Evaluation of macular vessel density changes after strabismus surgery using optical coherence tomography angiography.

PURPOSE: To compare retinal vessel density before and after strabismus surgery using swept-source optical coherence tomography angiography (SS-OCTA). METHODS: In this longitudinal, single-arm pilot study, vascular density in the deep capillary plexus (DCP), superficial retinal capillary plexus (SCP) and choriocapillaris layer (CCL) in consecutive subjects undergoing strabismus surgery was assessed using SS-OCTA preoperatively (T0), on the first day postoperatively (POD1), and 30 days postoperatively (POD30). RESULTS: A total of 92 eyes of 56 patients (54% males) were included. Mean patient age was 41.1 ± 22.7. OCT vascular density of the DCP was 50.20 ± 5.57 at T0, 52.74 ± 4.77 at POD1, and 50.92 ± 4.58 at POD30. The differences were statistically significant for T0 versus POD1 (P < 0.05). Vascular density of the CCL was 50.72 ± 4.80 at T0, 53.59 ± 3.65 at POD1, and 51.39 ± 4.64 at POD30. The differences were statistically significant for T0 versus POD1 (P < 0.05). No significant differences were found in SCP (P > 0.05). CONCLUSIONS: Transitory hemodynamic changes can occur in the DCP and in the CCL following muscle recession procedures.

Sutureless "Contact Lens Sandwich" Technique for Amniotic Membrane Therapy of Central Corneal Ulcers.

PURPOSE: To describe a new technique for sutureless and glue-free amniotic membrane transplantation (AMT) and to investigate its effectiveness to treat corneal persistent epithelial defects (PEDs), compared to bandage contact lens (BCL) application alone. METHODS: We performed AMT with "contact lens sandwich technique" (CLS-AMT) in 8 consecutive patients with central/para-central (up to 4.00 mm from the geometrical centre) PED/ulceration and we retrospectively compared the results with 11 BCL procedures. RESULTS: The procedures were performed successfully with no complications.CLS-AMT showed significantly shorter healing time than BCL (24.0 ± 19.1 vs 42.9 ± 14.6 days; P < 0.05, Mann-Whitney test). Recurrence rates were 12% and 27% for CLS-AMT and BCL, respectively. CONCLUSION: CLS-AMT technique, based on the suction effect due to the superposition of a bandage contact lens on the AM-ring complex, represents a quick, low cost, easy to perform and nearly non-invasive AMT technique. This approach is able to provide adequate fixation of AM, and it seems to be a safe and effective treatment for patients with PEDs.

Optical coherence tomography angiography application to pigmented iris: Could a new index quantify blood flow?

PURPOSE: To assess the blood flow and vascular visibility of irises in relation to pigmentation and pupil size, using an anterior segment optical coherence tomography angiography (OCTA). MATERIALS AND METHODS: This is a cross-sectional study. OCTA images were acquired in the nasal and temporal quadrants from a cohort of 30 healthy subjects in photopic (miosis) and scotopic (mydriasis) conditions. Patients were divided according to iris color (less pigmented: group L vs more pigmented: group D). Vascular parameters (vessel density (VD), vessel length density (VLD), fractal dimension (FD)) were applied and compared among groups L and D, location and different pupil status. A novel vascular index called Luminance Index (LI) was developed and applied in order to quantify vascular flow and evaluate its variation in photopic and scotopic conditions. Multivariable analyses were performed to evaluate possible predictors of VD and LI. RESULTS: No differences were found for all vascular measurements (VD, VDL, FD, LI) between nasal and temporal quadrants. All vascular measurements were higher in group L than in group D (p < 0.05), except for LI and FD in photopic condition. In group L, all vascular parameters increased (p < 0.001) after dark adaptation. In group D, only LI increased after dark adaptation (p < 0.001). Pigmentation and iris thickness were significantly associated with VD in scotopic and photopic conditions, and with LI only in scotopic condition. CONCLUSIONS: Pigmentation still remains a major issue for vascular visibility. Quantitative and qualitative vascular changes follow pupil size variation. LI could be a new surrogate to quantify blood flow.

