Late-Onset Chronic Corneal Fistula Following Phototherapeutic Keratectomy: A Case Report and Importance of Early Detection.

BACKGROUND We report a case of late-onset chronic fistula in a decompensated cornea after multiple ocular surgeries and a recent phototherapeutic keratectomy (PTK). CASE REPORT A 73-year-old woman presented to our service with a past ocular history of bilateral chronic angle closure glaucoma and pseudophakic bullous keratopathy in the left eye. Given a history of long-term uncontrolled glaucoma with advanced disc cupping and poor visual potential, the patient underwent multiple palliative procedures, including, most recently, a PTK. Few years later she presented with a spontaneous late onset of slowly appearing corneal leak on fluorescein staining upon routine clinical examination. Corrected distance visual acuity was hand motion and intraocular pressure (IOP) was 40 mmHg in the affected eye. Serial anterior segment optical coherence tomography (AS-OCT) sections were obtained, which aided in understanding the current presentation and revealed distinctive multilayer corneal changes during the healing process. The patient was successfully managed with cyanoacrylate corneal gluing and ocular hypotensive medications, which halted the corneal leak. CONCLUSIONS We report a case of a rare finding of corneal fistula in an eye with multiple previous ocular surgeries, and provide an explanation of the possible etiopathogenesis. We also highlight the pivotal role of AS-OCT for evaluating such cases and stress the importance of early detection of similar subtle leaks in the setting of a formed anterior chamber, which can often be missed, carrying a risk of infection.

Micropulse Laser Therapy as an Integral Part of Eye Disease Management.

Ocular diseases can significantly impact vision and quality of life through pathophysiological alterations to the structure of the eye. The management of these conditions often involves a combination of pharmaceutical interventions, surgical procedures, and laser therapy. Laser technology has revolutionized many medical fields, including ophthalmology, offering precise and targeted treatment options that solve some of the unmet needs of other therapeutic strategies. Conventional laser techniques, while effective, can generate excessive thermal energy, leading to collateral tissue damage and potential side effects. Compared to conventional laser techniques, micropulse laser therapy delivers laser energy in a pulsed manner, minimizing collateral damage while effectively treating target tissues. The present paper highlights the advantages of micropulse laser therapy over conventional laser treatments, presents the implications of applying these strategies to some of the most prevalent ocular diseases, and highlights several types and mechanisms of micropulse lasers. Although micropulse laser therapy shows great potential in the management of ocular diseases, further research is needed to optimize treatment protocols, evaluate long-term efficacy, and explore its role in combination therapies.

A comparison between topical and retrobulbar anesthesia in 27-gauge vitrectomy for vitreous floaters: a randomized controlled trial.

BACKGROUND: To compare the safety and efficacy of topical anesthesia versus retrobulbar anesthesia in 27-gauge pars plana vitrectomy (PPV) for vitreous floaters. METHODS: 30 patients with vitreous floaters were randomized into Group T (topical anesthesia, proparacaine eye drop) and Group R (retrobulbar anesthesia), and underwent 27-gauge PPV. A 5-point visual analogue pain scale (VAPS) was used to assess patients' pain experience of anesthesia and surgery procedure (during surgery, 2 h and 1 day after surgery). RESULTS: The VAPS of anesthesia procedure was 1.27 ± 0.59 for patients in Group R, while it was all 0 for patients in Group T (p < 0.001). There was no significant difference for VAPS during surgery (Group T: 1.13 ± 0.74, Group R: 0.67 ± 0.62, p = 0.67), 2 h (Group T: 0.80 ± 1.01, Group R: 0.67 ± 0.62, p = 0.67) and 1 day (Group T: 0.20 ± 0.41, Group R: 0.27 ± 0.46, p = 0.68) after surgery between these two groups. Only one patient (6.7%) in Group T required additional topical anesthesia during the surgery. Most of the patients reported the pain experience came from initial trocar insertion in both groups. None of the patients required post operative analgesia in both groups. No intraoperative or postoperative complications were noted in both groups. CONCLUSION: This study suggested that topical anesthesia is a safe and effective anesthetic approach for patients with floaters who underwent 27-gauge PPV. TRIAL REGISTRATION: ClinicalTrials.gov NCT03049163 . Registered 8 February 2017.

Effectiveness of meibomian gland massage combined with topical levofloxacin against ocular surface flora in patients before penetrating ocular surgery.

