Particular Anatomy of the Hyperopic Eye and Potential Clinical Implications.

Background and Objectives: Hyperopia is a refractive error which affects cognitive and social development if uncorrected and raises the risk of primary angle-closure glaucoma (PACG). Materials and Methods: The study included only the right eye-40 hyperopic eyes in the study group (spherical equivalent (SE) under pharmacological cycloplegia over 0.50 D), 34 emmetropic eyes in the control group (SE between -0.50 D and +0.50 D). A complete ophthalmological evaluation was performed, including autorefractometry to measure SE, and additionally we performed Ocular Response Analyser: Corneal Hysteresis (CH), Corneal Resistance Factor (CRF); specular microscopy: Endothelial cell density (CD), Cell variability (CV), Hexagonality (Hex), Aladdin biometry: Anterior Chamber Depth (ACD), Axial Length (AL), Central Corneal Thickness (CCT). IBM SPSS 26 was used for statistical analysis. Results: The mean age of the entire cohort was 22.93 years (SD ± 12.069), 66.22% being female and 33.78% male. The hyperopic eyes had significantly lower AL, ACD, higher SE, CH, CRF. In the hyperopia group, there are significant, negative correlations between CH and AL (r -0.335), CRF and AL (r -0.334), SE-AL (r -0.593), ACD and CV (r -0.528), CV and CRF (r -0.438), CH (r -0.379), and positive correlations between CCT and CH (r 0.393) or CRF (r 0.435), CD and ACD (r 0.509) or CH (0.384). Age is significantly, negatively correlated with ACD (r -0.447), CH (r -0.544), CRF (r -0.539), CD (r -0.546) and positively with CV (r 0.470). Conclusions: Our study suggests a particular biomechanical behavior of the cornea in hyperopia, in relation with morphological and endothelial parameters. Moreover, the negative correlation between age and ACD suggests a shallower anterior chamber as patients age, increasing the risk for PACG.

Diplopia due to a neurovascular compression.

A 36-year-old female patient presented to our clinic with a two months history of diplopia and dizziness. The symptoms appeared gradually and increased in frequency and intensity. She had no significant medical history and she did not take any medication. A full ophthalmological consult was performed, which revealed restricted ocular motility in the left eye (LE), in left gaze. Otherwise, the examination showed no pathological findings: best corrected visual acuity (BCVA) both eyes (OU) 1 (Snellen chart), normal slit lamp examination and pupillary reflexes, normal intraocular pressure (IOP) and fundus aspect. Diplopia tests revealed a horizontal diplopia, exacerbated in left gaze. Sixth nerve palsy suspicion was raised and the patient was directed to the neurology department. Following magnetic resonance imaging, with angiographic sequence, a complex intracerebral vascular malformation that interacted with the cranial nerves and determined horizontal diplopia, was found. For a correct diagnosis, we needed a good collaboration between various medical specialties, especially ophthalmology and neurology, because patients with diplopia often present for the first time at the ophthalmologist. Abbreviations: BCVA = best corrected visual acuity, IOP = intraocular pressure, LE = left eye, RE = right eye.

Corneal Biomechanics - an Emerging Ocular Property with a Significant Impact.

Corneal biomechanical properties reflect the capacity of the cornea to respond to applied mechanical forces. They are an increasingly important domain in ocular pathology, correlated to the diagnosis and evolution of eye diseases such as refractive errors, glaucoma or corneal ectasias. Refractive errors constitute a significant etiology of decreased vision worldwide, with a particular impact in children. Myopic eyes significantly differ from emmetropic eyes in terms of morphology and biomechanics, with differences being reported in both adults and children. In the latter, corneal hysteresis (CH) and the corneal resistance factor (CRF) are significantly lower in myopic individuals, and both biomechanical parameters correlate with the central corneal thickness and axial length. Glaucoma is a progressive optic neuropathy that leads to thinning of the nerve fiber layer and specific visual field loss, in which intraocular pressure (IOP) is an important risk factor. There is an inverse correlation between IOP and CH - a low hysteresis is associated with a high IOP. Furthermore, CH is on average lower in primary open angle glaucoma (POAG) compared to ocular hypertension (OHT) for the same IOP. Significant correlations between CH and the thickness of the ganglion cell layer (GCL) and retinal nerve fiber layer (RNFL), in both POAG and OHT, have been described. Keratoconus is the most frequent corneal ectasia, which leads to a progressive thinning and protruding of the cornea. Biomechanical parameters are severely affected in keratoconus - usually, both CH and CRF are lower compared to normal eyes. The biomechanical behavior of the cornea modulates the evolution of several ocular pathologies. As research is ongoing, more data will enable us to apply this knowledge in diagnosing disease more efficiently and targeting the right treatment for the right patient, including refractive surgery.

