ULTRASOUND MEASUREMENTS OF THE DISTANCE BETWEEN LIMBUS AND RETINAL BREAK IN EYES WITH MEDIA OPACITIES.

PURPOSE: To assess the reproducibility and accuracy of ultrasound (US) measurements in determining the distance between corneoscleral limbus and retinal break and its relation with the distance measured by indirect ophthalmoscopy, in patients undergoing a laser retinopexy procedure. METHODS: Forty-four patients with a single retinal break, scheduled for laser a retinopexy procedure (26 phakic patients and 18 pseudophakic patients), underwent 5 repeated measurements by high-resolution US and 3 measurements (at the time of the laser procedure, 1 and 3 months) by indirect ophthalmoscopy with scleral indentation of the corneoscleral limbus-retinal break distance with a caliper. RESULTS: In the phakic patients group, measurements ranged from 8.75 mm to 14.45 mm (12.56 ± 1.24, mean ± SD) and from 9.5 mm to 15 mm (12.35 ± 1.32) with US and indirect ophthalmoscopy, respectively. In the pseudophakic patients group, measurements ranged from 9.04 mm to 13.95 mm (11.88 ± 1.33) and from 8.5 mm to 13.2 mm (11.93 ± 0.99) with US and indirect ophthalmoscopy, respectively. The correlation coefficient was greater than 0.97. Measurement variability was very small. In phakic eyes, it was 0.13 ± 0.08 mm and 0.13 ± 0.07 mm with US and indirect ophthalmoscopy, respectively. In pseudophakic eyes, it was 0.12 ± 0.05 mm and 0.14 ± 0.05 mm with US and indirect ophthalmoscopy, respectively. US and indirect ophthalmoscopy measurements were not statistically different (Student's t-test, P = 1.71). The analysis of the variance among phakic and pseudophakic patients confirmed that measurements of the two groups do not differ significantly (Fisher's exact test, P = 0.16). The univariate analysis showed no significant difference in both US and indirect ophthalmoscopy measurements (ANOVA, P = 0.09) and between the two types of measurements and patient groups (ANOVA, P = 0.38). CONCLUSION: This study suggests relevant accuracy and reliability of US readings and provides the possibility of using this technique for localizing tears in eyes with media opacities by identifying the meridian and corneoscleral limbus-retinal break distance.

Long-Term Surgical Outcomes of Scleral Flap versus Scleral Pocket Technique for Sutureless Intrascleral One-Piece Lens Fixation.

Objectives: This study compared long-term surgical outcomes of the scleral flap versus scleral pocket technique for sutureless intrascleral one-piece intraocular lens (IOL) fixation. Methods: A retrospective comparative study was conducted at a single center, involving consecutive patients undergoing sutureless intrascleral one-piece IOL implantation, between January 2020 and May 2022. Eyes were divided into two groups based on the surgical technique: group 1 underwent scleral flap (n = 64), and group 2 received scleral pocket technique (n = 59). Visual acuity, refractive outcomes, and complications were assessed over a minimum 24-month follow-up period. Results: Both groups showed improvements in best-corrected visual acuity (BCVA), increasing from 0.84 ± 0.56 logMAR at baseline to 0.39 ± 0.23 logMAR (p = 0.042) at 24 months in group 1 and from 0.91 ± 0.63 logMAR at baseline to 0.45 ± 0.38 logMAR (p = 0.039) at 24 months in group 2. No significant differences in BCVA were observed between the groups at baseline (p = 0.991), 12 (p = 0.496) and 24 months (p = 0.557). Mean spherical equivalent (-0.73 ± 1.32 D in group 1 and -0.92 ± 0.99 D in group 2, p = 0.447), refractive prediction error (-0.21 ± 1.1 D in group 1 and -0.35 ± 1.8 D in group 2, p = 0.377), and surgically induced astigmatism (0.74 ± 0.89 D in group 1 and 0.85 ± 0.76 in group 2, p = 0.651) were comparable between the two groups. An IOL tilt of 5.5 ± 1.8 and 5.8 ± 2.0 degrees (p = 0.867) and an IOL decentration of 0.41 ± 0.21 mm and 0.29 ± 0.11 mm (p = 0.955) were obtained, respectively, in group 1 and group 2 at 24 months. Mean endothelial cell density remained stable at 24 months in both groups (p = 0.832 in group 1 and p = 0.443 in group 2), and it was 1747.20 ± 588.03 cells/mm2 in group 1 and 1883.71 ± 621.29 cells/mm2 in group 2 (p = 0.327) at baseline, 1545.36 ± 442.3 cells/mm2 in group 1 and 1417.44 ± 623.40 cells/mm2 in group 2 (p = 0.483) at 24 months. No cases of endophthalmitis were observed. Conclusions: The scleral pocket technique for sutureless intrascleral one-piece IOL fixation is comparable to the traditional scleral flap technique in terms of long-term visual outcomes and safety. The scleral pocket technique offers a simplified approach and a viable option even for less experienced surgeons.