OBJECTIVE: To investigate the bacterial profile in the conjunctiva and meibomian glands in patients before penetrating ocular surgeries, and to compare the anti-bacterial efficacy of 0.5% levofloxacin and its combination with meibomian gland massage. DESIGN: Hospital-based, case-control study. PARTICIPANTS: Two hundred and twenty-six eyes from 226 patients with non-infective ocular diseases and scheduled for penetrating ocular surgeries. METHODS: Tested eyes were administered topical 0.5% levofloxacin (4 times daily) for 2 days. Among them, 91 eyes received meibomian gland massage before levofloxacin application. Samples from the conjunctival sac and meibomian glands were collected for aerobic and anaerobic cultures. MAIN OUTCOME MEASURES: Culture-positivity and bacterial strains. RESULTS: Before treatment, aerobes and anaerobes were cultured from 38.5% and 11.0% of the conjunctival samples respectively, compared with 38.5% and 8.8% in the meibomian secretions respectively. Staphylococcus epidermidis and Propionibacterium acnes were the commonest isolated aerobe and anaerobe. Two-day application of levofloxacin reduced aerobic growth to 29.6% in the conjunctiva and 19.3% in the meibomian glands. It had no effect on the anaerobes in these regions (13.3% in the conjunctiva and 10.4% in the meibomian glands). Combined levofloxacin with meibomian gland massage further reduced aerobic growth to 19.8% in the conjunctiva and 11.0% in the meibomian glands. It also drastically decreased anaerobic growth in the meibomian glands (1.1%). CONCLUSIONS: Meibomian glands carrying considerable bacteria should be considered as a potential source of contamination in ocular surgery. Meibomian gland massage shows additional anti-bacterial effects to topical levofloxacin and could be recommended as a complementary preoperative prophylaxis.

¿Qué debemos hacer hoy y qué hacemos en CMA de oftalmología? / No disponible

No disponible

Two-Port Pars Plana Anterior and Central Core Vitrectomy (Lam Floaterectomy) in Combination With Phacoemulsification and Intraocular Lens Implantation Under Topical Anesthesia for Patients with Cataract and Significant Floaters: Results of the First 50 Consecutive Cases.

PURPOSE: To study the safety and efficacy of 2-port pars plana anterior and central core vitrectomy (Lam floaterectomy) in combination with phacoemulsification (phaco) and intraocular lens implantation (IOL) for patients with cataract and significant floaters under topical anesthesia. DESIGN: Retrospective review of the first 50 consecutive cases. METHODS: A standardized treatment protocol was used for patients with cataract and significant (moderate to severe) floaters (duration > 3 months). Data analysis included intraoperative and postoperative complications, floater status, and patient satisfaction. RESULTS: There were 50 eyes (38 patients) with a male-to-female ratio of 1 to 2.3. Twelve patients had bilateral eye surgeries. Mean age was 58.10 ± 9.85 years (range, 39-83). All patients completed the 3-month follow-up. One eye had mild vitreous hemorrhage at the end of surgery arising from sclerotomy wound oozing. No other intraoperative compli-cations were encountered. Postoperatively, there was 1 case of transient hypotony and 1 case of congestion at sclerotomy wound. No cases of retinal break or detachment, or clinically significant macular edema, were reported. There were 5 cases (10%) of mild residual floaters and 1 case (2%) of floater recurrence. Total floater clearance rate was 88%. Patient satisfaction rates were 80%, 14%, 6%, and 0% for very satisfied, satis-fied, acceptable, and unsatisfied, respectively. CONCLUSIONS: The 3-month results in terms of safety and efficacy of the Lam floaterectomy in combination with phaco and IOLfor patients with cataract and significant floaters under topical anesthesia are encouraging. Further larger-scale, prospective, multicenter studies seem warranted.

Free amino acids: an innovative treatment for ocular surface disease.

Amino acids are the basic constituents of living organisms, and have both a structural and an active dynamic role in tissue and cell physiology. Human tears contain 23 amino acids, the relative proportion of which may change with the different physiological states of the eye surface. In this review, we present a collection of data from the published literature that indicate an active role of amino acids in the maintenance of eye surface homeostasis. Moreover, another series of published clinical data indicate that supplementation of amino acids, either as food supplements or as a topical treatment in enriched eye drops, is beneficial to the eye surface, and may improve its healing in cases of eye surface disease due to different causes.

Nasal Floor Mucosa: New Donor Site for Mucous Membrane Grafts.

