Dietary profile of patients with Stargardt's disease and Retinitis Pigmentosa: is there a role for a nutritional approach?

BACKGROUND: Stargardt's disease (STGD) and Retinitis Pigmentosa (RP) are inherited retinal degenerations that may be affected, in opposite way, by diet. METHODS: Dietary profile was assessed in 24 patients with STGD and in 56 patients with RP. We documented in only 6 out of 24 (25%) STGD patients a daily intake of vitamin A within the recommended range while 14/24 (58.3%) reported a high daily intake and 4/24 (16.7%) showed a low daily intake. With regard to RP, 4/56 (7.1%) reported to be within the recommended range, 37/56 (66.1%) reported high daily intake and 15/56 (26.8%) showed low daily intake of vitamin A. RESULTS: Interestingly, STGD patients with low vitamin A intake (<600 µg RAE/day) showed significantly better visual acuity with respect to those introducing higher intake of vitamin A. CONCLUSION: The present study suggests insuitable nutrient intakes among patients with STGD and RP, especially for daily intake of vitamin A. The results may be used to provide tailored nutritional interventions in these patients.

Role of Vitreous Detachment in Epiretinal Membrane Peeling: A Multimodal Imaging and Microperimetry Study.

Background: To investigate anatomical and functional changes of the macula caused by epiretinal membrane (ERM) peeling procedures in patients with or without posterior vitreous detachment (PVD). Methods: This is a multicentric prospective observational study on thirty-seven (37) patients affected by symptomatic ERM who underwent 25-gauge pars plana vitrectomy (PPV), induction of a PVD (as needed) and peeling of both the internal limiting membrane (ILM) and ERM. Optical coherence tomography-angiography (OCT-A) (RS 3000, Nidek, Japan) and microperimetry (MP-3, Nidek, Japan) were performed; central retinal thickness (CRT), foveal avascular zone (FAZ) area and perimeter, vessel density and perfusion density, retinal sensitivity and fixation stability (as a total mean retinal sensitivity (MRS), and MRS in the ellipse area and bivariate contour ellipse area (BCEA)) were recorded at baseline and up to postoperative month 3. Results: Eyes were classified as having complete PVD (51.4%) or incomplete PVD (48.6%). At baseline, patients with incomplete PVD had worse best-corrected distance visual acuity (BCDVA), total MRS, MRS in the ellipse area and BCEA, and higher CRT than patients with complete PVD. At month 3, the differences in BCDVA between the two groups remained statistically significant, with patients with incomplete PVD having worse results (difference: 0.199 logMAR, p < 0.001). The difference in the MRS in the ellipse area was statistically significant at month 3 (-3.378 Db, p = 0.035), with greater improvement in patients with complete PVD. Conclusions: Our study shows that patients with incomplete PVD have worse conditions at baseline than patients with complete PVD, and the differences in visual acuity and retinal sensitivity were maintained postoperatively.

"Air and Visco" Technique: A Promising Innovation in the Surgical Implantation of the Xen Gel Stent Device.

We aimed to describe a variation of the surgical technique for the ab interno implantation of the XEN Gel Stent, which, in our experience, is yielding very successful results. The injection of 0.1 mL of air and then of 0.1 mL of a dispersive viscoelastic into the subconjunctival space at the beginning of the surgery allows one to perform a mechanical dissection between the conjunctiva and the Tenon's capsule, creating a real space. In total, 20 eyes of 16 patients underwent the implantation of a stent gel through the "Air and Visco" technique. We retrospectively analyzed the results. We obtained a reduction in the IOP from an average of 18.3 ± 2.2 mmHg preoperatively to at 13.5 ± 3.5 mmHg at month 12. The needling rate was 20%. We did not register any cases of hypotony (IOP < 6 mmHg), hypotony maculopathy or choroidal detachment. The "Air and Visco" technique allows one to correctly place the device in the subconjunctival space, which the pneumo- and visco-dissection transforms into a real space. This enables an easier surgical performance and more predictable postoperative results, with a low needling rate and reintervention in the follow-up period. It also ensures a greater safety profile because the presence of the OVD on the bleb prevents a sudden lowering of the IOP, eliminating complications such as hypotony, hypotony maculopathy and choroidal detachment in our cohort.

