Topical Insulin in Neurotrophic Keratopathy: A Review of Current Understanding of the Mechanism of Action and Therapeutic Approach.

Neurotrophic keratopathy is a corneal disease characterized by impaired corneal innervation. It can lead to corneal epithelial defects, ulcerations, and perforations. Topical insulin has been shown to be effective in treating this disorder. Insulin is a growth factor that can promote corneal epithelial cell proliferation and migration. In addition, it can also inhibit corneal epithelial cell apoptosis. Topical insulin has previously been found to enhance corneal wound healing. This article reviews the current understanding of the mechanism of action of topical insulin in the treatment of neurotrophic keratopathy.

Recurrent Intraocular Lens Dislocation in a Patient with Familial Ectopia Lentis.

A 36-year-old patient presented to the hospital with recurrent dislocation of the intraocular lens (IOL). The patient with the diagnosis of familial ectopia lentis was first operated on for crystalline lens subluxation in the left eye in 2007 and in the right eye in 2009. In both eyes, lens extraction with anterior vitrectomy and transscleral fixation of a rigid IOL was performed. In 2011, the IOL in the right eye luxated into the vitreous cavity due to ocular trauma. The patient underwent a pars plana vitrectomy with the IOL resuturation to the sclera. Seven years later, a spontaneous vision loss in the right eye was caused by a retinal detachment. The pars plana vitrectomy with silicone oil tamponade and a consequential oil removal three months later were performed in 2018. The follow-up examination revealed recurrent IOL dislocation in the same eye. Due to a history of previous suture-related complications a decision was made to remove the subluxated rigid polymethyl-methacrylate (PMMA) IOL and fixate to sclera a sutureless SOLEKO FIL SSF Carlevale lens. The purpose of this report is to present a single case of a 36-year-old patient who was presented to the hospital with recurrent dislocation of the intraocular lens. In a three-month follow-up period, a good anatomical and functional outcome was finally obtained with transscleral sutureless intraocular lens. This lens is an option worth considering especially in a young patient with a long life expectancy and physically active.

Non-penetrating very deep sclerectomy with a hydrophobic polymer implant in a rabbit model.

PURPOSE: The aim of the study was to evaluate the influence of an implant made of a terpolymer (PTFE-PVDF-PP) on the condition of rabbit eyes during a one year observation period. METHODS: The implant in the shape of an equilateral triangle (3 mm side length) was manufactured from a thin hydrophobic porous membrane. There were evaluated 40 eyes of 20 rabbits. The animals had non-penetrating very deep sclerectomy (NPVDS) performed, with insertion of an implant in the form of a triangular thin membrane. The control group consisted of 20 eyes where the animals had NPVDS performed without implant insertion. The evaluations included the study of the anterior part of the eye together with photographic documentation. Histopathological examination of the eyes 52 weeks after NPVDS procedure has been made. The process of wound healing was comparable in both groups. RESULTS: The evaluation of the rabbits did not reveal any acute process of intraocular inflammation. After 12 month period of observation, no statistically significant differences in the process of wound healing or status of eyes were found between the groups. An analysis of fibrous connective tissue attachment to the implant showed that its layer was not thick and did not differ significantly from the control. The procedure of very deep sclerectomy and insertion of a polymer implant were well tolerated by the rabbit eyes. CONCLUSIONS: The in vivo results indicate that the hydrophobic implant in the form of a membrane can serve as a sclera implant after further study.

Histopathological Evaluation of a Hydrophobic Terpolymer (PTFE-PVD-PP) as an Implant Material for Nonpenetrating Very Deep Sclerectomy.