PURPOSE: Mucous membrane grafts are used for various indications in oculoplastics. The authors report the use of nasal floor mucosa as a new donor site for mucous membrane grafts. METHODS: Following adequate anesthesia and vasoconstriction, the nasal floor is visualized with a 30° endoscope. Next, the interior turbinate is medialized, and the nasolacrimal duct is identified and preserved. Anterior, posterior, medial, and lateral incisions are made through the nasal mucosa to the nasal bone. The mucosa is dissected off the nasal bone with a periosteal elevator. Nasal saline irrigation is used postoperatively to aid healing. Histologic analysis of the harvested graft and mucosa from the inferior and middle turbinates were analyzed histologically for the number of mucin-producing cells per high power field and compared. RESULTS: Nasal floor mucosa provides ample tissue for grafting with little donor site morbidity. The surgery is technically easy to learn and perform. There is less risk for blood loss compared with harvesting tissue from the turbinates and less postoperative discomfort compared with buccal mucosal grafts. The grafts have been used in 9 different patients for a variety of ocular indications. Histologically, the nasal floor mucosa contains statistically more mucin-secreting cells than other nasal site, which can be helpful especially in cases of ocular surface disease. In 1 case, biopsy of the grafted tissue at postoperative year 2 showed survival of the respiratory mucin-secreting cells under histologic examination. CONCLUSIONS: Nasal floor mucosa should be considered a donor site when a mucous membrane graft is needed. The surgery is safe, easy to perform, and has less morbidity than either a nasal turbinate graft or a buccal mucosal graft.

Actualizaciones en anestesia para cirugía oftálmica / Update in anesthesia for oftalmic surgery

La práctica anestésica actual en cirugía oftálmica ha experimentado un gran cambio en los últimos años debido en parte a la creciente demanda en pacientes de edad avanzada con mayor fragilidad y comorbilidades, y en parte a los avances tecnológicos y a las técnicas quirúrgicas menos invasivas que se llevan a cabo en régimen ambulatorio en la mayoría de los hospitales hoy en día. En esta revisión se analizan los aspectos anatómicos más relevantes para el anestesiólogo, las principales técnicas anestésicas empleadas en la cirugía oftálmica moderna y algunos aspectos que generan controversia en la actualidad, como son el manejo de pacientes con nuevos fármacos que alteran la hemostasia y la solicitud de pruebas complementarias necesarias en la valoración preoperatoria de estos pacientes (AU)

The anesthetic practice for ophthalmic surgery has changed significantly in the last years due to the increasing demand in elderly patients, the technological advances and new surgical techniques, who are less invasive, and that are carried out in an ambulatory regime in the majority of the hospitals nowadays. This review discusses anatomical aspects of interest to the anesthesiologist, the main techniques used in modern ophthalmic surgery and certain controversies such as management of the patient who is taking medications that alter hemostasis and the systematic ordering of test necessary into the pre-operative evaluation (AU)

[Managing antithrombotic therapy in vitreoretinal surgery]. / Comment gérer les antithrombotiques en chirurgie vitréorétinienne ?

Given the growing number of patients on antithrombotic therapy we are increasingly confronted with the management of this therapy before, during and after vitreoretinal surgery. In the absence of a consensus, the decision to withdraw antithrombotic therapy is based on the cardiovascular thromboembolism risk versus the theoretical risk of bleeding if the antithrombotic treatment is continued. As suggested by the literature, antiplatelet therapy (acetylsalicylic acid or clopidogrel) may be safely continued for vitreoretinal surgery, including retinal detachment repair. However, the risk/benefit ratio for patients being treated with two antiplatelet therapies is unknown. It appears that an International Normalized Ratio (INR) less than 3 for patients treated with anticoagulant therapy does not increase the perioperative risk of ocular bleeding. This risk has not been evaluated in patients treated by new antithrombotic therapies (prasugrel, ticagrelor as antiplatelet medication, or dabigatran, rivaroxaban, apixaban as anticoagulant therapy), and there is a need to study it further.

Treatment outcomes of surgery, antifungal therapy and immunotherapy in ocular and vascular human pythiosis: a retrospective study of 18 patients.