Efficacy and safety of combined Xen Gel Stent-45 implantation and 25-gauge Pars Plana Vitrectomy: a case series.

Purpose: To report outcomes in terms of efficacy and safety of patients affected with Primary Open Angle Glaucoma (POAG) and Vitreoretinal Disease, who have undergone Pars Plana Vitrectomy (PPV) and ab-interno XEN gel 45 (Abbvie) implantations. Methods: This is a retrospective, observational, case series on five patients who underwent combined Pars Plana Vitrectomy and XEN gel Stent 45 implantation at "Careggi Hospital" Eye Clinic of Florence. Best-corrected visual acuity (BCVA) evaluation, intraocular pressure (IOP) measurements with Goldmann applanation tonometer (GAT), and several glaucoma medications were evaluated at the baseline and at one, three, six, and twelve months after surgery. Complications were recorded up to 1 year after surgery. Results: 5 eyes in five patients were enrolled. IOP dropped from an average of 21,2 ± 3,3 mmHg preoperatively to 14,6 ± 1,1 mmHg at the end of the follow-up period (month 12), with a mean percentage reduction of 58%. One patient needed a needling procedure (20%). None needed reintervention. We did not register any case of hypotony (IOP < 6,5 mmHg), hypotony maculopathy and choroidal detachment. The postoperative number of anti-glaucomatous molecules was on average 0,2 ± 0,4. Conclusion: Our results suggested that combined Pars Plana Vitrectomy and XEN gel stent 45 implantation is safe and effective for patients affected by visually significant vitreoretinal diseases and POAG. Abbreviations: AC = anterior chamber, BCVA = Best-corrected visual acuity, ERM = epiretinal membrane, FTMH = full-thickness macular holes, FU = fluorouracil, GAT = Goldmann applanation tonometer, IOP = intraocular pressure, MIGS = minimally invasive glaucoma surgery, MMC = mitomycin C, NVG = neovascular glaucoma, OCT = optical coherence tomography, POAG = Primary Open Angle Glaucoma, PPV = Pars Plana Vitrectomy, SD = standard deviation, TB = Trabeculectomy, VF = visual field, VMI = Vitreomacular Interface, VMA = vitreomacular adhesion, VMT = vitreomacular traction.

Combining primary and sulcus piggyback IOLs for the correction of a spherical-cylindrical defect in an eye with abnormal cornea.

INTRODUCTION: Piggyback IntraOcular Lenses (IOLs), or supplementary secondary implant lenses, have been developed to provide a sufficient dioptric power in eyes with high refractive defects, which are not fully correctable after cataract surgery with single IOL in the range of powers available. These lenses can also be used for the correction of refractive errors that occurred for a wrong choice of the IOL power after cataract surgery. CASE DESCRIPTION: We report the case of a complete refractive success obtained in a patient with an abnormal cornea, with a central stable ectasia, with thinning, high myopic astigmatism and cataract, obtained with the implant of a primary posterior chamber IOL at the time of cataract surgery and a subsequent implant of a secondary piggyback, sulcus-based customized toric IOL (Camellens FIL 622-2 Toric Monofocal IOL, Soleko, Rome, Italy). CONCLUSIONS: This brief report demonstrates the utility of combining primary and piggyback IOLs implant for the correction of a complex spherical-cylindrical refractive defect in a case of abnormal cornea and cataract.

Effectiveness and Safety of XEN45 in Eyes With High Myopia and Open Angle Glaucoma.