Efficacy and safety of UT-DSAEK combined with Carlevale's sutureless scleral fixation IOL.

PURPOSE: To evaluate a novel surgical combination of ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) and sutureless scleral fixation for Carlevale intraocular lens (SSF-Carlevale IOL) implantation to manage corneal endothelial decompensation when there is a concomitant need for secondary IOL fixation. METHODS: Clinical data collected from 10 eyes of 9 patients with bullous keratopathy (BK) who underwent combined UT-DSAEK and SSF-Carlevale IOL implantation in a single procedure were retrospectively analyzed. Anterior chamber IOL (4 cases), aphakia (4 cases, 1 of which associated with PEX), and previous trauma (2 cases) were the conditions responsible for BK. Corrected distance visual acuity (CDVA), intraocular pressure (IOP), endothelial cell density (ECD), central corneal thickness (CCT), graft thickness (GT) and complications were recorded over a 12-month follow-up period. RESULTS: In 90% (9/10) of eyes graft clarity was maintained during follow-up. The mean CDVA improved significantly (p < 0.0001) from 1.78 ± 0.76 logMAR preoperatively to 0.53 ± 0.3 logMAR at 12 months. ECD on average decreased from 2575 ± 125.3 cells/mm2 (donor tissue) to 1697 ± 133.3 cells/mm2 in 12 months. The mean CCT decreased from 870 ± 200 µm to 650 µm ± 9 at 12 months (ANOVA, p = 0.0005). CONCLUSIONS: Combined UT-DSAEK and SSF-Carlevale IOL implantation was associated with good corneal graft survival and IOP control, with few complications. These findings suggest that this surgical approach is a practical option for patients requiring both treatment for corneal endothelial dysfunction and secondary IOL implantation.

Accuracy of IOL Power Calculation Using the New Carlevale Sutureless Scleral Fixation Posterior Chamber IOL.

PURPOSE: To evaluate the refractive outcomes of the new Carlevale foldable sutureless scleral fixation intraocular lens (SSF-IOL) (Soleko in eyes without capsular support. METHODS: This retrospective, single-center, noncomparative interventional case series included 25 consecutive eyes of 25 consecutive patients with either aphakia or lens/IOL dislocation due to capsular or zonular defects. The Hoffer Q, Holladay 1, and SRK/T formulas, which do not need measurements of the anterior chamber depth to predict the IOL position, were used to calculate the IOL power. Constant optimization was performed to zero out the mean prediction error (PE). The main outcome measures were mean PE ± standard deviation, median absolute error (MedAE), mean absolute error (MAE), and percentage of eyes with a PE within ±0.50 and ±1.00 diopters (D). RESULTS: Mean axial length was 24.09 ± 2.09 mm (range: 21.85 to 32.17 mm). No statistically significant differences were found among the three formulas for any parameter. The PE was zero due to constant optimization and its standard deviation ranged between 0.89 and 0.95 D. The MedAE ranged between 0.30 and 0.34 D, whereas the MAE ranged between 0.62 and 0.67 D. The percentage of eyes with a PE within ±0.50 D was between 56% and 64% and the percentage of eyes with a PE within ±1.00 D was between 69% and 72%. CONCLUSIONS: Reasonably good refractive outcomes can be obtained when implanting SSF-IOLs in eyes with no capsular support, although the accuracy is lower than what is reported for normal in-the-bag IOL implantation. [J Refract Surg. 2021;37(7):472-476.].