OBJECTIVES: Human pythiosis is a life-threatening disease for which no standard treatment protocols with proven efficacy exist. We present the results of our institutional pythiosis treatment protocol, composed of surgery, antifungal agents, iron chelator (only vascular cases) and immunotherapy. METHODS: We retrospectively analysed patients with proven vascular and ocular pythiosis in King Chulalongkorn Memorial Hospital from April 2003 to May 2013. Fisher's exact test and Wilcoxon's rank-sum test were used. The MICs of seven antifungal agents and combination drugs were investigated in eight clinical Pythium insidiosum strains. RESULTS: Eighteen patients were evaluated. Disease-free surgical margins were obtained in all surviving patients with vascular pythiosis (P = 0.08). Patients who underwent eye enucleation were significantly older than those who did not (P < 0.05). Patients with vascular or ocular pythiosis did not differ significantly in the median time from disease onset to first surgery or in the relationship between the type of P. insidiosum antigen and treatment outcomes. In vitro susceptibility profiles of all isolates demonstrated that no single agent or combination treatment was substantially more effective than the others. The highest MIC was detected for amphotericin B, followed in order by voriconazole, fluconazole, anidulafungin, caspofungin, itraconazole and terbinafine. No synergistic effects of the combination drug treatments were found. CONCLUSIONS: Surgery with adequate surgical margins is a crucial determinant of survival in patients with vascular pythiosis. Itraconazole and terbinafine do not have synergistic effects on Thai P. insidiosum strains. The role of immunotherapy remains inconclusive for both vascular and ocular pythiosis.

Past, present, future: a review on visual prostheses.

This review presents the historic background, the present status and the future prospects of several visual implant types such as retinal implants, as well as optic nerve and thalamus stimulation, and stimulation of the visual cortex. Already achieved milestones, such as improved object recognition and letter reading, give hope that a breakthrough can be achieved in the coming years. Furthermore, clinical results from recent studies are presented in order to describe the obstacles that have to be overcome in the future. Currently, inner eye implants placed within the retina are the preferred option for electrical stimulation of the optic pathway. However, the limited number of stimulating electrodes and the non-focal activation of target neurons are still hindering the generation of percepts of higher quality. In the future, optogenetic approaches may be used to activate retinal neurons with a high temporal and spatial accuracy. The main challenge for all types of visual implants will be to utilize as many parts of the remaining optic pathway as possible and to focally activate functionally different pathways.

Novel retrobulbar anesthesia technique through the sub-Tenon's space using a sharp needle in a blunt cannula.

BACKGROUND AND OBJECTIVE: The authors developed a new technique for retrobulbar anesthesia and compared it with the conventional transcutaneous method in 223 eyes undergoing vitrectomy. PATIENTS AND METHODS: In the new technique, a 24-mm-long 19-gauge curved cannula with a 27-gauge straight needle with an oval tip was inserted into the sub-Tenon's space, and then the oval-tipped needle was replaced with a 50-mm-long 25-gauge curved needle. Anesthetic was then injected into the muscle cone from the syringe. The authors compared 118 eyes undergoing vitrectomy with the new technique and 105 eyes undergoing the procedure with conventional anesthesia. RESULTS: The pain scores were 0.1 ± 0.32 for the new technique and 1.57 ± 0.73 for the conventional technique (P < .001). Additional anesthetic required was 0.1 ± 0.33 mL using the new technique and 0.3 ± 0.68 mL using the conventional method (P = .03). CONCLUSION: This novel approach to retrobulbar anesthesia using a guarded cannula is safe and effective, causing less pain than the conventional technique.

Evidence for integrating eye health into primary health care in Africa: a health systems strengthening approach.

BACKGROUND: The impact of unmet eye care needs in sub-Saharan Africa is compounded by barriers to accessing eye care, limited engagement with communities, a shortage of appropriately skilled health personnel, and inadequate support from health systems. The renewed focus on primary health care has led to support for greater integration of eye health into national health systems. The aim of this paper is to demonstrate available evidence of integration of eye health into primary health care in sub-Saharan Africa from a health systems strengthening perspective. METHODS: A scoping review method was used to gather and assess information from published literature, reviews, WHO policy documents and examples of eye and health care interventions in sub-Saharan Africa. Findings were compiled using a health systems strengthening framework. RESULTS: Limited information is available about eye health from a health systems strengthening approach. Particular components of the health systems framework lacking evidence are service delivery, equipment and supplies, financing, leadership and governance. There is some information to support interventions to strengthen human resources at all levels, partnerships and community participation; but little evidence showing their successful application to improve quality of care and access to comprehensive eye health services at the primary health level, and referral to other levels for specialist eye care. CONCLUSION: Evidence of integration of eye health into primary health care is currently weak, particularly when applying a health systems framework. A realignment of eye health in the primary health care agenda will require context specific planning and a holistic approach, with careful attention to each of the health system components and to the public health system as a whole. Documentation and evaluation of existing projects are required, as are pilot projects of systematic approaches to interventions and application of best practices. Multi-national research may provide guidance about how to scale up eye health interventions that are integrated into primary health systems.

Anesthesia for ophthalmic procedures in the standing horse.