PRCIS: XEN45 implant was an effective and safe procedure in primary open angle glaucoma (OAG) eyes with high myopia. Although the hypotony incidence rate was relatively high, it resolved with medical therapy and was of short duration. PURPOSE: The purpose of this study is to evaluate the effectiveness and safety of the XEN45 stent in eyes with OAG and high myopia. DESIGN: Retrospective and multicenter study. METHODS: Consecutive OAG patients who underwent a XEN45, either alone or in combination with cataract surgery, and had a refractive error higher than -6 D and an axial length ≥26 mm. The primary endpoint was the mean intraocular pressure (IOP) lowering at the last follow-up visit. RESULTS: Thirty-one eyes were included (96.8% with a primary OAG diagnosis). The mean refraction was -13.2±5.6 (range: -6.75 to-23.0) D. In the overall study sample, preoperative mean IOP (95% CI) was significantly lowered from 23.5 (20.5-26.4) mm Hg to 13.0 (12.2-13.8) mm Hg at the last follow-up visit, P <0.0001. At the last follow-up visit, 16 (57.1%) eyes achieved an IOP ≤14 mm Hg, 11 (68.9%) of them without treatment. The number of ocular hypotensive medications was significantly reduced from 3.0±1.1 drugs at preoperatively to 0.6±1.0 drugs at the last follow-up visit, P <0.0001. Median (95% CI) follow-up was 24.0 (12.0-24.0) months. Linear regression analysis showed a significant correlation between the preoperative refraction and the IOP lowering ( r =0.43, P =0.0155). Needling procedure was performed in 11 eyes (39.3%) and hypotony (defined as an IOP <6 mm Hg) was observed in 8 eyes (28.6%) during the first postoperative day and remained for a week. CONCLUSION: Although the Xen implant effectively lowered IOP in highly myopic eyes with glaucoma, the incidence of hypotony was high, and in most cases, resolved within the first month with medical management and monitoring.

Enhancing Intermediate Vision in Patients Affected by Epiretinal Membrane Treated by Phaco-Vitrectomy.

BACKGROUND: The aim of this research was to see if a refractive enhanced monofocal IOL (Eyhance IOL, IOL Abbott Medical Optics, Inc., Santa Ana, CA, USA) can provide better intermediate vision in patients undergoing phaco-vitrectomy due to cataract and epiretinal macular membrane (ERM). METHODS: A nonrandomized prospective observational comparative study enrolled patients affected by cataract and ERM undergoing phaco-vitrectomy. A follow up of 6 months was established. Corrected and uncorrected visual acuity of both monocular and binocular types were assessed regarding intermediate and far distances. The CATQUEST 9-SF questionnaire was administered preoperatively and at the last follow-up. RESULTS: Twenty-three eyes of twenty-three patients were enrolled, with 11 in the enhanced monofocal group. The uncorrected and corrected distance visual acuity after 6 months was not statistically different. Both monocular and binocular uncorrected intermediate visual acuity after 6 months were higher in the enhanced monofocal group (p < 0.001). The corrected intermediate visual acuity after 6 months was higher in the enhanced monofocal group (p = 0.01). The CATQUEST-9SF questionnaire showed significant differences in the variation between the preoperative condition and six-month postoperative results (p < 0.001). CONCLUSIONS: This refractive enhanced monofocal IOL can provide better intermediate vision compared to a standard monofocal IOL in patients undergoing phaco-vitrectomy due to cataracts and ERM. Further studies are necessary to confirm these results.

Comparison of Visual and Aberrometric Outcomes in Suture-Free Scleral Fixation: Three-Piece Lenses versus Carlevale Lenses.

Purpose: To compare the refractive results between sutureless scleral fixation intraocular lens (IOLs) (Carlevale, Soleko) and suture-free scleral fixation three-piece IOLs (Sensar AR40, Johnson & Johnson) for secondary implantation in patients with IOL dislocation or aphakia. Methods: This is a monocentric retrospective study on 28 patients (28 eyes) with sutureless scleral fixation Carlevale IOL and 25 patients (25 eyes) with suture-free scleral fixation three-piece IOL. Best-corrected visual acuity (BCVA) evaluation, refractive measures and IOL tilt evaluation with anterior segment optical coherence tomography were conducted at one, three, six and twelve months after surgery. Point Spread Function (PSF) was measured using a total ocular aberrometer. Results: BCVA in both groups improved since the postoperative visit at 1 month and reached a stable value at 3 months At month 12, mean BCVA was 0.23 logMAR in group one and 0.32 logMAR in group two. Mean IOL tilt angle at 12 months was 2.76° ± 1.87 in group one and 2.51° ± 1.80 in group two. PSF at 12 months was 0.18 ± 0.09 in group one and 0.15 ± 0.05 in group two. There were no statistically significant differences (p > 0.05) for all comparisons. The post-operative complications were similar within the two groups. Conclusions: Our results show that secondary IOL implantation has similar visual and surgical outcomes when a sutureless Carlevale lens scleral fixation and a suture-free scleral fixation three-piece IOL are used.