Optical coherence tomography angiography for the measurement of optic disc: Macular relationship.

INTRODUCTION: Fundus photography is the gold standard for assessing ocular torsion over the last 30 years. However, it is not a precise and reproducible tool during clinical practice. Optical coherence tomography angiography is characterized by precise identification of the macula and the optic disc, and it could be an effective method to easily calculate the angle of ocular torsion, compared to fundus photography. The aim of this study was to show whether any difference in the measurement and the accuracy of the angle of torsion between the head of the optic nerve and the fovea was present. METHODS: This is a prospective single-, referral-center study conducted at the San Giuseppe Hospital in Milan on 80 eyes of 40 adult patients, included in a random-sample way. Exclusion criteria were non-cooperation, higher refractive errors of ±3 diopters, retinal and optic disc pathologies, and ocular movement disorders. RESULTS: Patients' mean age was 54.3 ± 16.3 (range: 22-83) years. The angle measured by the fundus camera was 7.78° ± 3.04°, while the angle measured by the angiography was 7.09° ± 3.08° (p = .035). The mean interocular difference was 1.54° ± 3.42° for fundus photography and 0.5° ± 4.71° for angiography (p = .013). CONCLUSION: Optical coherence tomography angiography is a very useful, fast, precise, reproducible, and reliable technique in cooperative subjects, not inferior to the fundus camera and less prone to human error.

Asymmetric superior oblique split Z-tendon lengthening for face turn in bilateral asymmetric superior oblique overaction and exotropia.

INTRODUCTION: The aim was to evaluate the effectiveness of the procedure of the superior oblique split Z-tendon lengthening to collapse A pattern and treat face turn in a cohort of patients with both incomitant intermittent exotropia and a vertical deviation associated with a bilateral asymmetric superior oblique overaction. METHODS: We retrospectively reviewed the clinical records of patients with facial turn associated with intermittent exotropia and bilateral asymmetric superior oblique overaction, who underwent superior oblique muscle split tendon lengthening and concurrent horizontal surgery between 2009 and 2017. RESULTS: A total of eight patients met the inclusion criteria. The preoperative average face turn was 26.8° (range, 20°-5°), and it significantly improved to 5.4° (range, 2°-8°) (p < 0.05). All the patients showed an improvement in the face turn with neutralization of the vertical deviation. The vertical deviation in the right gaze for the patient with a right turn and the left gaze in patients with left turn improved significantly (values of p < 0.05). CONCLUSION: The superior oblique split Z-tendon lengthening was an effective procedure to collapse the A pattern and the treatment of the face turn in a cohort of patients with both incomitant intermittent exotropia and a vertical deviation associated with a bilateral asymmetric superior oblique muscle overaction with less complications, and less varying results.

The Ocular Surface Frailty Index as a Predictor of Ocular Surface Symptom Onset after Cataract Surgery.

PURPOSE: The identification of healthy persons more susceptible to dry eye (DED) symptoms developing after surgery remains an unmet need. We performed this study to build a new Ocular Surface Frailty Index (OSFI) and assess its predictive value for DED symptom onset after cataract surgery. DESIGN: Single-center, observational, longitudinal study. PARTICIPANTS: We screened 405 consecutive patients scheduled for phacoemulsification for age-related cataract. Two hundred eighty-four eyes of 284 patients without preoperative DED symptoms who underwent uneventful cataract surgery were included in the analysis. METHODS: We built a tool to assess ocular surface frailty. Starting from a preliminary list of 19 potential items, the final OSFI, including 10 deficits in ocular surface health, factors potentially able to affect it, or both, was developed by a stepwise approach. Preoperative OSFI results were calculated for each enrolled patient and diagnostic tests for DED were performed at the screening visit and 1 week, 1 month, and 3 months after surgery. We evaluated the ability of OSFI to predict the presence of DED symptoms at 1 month or 3 months after surgery, or both. MAIN OUTCOME MEASURES: The rate of ocular surface symptoms at 1 month or 3 months after surgery, or both. RESULTS: Our patients' OSFI scores ranged from 0 to 0.666, with a median value of 0.200. The percentage of patients with postsurgical ocular surface symptoms was 17%. Using an OSFI cutoff of 0.300, we identified a small group (19% of the asymptomatic patients) with frail ocular surfaces who showed a significantly higher risk of postsurgical DED symptoms develop (50.0% vs. 9.6%; P < 0.001, chi-square test). Logistic regression analysis showed that OSFI results of 0.3 or more (but not age, gender, or any preoperative sign) was a good predictor of ocular surface symptom onset (odds ratio, 9.45; 95% confidence interval, 4.74-18.82). Regression remained significant when performed on 200 bootstrapped samples. CONCLUSIONS: The OSFI can be calculated easily and quickly using noninvasive and low-tech procedures, and it proved to be predictive of postoperative DED symptoms onset. This novel tool may allow cataract surgeons to perform a useful preoperative personalized risk assessment.