Effective delivery of local anesthesia is essential for successful standing surgical procedures in the horse. Local anesthesia can be used to facilitate examination of the eye, diagnostic procedures, therapeutic techniques, and surgical procedures. Understanding the relevant clinical anatomy and techniques for performing local anesthesia is critical to delivering successful local and regional anesthesia and analgesia.

Bases neurobiológicas de la analgesia de acupuntura en la cirugía ocular

Objetivo: Analizar las bases neurobiológicas de la analgesia de acupuntura en cirugía ocular. Metodología: Se revisó la literatura impresa y digital disponible en el mes de febrero de 2009 sobre el tema exponiéndose sus ventajas en la cirugía oftálmica y sus bases neurobiológicas. Se seleccionaron aquellos artículos considerados clásicos en este terreno y se comentan sus resultados. Resultados: La analgesia de acupuntura en la cirugía oftálmica ofrece muchas ventajas: no se produce isquemia sobre el nervio óptico, pues es más fisiológica y se acompana de sedación; la presión arterial, frecuencia cardíaca, frecuencia respiratoria y el electrocardiograma no sufren modificaciones importantes; no se producen alteraciones del peristaltismo, la recuperación postoperatoria es favorable y existe menos manipulación sobre el globo ocular y sus anexos. Su base neurobiológica comprende un conjunto de eventos electroquímicos, sucedidos desde el sitio de dano tisular activo y la percepción del dolor: traducción, transmisión, modulación y percepción teniendo en cuenta las características del punto de acupuntura. Conclusiones: Los mecanismos neurobiológicos por los que actúan los estímulos nociceptivos que constituyen la base de la aplicación de la analgesia de acupuntura en cirugía ocular son bastante complejos. La acción analgésica de la acupuntura, en la periferia, pudiera depender de la subregulación del receptor NMDA/Ca2+/ONS/ON/GMPc, de modo similar al proceso que ocurre a nivel central(AU)

Objective: To analyze neuro-biological basis of acupunctural analgesic in ocular surgery.Methodology: An exploratory study was conducted, making a review about its advantages and neuro-biological basis taking into consideration printed and digital bibliography in February 2009. Articles considered like classics in this fi eld were choosing and commented their results. Results: Acupunctural analgesic in ocular surgery off ers many advantages: doesnt produce damage in optic nerve, being more physiologic, and accompanied of sedation; arterial pressure, cardiac and respiratory frequency and electrocardiogram don´t suff er important changes; there arent alterations in bowel movements, postoperative recuperation is favourable with less manipulation on ocular globe and its annexes. Its neuro-biological basis contained various electro-chemical events that occur from seat with active tissue damage and pain perception: translation, transmission, modulation and perception onto acupunctural point characteristics. Conclusions: Neuro-biological mechanisms through act nociceptive impulses that constitute application base of acupunctural analgesia in ocular surgery are quite complex. Analgesic action of Acupuncture in periphery could depend on the sub-regulation of NMDA/Ca2+/ONS/ON/ CMPC receptor as similar as central level process(AU)

Evisceration with equatorial sclerotomy for phthisis bulbi and microphthalmos.

PURPOSE: To describe a new technique for ocular volume augmentation at the time of evisceration in patients with phthisis bulbi and microphthalmos. METHODS: A retrospective, interventional, noncomparative case series of all patients with phthisis bulbi and microphthalmos who underwent successful evisceration with equatorial sclerotomy. The medical records were reviewed for patient history, surgical method, and postoperative course. RESULTS: Eighteen patients (16 with phthisis bulbi and 2 with microphthalmos) underwent evisceration with equatorial sclerotomy and placement of an orbital implant of 20 mm in 11 patients (61%), 18 mm in 6 patients (33%) and 16 mm in 1 patient. Complications encountered were implant exposure in one patient, fornix shortening and symblepharon in one patient, and enophthalmos in another. CONCLUSION: Equatorial sclerotomy could be a useful adjuvant technique for placement of a larger orbital implant at the time of evisceration in patients with phthisis bulbi and microphthalmos.

[Local anesthesia in ophthalmology]. / Anestezia locala în chirurgia oculara.

Ocular surgery presents some particularities: local anesthesia continues to be the most utilized and it consists in topical corneo-conjunctival anesthesia and local or regional infiltrative anesthesia. The term of locoregional anesthesia is utilized in ophthalmology for the reason that the two forms of anesthesia could be associated. In this paper the authors insist on different types and methods of anesthesia utilized in ophthalmology and on indications and benefits of each method. There are also presented the incidents and complications of local anesthesia in ophthalmology.