A singular case of iatrogenic gas-filled double anterior chamber after DALK.

AIM: To present a case of double anterior chamber after DALK and its surgical management. CASE DESCRIPTION: A 67-year-old healthy woman underwent deep anterior lamellar keratoplasty (DALK) in her right eye for keratoconus with the big-bubble technique. About 7 days after surgery a partial detachment of the Descemet membrane from the posterior corneal stroma was revealed using AS-OCT (double anterior chamber appearance). In spite of two injections in the anterior chamber of air and gas on the 7th and 9th post-operative days respectively, the double anterior chamber still persisted. Furthermore, both air and gas passed through the little perforation of the host Descemet membrane-endothelium complex and enlarged the space between the stroma and Descemet membrane. About 10 weeks after DALK, a spontaneous resolution of the double anterior chamber was observed. CONCLUSION: This case suggests that an injection of air or gas into the anterior chamber, to deal with a Descemet membrane detachment following perforation during DALK procedure, can enlarge the double anterior chamber by increasing the space between stroma and Descemet membrane. These cases can be managed with a "wait and see" strategy for a spontaneous resolution to Descemet membrane detachment.

Efficacy and safety of intravitreal bevacizumab for the treatment of retinopathy of prematurity: a single-center retrospective review.

PURPOSE: The aim of this study is to report our experience in the management of type 1 retinopathy of prematurity (ROP) or aggressive posterior retinopathy of prematurity (APROP) in premature infants, who received intravitreal bevacizumab (IVB) injections either as first-line monotherapy or as rescue therapy following laser therapy. METHODS: Single-center retrospective study on 37 patients (74 eyes) affected by sight-threatening ROP that underwent treatment either with IVB alone or laser photocoagulation followed by IVB at the Neonatal Intensive Care Unit of Careggi University Hospital of Florence, between 2008 and 2015. RESULTS: Seventeen patients were males (45.9%) and 20 were females (54.1%). The mean gestational age was 24 weeks and the mean birth weight was 610 g. Fifty-six eyes (75.7%) of 28 patients were diagnosed as type 1 ROP and 18 eyes (24.3%) of nine patients as APROP. Sixty-six eyes of 33 patients received IVB as first-line monotherapy, eight eyes of four patients were treated with IVB after laser photocoagulation treatment, as rescue therapy. The mean postmenstrual age at treatment was 33.9 weeks. All the patients received bilateral injections. None of the infants required repeat injections. The mean follow-up time was 59.6 months. All the patients achieved a good response to treatment, showing the regression of the proliferative phase and a complete peripheral retinal vascularization within 2 months from the injection of bevacizumab. One patient with a bilateral ROP had only a partial resolution of a vitreous hemorrhage in the left eye. The procedures were well tolerated without local or systemic adverse events during the follow-up. No infants showed recurrences. Ocular motility alterations appeared in four patients (10.8%), with the absence of stereopsis in six cases (16.20%). After treatment, spherical equivalent values in cycloplegic refraction ranged from -4.0 D to +5.0 D, with a mean value of +1.75 D. All the patients showed a normal neuropsychomotor development. CONCLUSION: Our study confirms the effectiveness and safety of IVB in the treatment of ROP, both as monotherapy and rescue therapy after laser photocoagulation, according to the published literature.

Implantation of a Small Aperture Intraocular Lens in Eyes with Irregular Corneas and Higher Order Aberrations.