The pathophysiology of Sumatriptan induced non-arteritic anterior ischemic optic neuropathy.

Objective: To report a case of a non-arteritic anterior ischemic optic neuropathy (NAAION) in a patient treated with Sumatriptan. Materials and methods: NAAION represents a severe affection that frequently determines irreversible visual acuity damage. The exact cause is yet to be identified, but is usually connected to the systemic status of the patient. We presented the case of a 53-year-old female patient who complained of visual acuity loss in her right eye, associated with inferior visual field (VF) damage. Patient history revealed migraine attacks, raised arterial blood pressure (BP), mitral valve insufficiency and dyslipidemia. Systemic treatment included Sumatriptan for migraine attacks and Bisoprolol for arterial hypertension. Results: A complete ophthalmologic examination was performed, including a visual field examination and optic coherence tomography. Interdisciplinary consults, along with inflammatory biomarkers, brain scan and cardiovascular Doppler echography were used to establish the final diagnosis. Considering the patient's history, systemic medication, clinical picture, paraclinical findings and interdisciplinary check-ups, NAAION was established as a diagnosis. Discussion: NAAION occurs more frequently after the age of 50 years old and may be associated with systemic factors such as nocturnal hypotension, diabetes, atherosclerosis, sleep apnea. In the present case, the association of medically induced nocturnal hypotension and vasoconstriction led to optic nerve ischemia. Conclusions: In a patient with multiple pathology, we must consider the systemic therapy when performing any clinical examination. Abbreviations: AAION = arteritic anterior ischemic optic neuropathy, AION = anterior ischemic optic neuropathy, BCVA = best corrected visual acuity, BP = blood pressure, CS = corticosteroid, IOP = intraocular pressure, LE = left eye, MRI = magnetic resonance imaging, NAAION = non-arteritic anterior ischemic optic neuropathy, OCT = optical coherence tomography, ON = optic nerve, OU = both eyes, RE = right eye.

Ultrasound biomicroscopy in glaucoma assessment.

Ultrasound biomicroscopy (UBM) is an important tool in the diagnosis, evaluation and follow up of glaucoma patients. Even if we are dealing with a primary angle closure glaucoma (PACG) or a primary open angle glaucoma (POAG) patient, the mechanism of angle closure can be revealed by performing an UBM. The device can help differentiate between the two types of glaucoma even in patients with opaque corneas when gonioscopy cannot be performed. Knowing the type of glaucoma is vital, especially regarding an individualized treatment, since each patient is unique and needs to be treated accordingly, in order to prevent glaucomatous optic neuropathy and visual field loss. Abbreviations: AC = anterior chamber, ICE = iridocorneal endothelial syndrome, IOP = intraocular pressure, NTG = normal tension glaucoma, PACG = primary angle closure glaucoma, PC = posterior chamber, PEX = pseudoexfoliation syndrome, POAG = primary open angle glaucoma, UBM = ultrasound biomicroscopy.

The Relationship Between Corneal Hysteresis and Retinal Ganglion Cells - A Step Forward in Early Glaucoma Diagnosis.

BACKGROUND Glaucoma is a major cause of irreversible visual field (VF) loss across the world. Many studies have assessed the accuracy of glaucoma diagnostic tests for a more precise diagnosis to quickly identify patients with higher risk of progression. MATERIAL AND METHODS We conducted a study that included 214 eyes divided into 3 groups: 79 eyes from patients diagnosed with primary open-angle glaucoma (POAG), 68 eyes from patients diagnosed with ocular hypertension (OH), and 67 eyes from normal individuals (normal eyes, NE). All patients included in the study received a complete checkup. RESULTS In POAG patients, means of central corneal thickness (CCT), corneal hysteresis (CH), corneal resistance factor (CRF), mean defect (MD), visual field index (VFI), peripapillary retinal nerve fiber layer (pRNFL), and ganglion cell complex (GCC) are lower than in OH patients, and in NE are higher than in both groups. Also, we found a statistically significant direct correlation between CH and GCC thickness. Further statistical analysis revealed that both pRNFL thickness and GCC thickness are significantly influenced by CH value in a precise manner. CONCLUSIONS The first cell type affected in glaucoma is the retinal ganglion cell. We found a positive correlation between GCC thickness and CH, suggesting that CH might be a parameter to consider in the evaluation of all glaucoma patients from their first examination. Moreover, both pRNFL thickness and GCC thickness are influenced by CH, suggesting the utility of monitoring the value of CH at every checkup to detect its decrease in glaucoma patients.