Long-term Outcomes and Complications of the New Carlevale Sutureless Scleral Fixation Posterior Chamber IOL.

PURPOSE: To evaluate the visual outcomes and possible complications of a new foldable sutureless scleral fixation intraocular lens (SSF-IOL), the Carlevale IOL (Soleko). METHODS: The SSF-IOL, which has two T-shaped self-blocking plugs on each haptic, was inserted into the posterior chamber. Both haptics was grabbed through two sclerotomies and the two short arms were blocked under the scleral flap, without any suture. A complete clinical evaluation was done preoperatively and at 3, 6, and 12 months postoperatively. RESULTS: A total of 54 eyes of 50 consecutive patients were retrospectively analyzed. The mean corrected distance visual acuity was 0.93 ± 0.61 logMAR preoperatively and improved to 0.42 ± 0.34 logMAR at 3 months, 0.42 ± 0.37 logMAR at 6 months, and 0.38 ± 0.38 logMAR at 12 months postoperatively (all P < .0001). The mean corneal endothelial cell density decreased from 1,725.37 ± 528.06 to 1,612.81 ± 522.91 cells/mm2 at 12 months postoperatively (P < .0001). The mean IOL tilt value was 3.1 ± 1.1° at 12 months postoperatively. The authors observed 6 cases (11.1%) of intraoperative rupture of the IOL haptics, 4 cases (7.4%) of early hyphema, 4 cases (7.4%) of macular cystoid edema, 2 cases (3.7%) of haptic exposure under the conjunctiva, and 1 (1.8%) late retinal detachment. CONCLUSIONS: This newly introduced surgical technique provided promising results regarding efficacy and safety. Complications occurred in a few cases and were successfully managed. The Carlevale IOL seems to be a surgical solution combining the advantages of an easy and minimally invasive implantation with a good functional recovery with minimal complications. [J Refract Surg. 2021;37(2):126-132.].

Pediatric Use of Recombinant Human Nerve Growth Factor 20 µg/mL Eye Drops (Cenegermin) for Bilateral Neurotrophic Keratopathy in Congenital Corneal Anesthesia.

PURPOSE: This study aimed to present the efficacy and safety of cenegermin eye drop (Oxervate; Dompè Farmaceutici, Milan, Italy) treatment in a pediatric patient affected by neurotrophic keratopathy (NK) with Goldenhar syndrome. METHODS: This case reports an infant presenting ulceration and a small central opacity in the cornea of the right and left eyes, respectively. The NK bilaterally worsened despite the use of therapeutic contact lenses and temporary partial tarsorrhaphy. Magnetic resonance imaging showed absence and hypoplasia of the right and left trigeminal nerves, respectively. Cenegermin eye drops were administered 1 drop/each eye, 6 times daily for 8 weeks to promote corneal healing. RESULTS: Complete healing was achieved in both eyes after treatment. During the 16-month follow-up period, no epithelial defect, recurrence, or complications were noticed, whereas corneal opacities progressively became clearer, although insignificant improvements in corneal sensitivity or in the reflex tearing were observed. CONCLUSIONS: Cenegermin was effective in treating NK in an infant with Goldenhar syndrome.

Prevalence of diabetes and diabetic macular edema in patients undergoing senile cataract surgery in Italy: The DIabetes and CATaract study.