Purpose: Corneal irregularities can lead to high order aberrations (HOAs) and may influence the outcomes in terms of intraocular lens (IOL) selection and visual acuity assessment. The aim of this study was to evaluate the visual acuity and satisfaction after IC-8 implants in patients characterized by corneal irregularities and HOAs who could not undergo refractive surgery due to the poor residual thickness of the cornea or other conditions such as astigmatism secondary to previous radial keratotomy. Methods: This descriptive, retrospective cohort study was conducted on nine eyes in six patients affected by corneal irregularities and HOAs who had undergone IC-8 IOL implantation. The primary endpoint was the best-corrected visual acuity (BCVA), the subjective visual function, and the visual field. Results: Nine eyes of six patients (three bilateral implantation) were enrolled. For each patient, BCVA, vision, and lifestyle quality were evaluated. In all patients, we noticed an improvement in all parameters without visual field defects. Conclusion: Our work encourages the use of the IC8 lens to improve visual acuity in patients with irregular corneas and HOAs who cannot be treated with customized refractive surgery. Patients experience a subjective improvement of their quality of vision and also more self-confidence in their daily life. IC-8 lenses do not interfere with the visualization of retinal fundus and there is no impairment of the visual field detected by patients.

XEN Gel Staining with Trypan Blue: A Simple and Effective Technique to Improve Device Visualization during Implantation.

The Xen Gel Stent (Allergan, Irvine, CA, USA) is a hydrophilic collagen-based gelatin tube of 6 mm in length which creates a channel of communication between the anterior chamber and the subconjunctival space allowing aqueous humor outflow. XEN is an ab interno, minimally invasive, glaucoma surgery device which has a better safety profile and offers a less invasive way of lowering intraocular pressure. Unfortunately, one of its weaknesses is that visualization of the implant during surgery is difficult, and this difficulty may be exacerbated, for instance, by a subconjunctival hemorrhage. The purpose of this paper is to describe a simple and effective technique for improving device visualization (XEN 45 µm) during the implantation. How to cite this article: Ramovecchi V, Franco F, Barbera GR. XEN Gel Staining with Trypan Blue: A Simple and Effective Technique to Improve Device Visualization during Implantation. J Curr Glaucoma Pract 2021;15(3):161-163.

Patient and surgeon comfort in vitreoretinal surgery performed with Sub-Tenon's Anaesthesia.

Background. Since Stevens first introduced Sub-Tenon's anaesthesia into cataract surgery it has shown itself to be a safe, simple, and efficient technique. The advantages of this type of block are comparable to those of sharp needle anaesthesia and complications are minimal. Several studies have found that the anaesthesia provided by Sub-Tenon's capsule injection is as good as or better for cataract surgery than that achieved by retrobulbar injection, but the efficacy of Sub-Tenon's block in vitreoretinal surgery is less well established. Methods. We performed 50 vitreoretinal procedures; 50 eyes received a Sub-Tenon's injection of a 5 ml mixture (50:50) of lidocaine and ropivacaine, plus 15 IU mL-1 of Hyaluronidase. Results. In 45 cases, only one injection was needed to achieve sufficient anaesthesia and akinesia; in 5 cases a second injection was performed five minutes after the first. Mean surgical time was 45.7 minutes. After surgery, each patient was asked to indicate his value on the VAS pain scale. Mean VAS degree was 2.4. In 7 cases, VAS was > 3 and the pain was successfully managed with the administration of paracetamol in the postoperative period. No light perception was detected at the end of surgery in 33 patients. All cases with 2 injections had no light perception at the end of surgery. Anaesthesia lasted throughout the surgery in all cases. The surgeon performed all surgery comfortably and with no difficulty. Conclusions. According to our experience and to a growing body of evidence, Sub-Tenon's anaesthesia appears to be a safe, simple, versatile, and effective technique and should be considered as a real alternative method of anaesthesia in vitreoretinal surgery.

Efficacy and safety of Ab interno XEN gel implant after a failed filtering surgery.