Update on Myopia Risk Factors and Microenvironmental Changes.

The focus of this update is to emphasize the recent advances in the pathogenesis and various molecular key approaches associated with myopia in order to reveal new potential therapeutic targets. We review the current evidence for its complex genetics and evaluate the known or candidate genes and loci. In addition, we discuss recent investigations regarding the role of environmental factors. This paper also covers current research aimed at elucidating the signaling pathways involved in the pathogenesis of myopia.

Ultrasound biomicroscopy as a vital tool in occult phacomorphic glaucoma.

Ultrasound is a fundamental tool used in all medical specialties, including ophthalmology. Nowadays, ultrasound biomicroscopy (UBM), a method with higher resolution, allows the investigation of in vivo details of the anterior segment of the eye at microscopic resolution. The examination is especially useful in patients with secondary glaucoma that involves a lens component such as phacomorphic glaucoma and occult phacomorphic glaucoma (OPG). The purpose of this paper was to familiarize audience with UBM and the importance of this investigation in OPG, by presenting a series of cases in which performing an UBM was vital because it provided the information needed in order to safely accomplish a curative surgical treatment that preserved our patients' visual acuity.

The importance of corneal assessment in a glaucoma suspect - a review.

Glaucoma represents the main cause of irreversible blindness in the world and for this consideration, the interest in a quick and precise diagnosis and progression of the disease, prior to the appearance of irreversible damage, has been continuously rising. Glaucoma risk factors are already well known, but current studies reveal that it is necessary to make a proper analysis of the intraocular pressure (IOP) to obtain an accurate diagnosis, so we must take into consideration corneal properties that might affect IOP measurements. Starting from corneal geometrical properties represented by central corneal thickness (CCT) and continuing with biomechanical properties represented by corneal hysteresis (CH) and corneal resistance factor (CRF) we reviewed the value of investigating corneal properties in ocular hypertension (OH), primary open angle glaucoma (POAG) and normal tension glaucoma (NTG) patients. We can now say that CCT plays an important role in diagnosing glaucoma because it may mask the real value of the IOP and also, in setting the target for the IOP needed to stop disease progression. Also, CH is a factor that needs to be screened from the first consult of a glaucoma patient or suspect because it is correlated to the response to treatment, visual field (VF) and retinal nerve fiber layer (RNFL) progression and could anticipate the future evolution and patients prognosis. Both CCT and CH are factors that must be thought-about when we encounter a glaucoma suspect. CCT has a predictive role in OH and NTG patients, while CH has on the other hand a prognostic role in POAG, OH and NTG patients.

Goldenhar Syndrome - ophthalmologist's perspective.

Goldenhar syndrome (oculo-auriculo-vertebral dysplasia, OAVS) is a rare, congenital disease arising from the abnormal development of the first and second branchial arches. The incidence is between 1:3500 and 1:5600, with a male: female ratio of 3:2. The etiopathogenesis is multifactorial and dependent on genetic and environmental factors but there are still many unknown aspects. The classic features of Goldenhar syndrome include ocular anomalies - epibulbar dermoids, microphthalmia and coloboma, ENT features such as preauricular tragi, hearing loss, low implantation of the auricular pavilion, micrognathia, and vertebral anomalies such as scoliosis or hemivertebrae. The abnormalities are unilateral in 85% of the cases. Ocular features, especially bilateral dermoids are seen in 60% of the cases. The treatment varies with age and systemic associations, from mainly cosmetic, in uncomplicated cases, to complex reconstructive surgeries in severe cases. While the oculoplastic surgeon manages the oculo-palpebral defects, severe forms require a multidisciplinary approach. Treatment should be individualized, adapted to age, as well as to the extent and severity of the disease. The paper is based on the editorial team cases and experience.

The importance of corneal biomechanics in assessing first degree family members of keratoconus patients.