PURPOSE: The purpose of the study was to assess the biocompatibility of porous terpolymer (polytetrafluoroethylene-co-polyvinylidene fluoride-co-polypropylene, PTFE-PVDF-PP) membranes as an implant material to be placed during nonpenetrating very deep sclerectomy (NPVDS). Another study objective was to determine whether the polymer membrane under investigation could be used to manufacture a new-generation implant, which would actively delay the process of fistula closure and facilitate aqueous humor drainage. METHODS: Histological response and tissue tolerance of the implant material were assessed. The study was performed on 38 eyeballs of 19 New Zealand white rabbits (19 implanted, 19 control). Histological assessment was carried out between 2 and 52 weeks after surgery. We routinely assessed inflammatory infiltrate, neovascularization, hemorrhage, and stromal edema as well as connective tissue attachment to the implant and adjacent tissues. RESULTS: At 52 weeks of observation, a statistically significant difference was revealed between the study and control groups in terms of resorptive granulation, tissue, and the inflammatory infiltrate. No features of acute inflammatory response to the implant were observed, and there was an absence of histological features of acute inflammatory infiltrates and subsidence of chronic inflammatory infiltrates and resorptive granulation over time. CONCLUSIONS: Slight fibrotic response and insignificant changes in neighboring eye tissues all indicate good tolerance to bioimplant materials. This allows for some optimism regarding the use of hydrophobic terpolymer in the construction of new intrascleral implants. However, the ultimate decision regarding its usefulness and safety in the treatment of glaucoma requires further investigation.

Nonpenetrating very deep sclerectomy with hyaluronic acid implant vs trabeculectomy--a 2-year follow-up.

OBJECTIVE: To study and compare the efficacy and safety of nonpenetrating very deep sclerectomy (NPVDS) with the use of hyaluronic acid implant (SKGEL) to trabeculectomy (TB) in patients with with medically uncontrolled glaucoma. METHODS: Prospective, controlled study of patients with open-angle glaucoma was designed. Seventy-eight eyes of 68 patients with medically uncontrolled glaucoma were assigned either to the NPVDS or to the TB group of trial. Examinations were applied before and 7 days, 1, 3, 6, 12, 18, and 24 months after surgery. MAIN OUTCOME MEASURE: Best-corrected logMAR visual acuity, intraocular pressure, number of additional procedures, antiglaucoma medications, number of complications. RESULTS: At 24 months, success rate defined as IOP ≤ 21 mmHg with medication and additional procedures in NPVDS group was 92.31 %, and 94.88 % in control group (p = 0.64). There was no statistically significant difference between intraocular pressure in NPVDS (14.56 ± 4.07 mmHg ) and control (TB) (15.38 ± 3.38 mmHg) group (p = 0.34). Number of glaucoma mediations decreased from 2.18 ± 0.56 to 0.54 ± 0.56 in NPVDS and from 2.28 ± 1.41 to 0.61 ± 0.03 in TB group (p = 0.71). Early and late postoperative complications included two cases of hyphema, two of choroidal detachment, two of filtering bleb fibrosis, four of cataract progression in the NPVDS group; and five cases of hyphema, four of choroidal detachment, one of filtering bleb fibrosis, one of blebitis, and 12 of cataract progression in the control group. CONCLUSIONS: NPVDS is an effective surgical option for patients with medically uncontrolled glaucoma. NPVDS is associated with a lower risk of complications, and in particular cataract progression, compared to TB. APPLICATION TO CLINICAL PRACTICE: NPVDS is a modification of NPDS devised for patients with medically uncontrolled open-angle glaucoma.

In vivo biocompatibility assessment of (PTFE-PVDF-PP) terpolymer-based membrane with potential application for glaucoma treatment.

The aim of the work was to evaluate the in vivo biological behaviour of polymeric membrane materials for glaucoma implants. The base material was biostable synthetic terpolymer (PTFE-PVDF-PP) with proved biocompability (PN-EN ISO 10993). The samples manufactured in the form a membrane were subjected to chemical and physical treatment to create an open pore system within the polymer matrix. As a porogenic phase biodegradable natrium alginate in a fibrous form was employed. The non-perforating deep sclerectomy technique was performed in a rabbit model. The clinical observations were made after 14 and 30 days. During the study clinical symptoms of a moderate degree were observed, and histopathological changes were typical for foreign body implantation. At the end stage of the study no significant difference in histopathological assessment was found between control and experimental group. Similarities observed in both groups and relatively mild histopathological changes in the tissue surrounding the implant indicate that the observed symptoms come from a deep scleral trauma caused by surgery, and not by the presence of the implant itself.

Etiopathogenesis and management of high-degree myopia. Part I.