Imaging Biomarkers for Dry Eye Disease.

The clinical, scientific, economic, and regulatory impact of validated biomarkers and surrogate endpoints has the potential to revolutionize the approach to ocular surface diseases. At present, there is a growing interest in developing biomarkers for dry eye disease, and other ocular surface disorders and imaging are of the most promising approaches to this issue. Among the several and constantly evolving imaging technologies, some tools that are aimed to assess tear film stability and volume, meibomian gland morphology and function, and ocular surface microanatomy are now supported by a good body of evidence. To date, clinical trials on ocular surface diseases have slowly started incorporating imaging biomarkers for disease diagnosis and stratification and as surrogate endpoints. Major efforts are still needed, mainly aimed to improve automatic acquisition and quantitative analysis, standardization (standard operating procedures, normative databases etc.), and validation of imaging biomarkers.

High-dose-rate brachytherapy as monotherapy for localized prostate cancer using three different doses - 14 years of single-centre experience.

PURPOSE: To evaluate clinical outcomes in patients with localized prostate cancer (LPC) treated with 3D conformal high-dose-rate (HDR) brachytherapy (BT) as monotherapy. MATERIAL AND METHODS: From March 2004 to November 2017, 277 men with LPC underwent 3D conformal HDR-BT as monotherapy, with a temporary implant. The dose prescription was: 38 Gy in 4 fractions (149 patients), 27 Gy in 2 fractions (41 patients), and 19-20 Gy in a single fraction (87 patients). Biochemical progression-free survival (bPFS), progression-free survival (PFS), and cancer-specific survival (CSS) were calculated. Acute and late genitourinary (GU) and gastrointestinal (GI) toxicity assessment were performed using Common Terminology Criteria for Adverse Events v5.0. RESULTS: The mean age was 67 (range, 47-81) years. Overall, 145 patients were low-risk, 116 intermediate-risk, and 16 high-risk prostate cancer. After a median follow-up of six years (range, 6-160 months), bPFS, PFS, and CSS were 81%, 96%, and 97%, respectively. Dose prescription, initial prostate specific antigen (iPSA) ≥ 9,5 ng/ml, and high-risk disease resulted in prognostic factors regarding bPFS. Only G2-G3 acute or late GI and GU toxicities were observed. CONCLUSIONS: HDR-BT as monotherapy is a valid and safe treatment modality for localized prostate cancer. After a long follow-up, patients receiving 19-20 Gy in a single fraction had a lower biochemical control rate compared to patients receiving 38 Gy in 4 fractions or 27 Gy in 2 fractions. Randomized prospective trials with a longer follow-up are necessary to confirm our results, and define total doses and dose per fraction for HDR-BT in patients with LPC.

Mushroom keratoplasty and contact lens application: Strategy for management of a pediatric eye injury.

We show the challenging visual rehabilitation of a penetrating eye injury in a child with wide central corneal scar and aphakia. A 9-year-old male patient underwent combined surgery, including membranectomy with pupilloplasty and mushroom penetrating keratoplasty. Corneal transparency was restored; aphakia and irregular astigmatism were corrected first with a rigid gas-permeable contact lens (CL) and then, successfully, with hybrid CL. We discuss the surgical treatment used to restore corneal transparency and the choice of the best CL to overcome irregular astigmatism and aphakia.