Aim: to determine the values of biomechanical parameters (corneal hysteresis - CH, corneal resistance factor - CRF and keratoconus match index - KMI) in patients with keratoconus and their first degree family members. The purpose of the present study was to investigate the importance of assessing corneal biomechanics in subjects at risk of developing the primary ectasia. Materials and methods: 48 participants divided into three groups were analyzed in an observational study after a complete ophthalmological exam with the primary focus on Ocular Response Analyzer. Results: The mean values of CH, CRF, and KMI in the group of relatives were lower compared with the controls but higher when compared with keratoconus patients. We noted significant differences of CH and CRF between all three groups, while in the case of KMI, only the keratoconus group presented statistically significant differences compared with the relatives, respectively with the healthy subjects. Conclusions: the decreased values of CH and CRF may raise the question whether corneal biomechanics could be an adjuvant tool in the screening of a first-degree family member of a keratoconus patient in the attempt of the early detection of a possible forme fruste keratoconus.

Overexpression of Tear Inflammatory Cytokines as Additional Finding in Keratoconus Patients and Their First Degree Family Members.

Keratoconus is a progressive corneal ectasia that may lead to severe visual impairment due to the irregular astigmatism caused by corneal thinning. In addition to its association with atopy, eye rubbing, or genetic component, late reports suggest the involvement of inflammation in the pathogenesis of the disease. Our aim was to determine the concentration of IL-4, IL-6, IL-10, RANTES, IFN gamma, and TNF alpha in the tear film of patients with keratoconus and their first degree family members. We analyzed forty-eight participants in an observational cross-sectional study. The diagnosis of keratoconus had to be confirmed in addition to a minimum of 47 D corneal refractive power by corneal topography readings provided by a Placido-based topography system and analysis of the pattern: irregular astigmatism with an asymmetric "bow-tie." As for the other groups, the most important diagnosis criteria were a normal topographic pattern with a regular astigmatism. 17 keratoconus patients, 16 relatives, and 15 controls were recruited after clinical assessment as part of the research. The cytokine's mean values were similar in the keratoconus group and the relatives' samples but significantly higher compared to the controls. Important differences were found in IL-4 levels between keratoconus patients and relatives and between relatives and controls (mean difference of 302.42, p < 0.0016 and 219.16, p < 0.033, Tukey's HSD procedure). In the keratoconus group, using the CORR procedure, we found statistically strong correlations of IL-6 lacrimal concentrations with the disease stage (r = 0.56, p < 0.01), keratometry (r = 0.55, p < 0.02), pachymetry (r = -0.64, p < 0.048), and corneal hysteresis (r = -0.53, p < 0.02). Cytokine overexpression may be relevant for the inflammatory etiology of keratoconus. In conclusion, in the case of some first degree family members, the elevated tear biomarkers may represent a supplementary risk factor.

The ganglion cell complex as an useful tool in glaucoma assessment.

Glaucoma is known as an optic neuropathy prone to progression that determines characteristic not only structural (loss of the ganglion cells as well as their axons) but also functional defects (visual field loss). Objective: To evaluate the possibility of applying ganglion cell complex analysis (GCC) in patients who associate ocular hypertension with tilted disc and marked peripapillary atrophy. Methods: In order to evaluate its components, GCC can be investigated using the Optical Coherence Tomography (OCT) revealing: ganglion cell layer (cells bodies), inner plexiform layer (dendrites and synapses), and nerve fiber layer (axons). Our study included 196 eyes divided into 3 groups: 52 diagnosed with primary open angle glaucoma (POAG), 63 with ocular hypertension (OH), and 81 healthy (normal) eyes (NE). All eyes were submitted to a complete ophthalmologic checkup that involved advanced optic nerve and GCC evaluation. Results: A positive statistically significant correlation was identified between the GCC thickness and the RNFL in all three categories taken into account: R=0,6, p<0,0001 for glaucoma group, R=0,66, p<0,0001 for OH group and R=0,46, p<0,0001 for normal group. Conclusions: GCC has been proved useful for the assessment of the retinal nerve fiber layer (RNFL) in eyes with OH that associate tilted disc or peripapillary atrophy where the optic disc edges might not be certainly determined by the OCT.

The importance of ganglion cell complex investigation in myopic patients.