High-degree myopia (HM) is defined as a refractive error above -6 D (-8 diopters). An axial eyeball length above 26 mm and is also connected with excessive myopisation. Mechanical stretching and thinning of the choroids may lead to the development of irreversible degenerative changes in the eyeball and visual impairment. HM prevalence varies significantly by geographical area, ranging from 1.7-3.3%, while in highly urban regions of South-East Asia it affects up to 24% of university students. HM is not a homogenous disease. It is considered to be inherited in different patterns: dominant, autosomal recessive, and X-linked. Many genetic mutations linked to HM development have been described and the different patterns of inheritance may reflect different types of HM. Moreover, the clinical state of the HM eyeball may result from both genetic and environmental risk factors influencing the progression of the refractive error. The development and progression of HM is connected with sustained prolonged near work involving accommodation-convergence imbalance leading to retinal blur, the years spent at school, the amount of near work, especially writing and reading, which is related to slight chronic under-accommodation, and improper light stimuli in early childhood. Contemporary definitions of HM, views on etiopathogenesis, excessive axial elongation, and pathological changes within the eyeball in the course of HM leading to visual impairment are presented here. Genetic and environmental risk factors influencing the progression of HM, its significantly different prevalence in various geographical areas, and therapeutic options for the refractive error are also presented.

Contact transscleral cyclophotocoagulation in the treatment of neovascular glaucoma: a five-year follow-up.

BACKGROUND: The purpose of the study was to evaluate the long-term efficacy of contact transscleral cyclophotocoagulation (TSCPC) performed after panretinal photocoagulation and cryoapplication in patients with angle closure neovascular glaucoma. MATERIAL/METHODS: Thirty eyes of 30 patients with angle closure neovascular glaucoma were enrolled (15 women and 15 men, mean age: 55+/-21 years). Diode TSCPC was performed in all patients after panretinal photocoagulation and cryotherapy. Follow-up was 60 months. RESULTS: The mean pretreatment and postoperative intraocular pressures (IOPs) were 39.8+/-12 and 20.6+/-3.6 mmHg, respectively (p<0.00001). The mean number of treatment sessions was 2.4+/-1.5 (range: 1+/-7), with 18 eyes receiving only one treatment. There was a decrease in visual acuity in 3, hyphema in 4, uveitis in 2, cataract in 3, and phthisis in 1 eye. CONCLUSIONS: 1. TSCPC provides long-term control of IOP in patients with angle closure neovascular glaucoma. 2. Laser panretinal photocoagulation and cryoapplication should be considered before TSCPC. 3. TSCPC is associated with numerous complications, hyphema being the most frequent.

Nonpenetrating very deep sclerectomy with reticulated hyaluronic acid implant in glaucoma treatment.

BACKGROUND: The purpose of our study was to assess intraocular pressure control (IOP) and postoperative complications in nonpenetrating very deep sclerectomy (NPVDS) with reticulated hyaluronic acid implant (SKGEL) and Mitomycin C (MMC). MATERIAL/METHODS: Fifty eyes from fifty patients with medically uncontrolled glaucoma were randomized to either the NPVDS or NPDS group. The NPVDS procedure was similar to traditional NPDS (control group); however, excision of sclera and exposure of ciliary body were also performed, and only a narrow scleral flap was retained at a distance of 0.5 mm from Schlemm's canal. Mitomycin-C 0.2 mg/ml was applied on and under the superficial flap of the sclera during both NPVDS and NPDS. Follow-up examinations were carried out at 1 week, and then at 1, 3, 6, and 12 months after surgery. Success was defined as IOP <22 mmHg with or without glaucoma medication and laser procedures. RESULTS: The 12-month success rate in the NPVDS group was 96%, not significantly higher than in the control group (88%, p=0.88). There was no statistically significant difference in IOP between the NPVDS (15.9+/-2.5 mmHg) and NPDS (16.3+/-3.6 mmHg) groups (p=0.57). Complications included four cases of hyphema, three of choroidal detachment (myopic eyes), and one of filtering bleb fibrosis in the NPVDS group, and three cases of hyphema, two of choroidal detachment (myopic eyes), and three of filtering bleb fibrosis in the NPDS group. CONCLUSIONS: NPVDS is an effective surgical modality for patients with glaucoma. The safety of NPVDS is comparable to that of NPDS.