BACKGROUND: The purpose of this study is to determine the prevalence of diabetes and diabetic macular edema in patients undergoing senile cataract surgery in Italy. METHODS: It is a prospective, multicenter, cross-sectional study. Thirteen ophthalmic units equally distributed across the Italian territory have been involved in the study. For a period of 3 months, all subjects undergoing phacoemulsification received an Optical Coherence Tompgraphy (OCT) scan and were screened for the anamnestic presence of diabetes. In addition, five selected units collected blood samples from all their patients to measure glycated hemoglobin (HbA1c) levels and detect the presence of occult diabetes (HbA1c > 6.5%). In diabetic patients, levels of retinopathy were measured and diabetic macular edema was considered significant (clinically significant macular edema) when foveal thickness was above 30% of normal levels. RESULTS: A total number of 3657 subjects have been screened. Among them, 20.4% were diabetics. Prevalence of diabetes was significantly higher in males (24.7%) than in females (17%). Levels of HbA1c were tested in a representative sample of 1216 consecutive subjects, and occult diabetes was diagnosed in 4.8% of cases. No significant differences were observed between age groups or different geographic areas. Among diabetic patients, diabetic macular edema of any kind was present in 27.5% (clinically significant macular edema (6.6%)). No significant differences were seen in the prevalence of diabetic macular edema between males and females or between age groups. Among the 745 diabetic patients, no signs of retinopathy were seen in 537 subjects (76.3%), while 101 patients (14.3%) had nonproliferative retinopathy, 13 (1.7%) had nontreated proliferative diabetic retinopathy, and 53 (7.5%) had laser-treated retinopathy. In the entire sample of 3657 subjects, a normal macula was present in 90.9% of cases, diabetic macular edema of any kind in 5.4%, and other maculopathies in 3.4%. CONCLUSION: In this large cohort study on patients undergoing cataract surgery, more than one-fourth were diabetics and more than one-fourth of these had diabetic macular edema. These high prevalences suggest the opportunity to plan an adequate preoperative assessment in all patients in order to reduce the risk of postoperative development or worsening of a sight-threatening complication such as chronic diabetic macular edema.

Oral azithromycin and oral doxycycline for the treatment of Meibomian gland dysfunction: A 9-month comparative case series.

Purpose: To compare the efficacy and safety profile of oral azithromycin with that of doxycycline over 9 months in patients experiencing failure with conservative and topical treatment for Meibomian gland dysfunction (MGD), to assess recurrence of MGD, and to determine the number of treatments required. Methods: This is a randomized controlled trial with a cross-over design at a tertiary care center. In all, 115 consecutive patients underwent a complete ophthalmological examination before being randomly assigned to oral treatment with doxycline (4 g for 30 days) or azithromycin (1.25 g for 5 days). Patients were evaluated at 3, 6, and 9 months. Therapy was switched or conservative management maintained according to signs and symptoms. Results: In the azithromycin group, 83.25% of the patients were stable after one treatment, 16.5% needed a further one or two treatments (some had previously been switched to doxycycline), and 5.77% did not improve despite treatment. In the doxycycline group, 33.79% of patients were stable after one treatment, 66.21% needed a further one or two treatments (some had previously switched to azithromycin), and 29.41% did not improve despite treatment (P < 0.05). Minimal gastrointestinal adverse effects (nausea, diarrhea, abdominal cramp, and decreased appetite) were reported, mostly unchanged at the follow-up visits. At the first visit, more adverse effects were reported in the doxycycline group (14/51, 24%) than in the azithromycin group (3/52, 6%; P < 0.005). Conclusion: Both antibiotics were effective and safe for treating patients with persistent MGD, although azithromycin was superior when the reduced dose and the shorter course of therapy (5 days vs. 4 weeks) were taken into consideration. Given the chronic nature of the disease and the improvement in some signs with minimal adverse effects, a shorter therapy seems a safer and more logical alternative to longer regimens.

Transient cortical blindness after intradiscal oxygen-ozone therapy.

A 54-year-old caucasian male developed bilateral blindness during an oxygen-ozone injection for disc herniation. The visual loss (VL) was immediately followed by severe frontal headache, vomiting, and nausea. The patient underestimated the VL showing Anton's syndrome, with a complete visual recovery after 2-month follow-up. Magnetic resonance data were consistent with recent ischemic lesions in bilateral vascular territories of posterior cerebral arteries.

Underestimate of tonometric readings after photorefractive keratectomy increases at higher intraocular pressure levels.

