases after the third decade of life, severe renal dysfunction or cardiomyopathy becomes obvious. Corneal opacities (cornea verticillata) occur in 90% conjunctival vascular changes in 60%, retinal vessel tortuosity in 55%, and cataracts in 50% of cases. Recently, enzyme replacement therapy has been shown to be an effective treatment modality that can eliminate glycolipid stores and reverse the disease pathology. CASE REPORT: A male patient born in 1971 was admitted for clinical examination due to proteinuria and erythrocyturia. During further evaluation nephrologist suspected Fabry's disease, because patient had skin changes early referred as petechiae, and acroparesthesias. He had also low heat tolerance and virtually no sweat. Physical status: angiokeratoma on gluteat regions and upper arms. Urine analysis in several occasions 10-15 E in sediment, alb. positive. On ECG, 2-mm depression of ST in precordial region. Heart ultrasound: low mitral regurgitation angio stage 1, left ventricle hypertrophy. Abdomen ultrasound: both kidneys around 12 cm large, parapyelic cysts in both kidneys of 2.5 cm in diameter. Biomicroscopy of both eyes: cornea verticillata. Fundus of both eyes: papillae n. optici with poorly defined edges, but without prominence, very tortuotic retinal blood vessels. In March 2002, very low alpha GAL enzyme activity in blood (alpha-Gal A = 0.5 +/- 0.2 nmol of substrate hydrolyzed hourly per serum mL--normal serum enzyme level 8.5-18.9 nmol/mL/h). In May 2002, enzyme replacement therapy was started with recombinant alpha-Gal A enzyme (Fabrazyme) 1 mg/kg every 14 days. Control evaluation and examination showed good cardiac and renal function. The patient felt better and stronger with improved heat tolerance. CONCLUSION: Fabry's disease occurs in all ethnic groups. It is estimated that one in 200 people is a carrier, and one in 40,000-100,000 has the disease. Today in Croatia, Fabry's disease has been diagnosed in only one patient, and according to the usual prevalence there are still 45-100 unrecognized patients. The ophthalmologists are in excellent position to diagnose Fabry's disease in early stages. Therefore it is very important that the ophthalmologists in Croatia become aware of the importance of ocular findings in Fabry's disease, so they can participate in the identification of unrecognized patients.

Were today's professors good students? Case study of the Zagreb University School of Medicine.

AIM: To determine whether the medical school grades of today's professors at the Zagreb University School of Medicine could serve as the predictors of their subsequent academic success. METHODS: We performed a retrospective descriptive study of medical school grades of professors and/or assistant professors at the Zagreb University School of Medicine from 1990 to 2003. The professors were divided into four groups according to the course they taught: Basic Science, Clinical Non-Surgery, Clinical Surgery, and Public Health. In total, data for 297 professors were analyzed. RESULTS: Today's professors were above-average students. The analysis of grades of professors teaching different disciplines revealed that Basic Science professors were the best students, followed by Non-Surgery and Surgery professors, whereas Public Health professors were the worst. Grades that professors earned in Public Health courses were the highest, followed by grades in Non-Surgical and Surgical courses. The grades in Basic Science courses were the lowest. CONCLUSION: Professors at the Zagreb University School of Medicine were above-average students and their grades seem to be important predictors of future success in academic career. Among today's professors, Basic Science professors were the best students.

Is there grade inflation at medical schools? Case study of the Zagreb University School of Medicine.

AIM: To investigate if students' grades at the Zagreb University School of Medicine increased since the establishment of the School in 1917. METHODS: In this retrospective descriptive study, we analyzed student sex, the length of studying, average of all grades, and grades from 5 major courses--anatomy, physiology, pathology, internal medicine, and surgery. The passing grades at the Zagreb University range from 2 (sufficient) to 5 (excellent). We analyzed data for 2,861 students from 9 representative classes, enrolled in 1920, 1930, 1940, 1950, 1960, 1970, 1980, 1985, and 1990. RESULTS: The number of female students constantly increased up to 1970 and hereafter the female to male ratio remained stable, 60:40. The percentage of enrolled students who graduated from the School increased from 1920 to 1940 and from 1960 to 1985. Between 1940 and 1960, the percentage of students who graduated was lower than 50%. There was a continuous increase in grades during the investigated period (p<0.001), except for students enrolled in 1960, who had lower grades than those enrolled in 1950. Students who enrolled in 1990 also had lower grades than those enrolling in 1985. Grades from the individual courses mostly followed the increasing trend of total grades. CONCLUSION: There has been an increasing trend in grades at the Zagreb University School of Medicine since its establishment in 1917.

Zagreb University School of Medicine: students grades during war.

AIM: To investigate whether examination grades of the students at the Zagreb University School of Medicine changed during the 1991-1995 war in Croatia. METHODS: The retrospective descriptive study included examination grades from 5 major courses in the first 5 years of the medical studies: Anatomy (first year), Physiology (second year), Pathology (third year), Internal Medicine (fourth year), and Surgery (fifth year). We compared the war-period (1991-1995) with two control periods: before (1989-1990) and after the war (1996-2000). The passing grades at the Zagreb University range from 2 to 5, with 2 as the lowest and 5 as the highest grade. There were a total of 17,682 examinations from the 5 courses in the studied periods. RESULTS: Grades were higher in the pre-war and post-war periods than in the war period (p<0.001 for both comparisons). Grades in the individual courses followed the general trend, except for the surgery course, where grades during the war were better than in the control periods, and the physiology course, where continual worsening, irrespective of the war, was observed. CONCLUSION: Medical students obtained significantly lower grades in 5 major courses during the war than before or after it. Thus, it is reasonable to assume that different factors, some related and some unrelated to war, could have adversely influenced students performance.