[Non-penetrating deep sclerectomy in the treatment of advanced cases of open angle glaucoma]. / Zastosowanie nieprzenikajacej sklerektomii glebokiej w leczeniu zaawansowanych postaci jaskry pierwotnej otwartego kata przesaczania.

PURPOSE: The purpose of the paper was to examine the efficacy of non-penetrating deep sclerectomy (NPDS) with sodium hyaluronate implants and mitomycin C in the treatment of advanced cases of open angle glaucoma. MATERIAL AND METHODS: Thirty-five eyes of 35 patients with medically uncontrolled advanced open angle glaucoma were retrospectively analyzed. Visual acuity and intraocular pressure measurement were performed before and after surgery at 1 and 7 days and 1, 6 and 12 months. Visual field was analyzed before and 12 months after surgery. RESULTS: The mean preoperative intraocular pressure was 27+/-3.1 mm Hg and 18.1+/-1.5 at 12 month after surgery (p<0.05). Visual acuity decreased more than two rows on Snellen chart in 4 patients. Visual field analysis shows mean defect MD--17+/-5.2 before surgery and 20.1+/-6.2 after 12 month of follow up (p>0.05). Complete success rate defined as an IOP lower than 21 mmHg without medications was 51%. In 3 eyes we performed needling and in 8 goniopuncture. Postoperative complications included hyphaema in 3 eyes, choroidal detachment in 1 eye, bleb fibrosis in 2 eyes. CONCLUSIONS: 1. Deep sclerectomy with SK-GEL implant and antimetabolites provided good reasonable control of intraocular pressure. 2. In uncomplicated cases it let us achieve stabilization of the visual field.

[Cyclodestructive procedures in secondary glaucoma in children]. / Zabiegi cyklodestrukcyjne w jaskrze wtórnej u dzieci.

PURPOSE: Comparison of the effectiveness and safety of cyclocryocoagulation and transscleral contact cyclophotocoagulation with diode laser (TSCPC) in children. PATIENTS AND METHOD: Sixty nine eyes of 60 children at the age from 4 months to 16 years were examined. Majority of patients was aphakic after congenital, traumatic and complicated cataract extraction. Aniridia, Sturge-Weber disease and ROP complications were observed. In 40 eyes cyclocryotherapy (I group), in 29 eyes TSCPC (II group) were performed. Intraocular pressure (IOP) was assessed in the early and late postoperative period. The number of procedures per one eye, IOP, visual acuity, and complications after cyclodestructive procedures were estimated. Follow-up ranged from 3 months to 4 years, mean 23 months. RESULTS: Transscleral cyclocryocoagulations were performed once to 4 times in one eye with intervals from 1 month to 1 year, mean 1.3 procedures per eye. TSCPC was performed once in 29 eyes and twice in 4 cases, it was 1.14 procedures per eye. Before treatment IOP ranged from 21.3 to 50.6 mmHg, mean 29.18 mmHg in the I group and 24.4-54 mmHg mean 34.85 mmHg in the II group and in the early postoperative period were 10-25 mmHg, mean 17.7 and 2-26 mmHg, mean 14.65 mmHg relatively. Decreasing of IOP was observed in 39% of eyes after cryotherapy and 57.9% after TSCPC, p = 0.0003. In the long-term follow-up in IOP below 22 mmHg after cyclocryotherapy in 60% of eyes and after TSCPC in 79% was observed. Visual acuity ranged from no light perception to 0.5, mean 0.04. No changes of vision after cyclocryocoagulation were noted. After TSCPC transient visual function decreased from 0.2 to 0.04 in 1 eye but recovered after 2 weeks. After cyclocryotherapy only conjunctival oedema was observed in majority of cases. In the early postoperative period after TSCPC uveitis occured in 3 eyes (10.35%), transient hypotony in 2 eyes, hyphaema in one eye. CONCLUSION: Diode cyclophtocoagulation decreases IOP more effective than cyclocryocoagulation in children but complications after TSCPC are more severe than after cyclocryotherapy.

[Use of scanning laser ophthalmoscope and scanning laser polarimeter in diagnosis and monitoring of early stages of primary open-angle glaucoma]. / Zastosowanie skaningowego oftalmoskopu laserowego oraz skaningowego polarymetru laserowego we wczesnej diagnostyce i monitorowaniu jaskry pierwotnej otwartego kata.