PURPOSE: To determine whether tonometric readings of increases in intraocular pressure (IOP) during the water-drinking test (WDT) are affected by variations in central corneal thickness (CCT) induced by photorefractive keratectomy (PRK). METHODS: Data from 30 randomly selected eyes of 30 patients (18 men and 12 women; mean age, +/- SD: 33.9 +/- 7.6 years) undergoing bilateral PRK for myopia (-6.57 +/- 2.39 D) were obtained. Objective refraction, anterior radius of corneal curvature (R), CCT, and IOP measurements at baseline and at different time intervals after ingestion of 1 L of water within 5 minutes, were performed before and 6 months after PRK. All measured IOPs were recalculated by a correction factor for R and CCT and expressed as corrected intraocular pressure (IOPC) measurements. RESULTS: The mean R +/- SD was 7.84 +/- 0.20 and 8.76 +/- 0.34 mm, and the mean CCT was 544.83 +/- 19.69 and 453.97 +/- 29.95 microm, before and after PRK, respectively. The mean IOP at baseline was 15.05 +/- 2.78 and 9.83 +/- 2.56 mm Hg, and during WDT was 18.32 +/- 3.42 and 11.42 +/- 3.10 mm Hg at 10 minutes, 18.59 +/- 2.99 and 11.54 +/- 2.54 mm Hg at 20 minutes, 17.80 +/- 2.85 and 10.87 +/- 2.22 mm Hg at 30 minutes, 16.35 +/- 3.02 and 10.26 +/- 2.21 mm Hg at 45 minutes, and 14.90 +/- 2.52 and 9.81 +/- 2.32 mm Hg at 60 minutes, before and after PRK, respectively. The mean IOPC at baseline was 13.64 +/- 2.33 and 13.05 +/- 2.98 mm Hg, and during WDT was 16.61 +/- 2.77 and 15.08 +/- 3.59 mm Hg at 10 minutes, 16.96 +/- 2.69 and 15.33 +/- 2.96 mm Hg at 20 minutes, 16.10 +/- 2.50 and 14.42 +/- 2.60 mm Hg at 30 minutes, 14.92 +/- 2.72 and 13.62 +/- 2.65 mm Hg at 45 minutes, 13.82 +/- 2.27 and 13.05 +/- 2.55 mm Hg at 60 minutes, before and after excimer laser treatment, respectively. Pre- and postoperative IOPs and percentages of IOP increase differed significantly (P < 0.05), in particular at the peak, as did IOPCs but not the percentages of increase in IOPC, apart from the highest values. CONCLUSIONS: Corneal changes after PRK for myopia may induce an uneven underestimate of the IOP increases. The inadequacy of a correction factor to compensate for CCT and R at high IOP levels indicates that other biomechanical factors may play a role when the cornea is subjected to dynamic actual IOP variation. Such increase of the well-known underestimate of IOP after PRK at higher actual IOPs may have significant clinical implications in tonometric assessment of subjects at risk of glaucomatous damage.

Tonometric changes of latanoprost-induced intraocular pressure reduction after photorefractive keratectomy.

PURPOSE: To assess whether tonometric measurements of the drop in intraocular pressure (IOP) induced by 0.005% latanoprost are modified after photorefractive keratectomy (PRK). METHODS: Data from 24 randomly selected eyes of 24 patients (12 men and 12 women, mean age +/- SD: 31.7 +/- 6.2 years) who were undergoing bilateral PRK for myopia (-6.38 +/- 2.26 D) were obtained. Objective refraction, central corneal thickness (CCT), anterior radius of corneal curvature (R), and IOP measurements at baseline and 24 hours after 1 drop of 0.005% latanoprost, were performed before and 6 months after PRK. All measured IOPs were recalculated by a correction factor for CCT and R and expressed as true IOP (IOPT) measurements. RESULTS: The mean CCT +/- SD was 544.58 +/- 36.03 and 463.21 +/- 38.59 micro m, and the anterior radius of corneal curvature was 7.73 +/- 0.26 and 8.33 +/- 0.37 mm, before and after PRK, respectively. The mean IOP at baseline was 15.8 +/- 2.92 and 12.23 +/- 2.37 mm Hg, and after latanoprost administration was 12.54 +/- 1.97 and 10.19 +/- 1.47 mm Hg, before and after PRK, respectively. The mean IOPT at baseline was 15.46 +/- 1.08 and 16.18 +/- 2.31 mm Hg, and after latanoprost administration was 11.85 +/- 1.56 and 12.96 +/- 1.71 mm Hg, before and after PRK, respectively. The mean IOP and IOPT reductions after latanoprost administration were, respectively, 3.25 +/- 1.66 and 3.61 +/- 1.7 mm Hg before PRK, and 2.03 +/- 1.42 and 3.22 +/- 1.79 mm Hg after PRK. Pre- and postoperative IOP reduction significantly differed (P < 0.001), but not IOPT. CONCLUSIONS: The effect of hypotensive drugs on IOP readings may be underestimated because of measurement errors due to CCT reduction and R increase after PRK for myopia. Misdiagnosis of reduced pharmacologic efficacy may be avoided if the measured IOP is corrected by a proper nomogram.