Purpose: To evaluate the efficacy and safety of Ab interno XEN gel stent in patients with open angle glaucoma who underwent a previous failed filtering surgery. Methods: A retrospective, observational, multi-centered and descriptive cohort study was conducted from January 2019 to February 2020 on patients with primary open angle glaucoma (POAG) who underwent XEN gel stent implant after a failed filtering surgical procedure. Main parameters evaluated were: changes in IOP measured with Goldmann applanation tonometer, number of anti-glaucomatous eye drops, postoperative complications, and necessity of further surgical procedures. The quantification of quality of life was obtained from the VFQ-25 questionnaire. A descriptive analysis based on pre- post- and intra-operative data was carried out. Results: In all patients included in the study (6 patients for a total of 7 eyes), IOP dropped during the follow up time. We found a mean percentage reduction of -41.5% at 9 months compared to the preoperative data (baseline). IOP lowered from 21.71 ± 4.64 mmHg to 9 ± 3,21 mmHg 1 day after the operation, 11 ± 3.21 at 1 week, 11.42 ± 1.81 mmHg at 1 month, 12.42 ± 3.10 mmHg at 3 months, 13.57 ± 3.45 at 6 months, 12.71 ± 1.79 at 9 months. In 71.4%, the procedure turned out to be complication free and only one case required needling of the bleb in order to achieve optimal intraocular pressure control. A total of 71.4% patients reached a medication free regimen with a percentage of reduction in the mean number of drugs needed of -88.9%. Conclusion: In our experience, XEN gel stent implant performed in Caucasian patients with POAG and a history of failed filtrating surgery, showed to be an effective and safe procedure.

Perfluorodecalin Versus Densiron 68 Heavy Silicone Oil in the Management of Inferior Retinal Detachment Recurrence.

BACKGROUND AND OBJECTIVE: To assess the efficacy of perfluorodecalin (PFD) or Densiron 68 heavy silicone oil (HSO) in the management of inferior complex retinal detachment recurrence. PATIENTS AND METHODS: A retrospective, comparative consecutive case series study. Twenty-four eyes of 24 patients affected by inferior complex retinal detachment recurrence underwent pars plana vitrectomy with PFD or HSO as endotamponade. All patients recruited were affected by complicated inferior retinal detachments and had already undergone at least one vitreoretinal procedure. The primary endpoint was anatomical success with primary and secondary surgery. The secondary endpoints were functional outcome and inflammatory complications. RESULTS: Out of 24 cases of inferior retinal detachment recurrence, 12 were tamponed with PFD (PFD group) and 12 with HSO (D68 group). Retinal reattachment rate at first surgery was 50% for the D68 group and 66.6% for the PFD group. Final reattachment rate after two or more surgical operations was 91.6% for the PFD group and 83.3% for the D68 group. Best-corrected visual acuity improved in both groups from a mean of 1.00 logMAR (20/200; standard deviation [SD]: 1) to 0.60 logMAR (20/80; SD: 0.3), and from a mean of 1.81 logMAR (20/2000; SD: 1.1) to a mean of 2.00 logMAR (20/2,000; SD:1) for the PFD and D68 groups, respectively. CONCLUSION: Both the endotamponades used showed good results in solving inferior retinal detachment recurrence with a slightly better rate in the PFD group, but it was not statistically significant (P > .05). [Ophthalmic Surg Lasers Imaging Retina. 2019;50:274-280.].

IOL repositioning using iris sutures: a safe and effective technique.

This retrospective non-comparative consecutive case series study was conducted at Azienda Ospedaliera Universitaria Careggi, Florence, Italy and describes a useful intraocular lens (IOL) repositioning technique using iris sutures. In our study, 41 consecutive cases of posteriorly dislocated IOLs were surgically treated between January 2015 and May 2017. Six of the cases were post-traumatic luxations, and 20 patients had pseudoexfoliation syndrome. All the patients underwent pars plana vitrectomy and same IOL repositioning using iris sutures. The mean follow-up was 12.2mo. The mean preoperative best corrected visual acuity (BCVA) was 0.10±0.15 logMAR, whereas the mean postoperative BCVA was 0.08±0.14 logMAR. The mean postoperative BCVA did not change significantly from the preoperative BCVA. The final mean spherical equivalent was -0.44±0.49 SD. Three lenses (7.31%) were found tilted during post-operative follow-up. Two eyes (4.87%) had postoperative cystoid macular edema. No eyes had endophthalmitis, hypotony, retinal or choroidal detachment. The iris fixation technique seems to be a safe and valid option for the management of dislocated IOLs.