Efficacy of atropine 0.01% for the treatment of childhood myopia in European patients.

PURPOSE: To evaluate the efficacy and safety of atropine 0.01% in slowing myopia progression in European paediatric patients. METHODS: Retrospective, medical records review study. Medical charts of paediatric patients with a myopia progression > 0.5 D/year treated with atropine 0.01% for at least 1 year were included. Patients receive a complete ophthalmic examination before and 12 months after initiation of atropine treatment. A group of myopic untreated children serves as a control group. The rate of myopia progression at baseline and 12 months after treatment with atropine was evaluated. The rate of myopia progression in treated and untreated patients was also compared. Adverse events were recorded. RESULTS: Medical records of 52 treated and 50 control subjects were analysed. In the atropine group, the mean rate of myopia progression after 12 months of treatment (-0.54 ± 0.61 D) was significantly slower compared with the baseline progression (-1.20 ± 0.64 D; p < 0.0001) and to the progression in the control group (-1.09 ± 0.64; p < 0.0001). The responders patients were 41/52 (79%), whereas 11/52 patients (21%) showed a progression > 0.50 D despite treatment. The only adverse event was temporary photophobia in five patients (9.6%), severe adverse events were not reported, and none of the patients discontinued the treatment. CONCLUSION: Low-dose atropine significantly slowed the rate of myopia progression in European paediatric patients with a favourable safety profile.

WIDE-FIELD SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY.

PURPOSE: To describe wide-field spectral domain optical coherence tomography morphologic relationships of the vitreous, retina, and choroid in healthy and pathologic eyes. METHODS: Standardized horizontal, vertical, and two oblique (supertemporal to inferonasal and supranasal to inferotemporal) spectral domain optical coherence tomography sections were collected for each patient. For extramacular imaging, images were obtained from 8 locations: (1) nasal to the optic disk, (2) extreme nasal periphery, (3) superior to the superotemporal vascular arcade, (4) extreme superior periphery, (5) inferior to the inferotemporal vascular arcade, (6) extreme inferior periphery, (7) temporal to the macula, and (8) extreme temporal periphery. Wide-angle montage images of optical coherence tomography from equator-to-equator were composed with a montaging software. RESULTS: Wide-field spectral domain optical coherence tomography scans were obtained in 10 healthy subjects, in 7 patients with central serous chorioretinopathy, in 5 patients with wet age-related macular degenerations, in 5 patients with dry age-related macular degenerations, in 4 patients with retinitis pigmentosa, and in 1 patient with acute exudative polymorphous vitelliform maculopathy. CONCLUSION: The novel approach of montaging spectral domain optical coherence tomography images to examine relationships between the choroid, retina, and associated structures adjacent to and outside of the macula may have a number of relevant applications in the study of vitreoretinal interface, paramacular and macular pathologic features.

A case of acute exudative polymorphous vitelliform maculopathy: follow-up and wide-field spectral-domain optical coherence tomography.

PURPOSE: To present a case of an HIV-positive patient with acute exudative polymorphous vitelliform maculopathy (AEPVM) and evaluate the presence of specific spectral-domain optical coherence tomography (SD-OCT) findings. METHODS: Case report. RESULTS: We reviewed the AEPVM cases reported in the literature and compared those to our patient to determine if there is a correspondence between the etiology that leads to the onset of AEPVM and clinical and SD-OCT findings. CONCLUSIONS: Acute exudative polymorphous vitelliform maculopathy is a disease that involves the outer retinal layers with lipofuscin deposits and serous detachment of the neuroepithelium with or without intraretinal cysts. Not much is known about the etiology and pathogenesis, and not many cases have been described. A review of the few clinical cases reported in the literature does not show a specific correspondence between etiology and SD-OCT findings.

Wide-field spectral domain-optical coherence tomography in central serous chorioretinopathy.