Ultrasound of the horizontal rectus muscle insertion sites: implications in preoperative assessment of strabismus.

PURPOSE: To determine the reproducibility and accuracy of ultrasonographic (US) measurements of distances between the corneoscleral limbus and the insertion site of the medial (MR) or lateral rectus (LR) muscle compared with intraoperative measurements in patients with strabismus. METHODS: One eye in each of 17 patients with postoperative secondary strabismus caused by over- or undercorrected eso- and exotropia and one eye of each of 19 patients with previously untreated strabismus underwent five repeated measurements by high-resolution ultrasonography of the distance from the corneoscleral limbus to the muscle insertion and three actual intraoperative measurements. Reproducibility, expressed as the coefficient of variation, accuracy (relative error) of US measurements, and the agreement with intraoperative measurements were assessed. RESULTS: The coefficients of variation for US data were 2.02% and 3.18% for the MR and 7.33% and 11.77% for the LR, in the surgical and untreated groups, respectively. The relative error was 6.15% +/- 8.14% (mean +/- SD) and 3.66% +/- 12.83% for the MR muscle, and 12.21% +/- 10.66% and -7.69% +/- 7.83% for the LR muscle, in the surgical and untreated groups, respectively. The 95% limits of agreement (mean +/- 2 SD) between the US and intraoperative measurements were 0.65 +/- 1.82 and 0.15 +/- 1.42 mm for the MR muscle, and 1.12 +/- 2.01 and -0.49 +/- 0.98 mm for the LR muscle, in the surgical and untreated groups, respectively. CONCLUSIONS: The results indicate good reliability and accuracy of US readings and suggest a potential usefulness in preoperative assessment of patients with strabismus with surgical failure and missing preoperative clinical data.

Combined deep sclerectomy and descemet stripping automated endothelial keratoplasty.

PURPOSE: The aim of this study was to evaluate a novel surgical combination of Descemet stripping automated endothelial keratoplasty (DSAEK) and deep sclerectomy (DS) for the management of concomitant corneal endothelial decompensation and uncontrolled glaucoma. METHODS: This retrospective case series noncomparative study included 9 eyes of 6 consecutive patients with coexistence of corneal edema resulting from Fuchs dystrophy or pseudoexfoliation keratopathy and medically uncompensated glaucoma; these patients underwent combined DSAEK and DS with mitomycin C and an absorbable collagen implant. Corneal graft clarity, endothelial cell density, visual acuity, intraocular pressure (IOP), and identification of complications were assessed over a 2-year follow-up. RESULTS: All eyes obtained graft clarity throughout the follow-up, with a final average endothelial cell decrease of -36% from baseline, and showed improved vision and good IOP control without hypotensive therapy. Measured at 3 and 24 months postoperation, the mean visual acuity improvement was 154% and 372% and IOP decrease was 51.1% and 46.4%, respectively. Two anterior segment complications occurred in 2 (22%) patients' eyes. This consisted of a graft dislocation and a modest IOP elevation, treated successfully. CONCLUSIONS: Combined DSAEK and DS was longitudinally associated with good corneal graft survival and IOP control, with few complications. These findings suggest that this surgical approach is a viable option for patients with coexisting glaucoma and corneal endothelial dysfunction. Our study should stimulate a multicenter, randomized, controlled trial of our technique.