PURPOSE: To evaluate the usefulness of scanning laser ophthalmoscope (TopSS) and scanning laser polarimeter (GDx) in diagnosis and monitoring patients suspected of primary open angle glaucoma (POAG). MATERIAL AND METHODS: In eighty eyes of 40 patients, we performed TopSS, GDx and static perimetry (Octopus 123) in the time period of three years. RESULTS: The GDx analysis showed progression of changes in the retinal fiber thickness in 28 (35%) eyes (p<0.05). In 18 eyes we found non-specific changes in GDx examinations, which were related to no glaucomatous reason. TopSS analysis of the optic nerve head revealed progression in c/d in 16 (20%) eyes (p<0.05). In seven eyes we detected changes in the visual field, which were more strongly connected with changes in TopSS than GDx. CONCLUSIONS: 1. The TopSS and GDx examinations enabled diagnosis and monitoring of early glaucomatous changes in the period of observation. 2. The GDx examination seems to be more sensitive, and TopSS more specific to glaucoma.

[Laser therapy in the treatment of glaucoma]. / Zastosowanie laseroterapii w leczeniu jaskry.

PURPOSE: The paper is presenting the possibility of laser surgery in the treatment of glaucoma, new operations, and laser equipment. In the treatment of primary open angle glaucoma, argon laser was replaced by diode laser with continuous wave and in recent years by Nd:YAG Q switch, second harmonic 532 nm. This laser allows ophthalmologists for selective photoablation of cells with pigment in trabeculum without thermal effect. The introduction of fibers to transport energy let us increase accuracy and efficacy of laser therapy. Application of excimer lasers 308 nm enables to perform trabeculectomy by internal (ELT) and deep sclerectomy. After NPDS we sometimes have to use Q switch Nd:YAG for goniopuncture, to prolong filtration function of trabeculum--Descemet membrane. In primary angle closure glaucoma the most often laser treatment is iridotomy and gonioplasty. Laser cyclodestructive procedures almost completely eliminated cyclodiathermy and cyclokriotherapy, which were performed so far. The main cyclophotocoagulative procedures are contact transscleral cyclophotocogulation, transpupillary cyclophotocoagulation and intraocular cyclophotocoagulation. CONCLUSIONS: 1. The introduction of lasers enables safer, quicker and more effective antiglaucoma operations. 2. New laser equipment increases efficacy of so far performed laser surgery. 3. Laser surgery allows for the resignation of patients hospitalization and thereby enables to decrease the cost of treatment, and to increase the comfort of patients.

Transscleral cyclophotocoagulation in the treatment of secondary glaucoma.

BACKGROUND: The purpose of this study was to evaluate the results obtained by using transscleral cyclophotocoagulation (TSCPC) in the treatment of refractory secondary glaucoma. Our study attempted to assess the functional effects of TSCPC in different types of secondary glaucoma. MATERIAL/METHODS: We studied 83 eyes in 81 patients: 52 men and 29 women, aged 9-88 years old (mean 52.8+/-21.85). Contact transscleral cyclophotocoagulation was performed with an OcuLight SLx photocoagulator using a G probe. The follow-up period was 12 months. All the eyes were photographed for documentation of details. RESULTS: The mean intraocular pressure (IOP) significantly decreased, from 46+/-12 mmHg at baseline to 18+/-6.4 mmHg (p<0.05) at the end of the 12-month observation period. Average visual acuity showed no statistically significant changes. The number of TSCPC procedures ranged from 1 to 4. The number of anti-glaucoma drugs decreased from 2.8+/-0.9 to 1.9+/-0.9 (p<0.05). The T/E coefficient was the lowest in pediatric secondary glaucoma (p<0.05). Most of the severe complications developed in neovascular glaucoma (p<0.05). CONCLUSIONS: Contact transscleral cyclophotocoagulation effectively decreases intraocular pressure and the number of anti-glaucoma medications and also alleviates pain in the majority of patients with severe secondary glaucoma. Patients with neovascular glaucoma are at the highest risk of severe complications following TSCPC. TSCPC was the least effective in patients with refractory pediatric glaucoma. Since there is a risk of photocoagulative damage to the sclera and conjunctiva, areas of hyperpigmentation, hemorrhage and scleral thinning should be avoided.