The aim the study was to describe wide-field spectral-domain optical coherence tomography morphologic relationships of the vitreous, retina, and choroid in central serous chorioretinopathy (CSCR) eyes. Standardized horizontal, vertical, and two oblique (supertemporal to inferonasal and supranasal to inferotemporal) SD-OCT sections were collected for 40 patient with CSCR. For extramacular imaging, images were obtained from eight locations: (1) nasal to the optic disk, (2) extreme nasal periphery, (3) superior to the superotemporal vascular arcade, (4) extreme superior periphery, (5) inferior to the inferotemporal vascular arcade, (6) extreme inferior periphery, (7) temporal to the macula, and (8) extreme temporal periphery. Wide-angle montage images of OCT from equator to equator were composed with a montaging software. Average subfoveal choroidal thickness was 478 ± 114 µm (range 232-695 µm) at the macular level, 367 ± 94 µm in the superior periphery, 257 ± 103 µm in the inferior periphery, 431 ± 121 and 280 ± 88 µm in the nasal and in the temporal periphery, respectively. Wide-field EDI-OCT revealed a relative thinning of the inner choroidal layer in the periphery, including the small and medium large vessels, which ranged from 86 µm nasally to 120.1 µm superiorly, with a mean of 98.8 ± 13.6 µm. Beneath the thinned inner choroidal layer, hyporeflective lumina, corresponding to the outer choroidal layer, were identified in the periphery of all eyes. The outer choroidal layer thickness ranged from 175.5 µm temporally to 235.5 µm superiorly, with a mean of 217.8 ± 41.4 µm. The novel approach of montaging SD-OCT images to examine relationships between the choroid, retina, and associated structures adjacent to and outside of the macula may have a number of relevant applications in the study of pathologic features of central serous chorioretinopathy.

Static and rotational intensity modulated techniques for head-neck cancer radiotherapy: a planning comparison.

PURPOSE: To compare helical Tomotherapy (HT), two volumetric-modulated arc techniques and conventional fixed-field intensity modulated techniques (S-IMRT) for head-neck (HN) cancers. METHODS AND MATERIALS: Eighteen HN patients were considered. Four treatment plans were generated for each patient: HT, S-IMRT optimised with Eclipse treatment planning system and two volumetric techniques using Elekta-Oncentra approach (VMAT) and Varian-RapidArc (RA), using two full arcs. All techniques were optimised to simultaneously deliver 66Gy to PTV1 (GTV and enlarged nodes) and 54Gy to PTV2 (subclinical and electively treated nodes). Comparisons were assessed on several dosimetric parameters and, secondarily, on planned MUs and delivery time. RESULTS: Concerning PTV coverage, significantly better results were found for HT and RA. HT significantly improved the target coverage both compared to S-IMRT and VMAT. No significant differences were found between S-IMRT and volumetric techniques in terms of dose homogeneity. For OARs, all the techniques were able to satisfy all hard constraints; significantly better results were found for HT, especially in the intermediate dose range (15-30 Gy). S-IMRT reached a significantly better OARs sparing with respect to VMAT and RA. No significant differences were found for body mean dose, excepting higher values of V5-V10 for HT. A reduction of planned MUs and delivery treatment time was found with volumetric techniques. CONCLUSIONS: The objectives of satisfying target coverage and sparing of critical structures were reached with all techniques. S-IMRT techniques were found more advantageous compared to RA and VMAT for OARs sparing. HT reached the best overall treatment plan quality.

Acceptance tests of diagnostic displays in a PACS system according to AAPM TG18.

In a filmless environment it is necessary to execute acceptance and constancy tests on monitors used for interpretation of medical images. Performances of Barco CRT MGD521 MKII, Barco LCD L685EX monitors have been evaluated. Acceptancepress were executed following AAPM Task Group 18 guidelines. Visual and instrumental evaluations of geometric distortions, reflections, luminances response, contrast, uniformity, resolution, angular response and veiling glare were made. Barco monitors showed optimal performances, while EIZO monitors were accepted with some reserve on their quality level. Finally a comparative evaluation between monitors and film (the actual gold standard) was performed by an interview of ten radiologists: the monitors showed a quality at least equal to film. These monitors are currently in use for routine medical interpretation.