Glaucoma is an optic neuropathy that affects the ganglion cell complex in all its components: cell bodies, dendrites, and axons, the dendritic arbor being the first one damaged. This is the reason why the thickness of the ganglion cell and internal plexiform layers can be taken into account as an early predictor of the glaucomatous changes, along with the retinal nerve fiber layer (RNFL) thickness. However, due to disc tilting and peripapillary atrophy, the RNFL evaluation may be prone to errors in myopic patients. We presented the cases of two myopic patients, who, after a routine examination, were identified as glaucoma suspects. The Optical Coherence Tomography (OCT) scan revealed a nerve fiber loss which was not confirmed by the ganglion cell complex scan. Thereafter we manually adjusted the optic disc margins according to the patients' myopic changes and this time the retinal nerve fiber layer was also normal. We observed that the ganglion cell complex evaluation led to fewer errors than the retinal nerve fiber layer evaluation, particularly in front of a myopic patient. Nevertheless, various investigations should be considered in the attempt to issue a diagnosis of glaucoma.

Inflammatory Biomarkers Profile as Microenvironmental Expression in Keratoconus.

Keratoconus is a degenerative disorder with progressive stromal thinning and transformation of the normal corneal architecture towards ectasia that results in decreased vision due to irregular astigmatism and irreversible tissue scarring. The pathogenesis of keratoconus still remains unclear. Hypotheses that this condition has an inflammatory etiopathogenetic component apart from the genetic and environmental factors are beginning to escalate in the research domain. This paper covers the most relevant and recent published papers regarding the biomarkers of inflammation, their signaling pathway, and the potentially new therapeutic options in keratoconus.

Secondary congenital aphakia.

UNLABELLED: Abstract PURPOSE: We present the clinical, paraclinical and therapeutic features in a patient with secondary congenital aphakia. METHODS: A 2-year-old patient, diagnosed with congenital rubella syndrome including sensorineural deafness, congenital heart disease, intellectual disability, microcephaly, microphthalmia, and congenital cataract, presented to our clinic for the surgical treatment of cataract. RESULTS: During the surgery, the absence of the lens' cortex was observed, hence, the final diagnose was of secondary congenital aphakia. Surgery was then continued with a posterior capsulorhexis and an anterior vitrectomy, deciding to postpone the implantation of the posterior chamber intraocular lens.

The importance of assessing corneal biomechanical properties in glaucoma patients care - a review.

Purpose: to familiarize the public with the role of corneal biomechanics in glaucoma patient management. Methods: Ocular Response Analyzer (ORA) is the only device that measures in vivo corneal biomechanics. Recent studies regarding "corneal biomechanics and glaucoma" were reviewed and the obtained data were compared in order to present a better understanding of the corneal biomechanical properties involvement in glaucoma care. Results: According to the studies reviewed, in primary open angle glaucoma (POAG) the mean corneal hysteresis (CH) and the corneal resistance factor (CRF) were approximately 2 mmHg lower than in normal eyes. In ocular hypertension (OH), the mean CH was about 1mmHg higher than in POAG patients and 1mmHg lower than in the control group, while the mean CRF was about 2mmHg higher than in POAG and 1mmHg higher than in the control group. Regarding the normal tension glaucoma (NTG), there were studies that showed that the mean CH and CRF were approximately 1mmHg lower than in POAG and studies that showed similar values between the POAG and NTG groups. The mean CH did not differ much between POAG and angle closure glaucoma (ACG), being lower than in normal individuals, while CRF appeared to be higher in the ACG than in normal individuals. Concerning congenital glaucoma (CG), both CH and CRF were about 2mmHg lower than in normal eyes. Conclusions: Corneal biomechanics influenced the IOP measurement and have been proven to be of a great significance in glaucoma patients regardless of the central corneal thickness (CCT). Lower values of CH and CRF could suggest an alteration in the corneal response associated to glaucoma.

Correlations between Corneal Biomechanics and Glaucoma Severity in Patients with Primary Open Angle Glaucoma.

OBJECTIVES: To investigate the relationship between corneal biomechanical changes and glaucoma severity in primary open angle glaucoma patients. DESIGN: Correlation study. MATERIALS AND METHODS: Our study included 70 glaucomatous eyes; they were divided in groups using Glaucoma Staging System Based on Humphrey Visual Field. Ocular Response Analyzer (ORA) was used in order to determine corneal hysteresis (CH) and corneal resistance factor (CRF); ultrasonic pachimetry (Ocuscan) to measure central corneal thickness (CCT) and Humphrey Visual Analyser to determine mean deviation (MD), pattern standard deviation (PSD) and visual field index (VFI). For statistical analysis we used descriptive analysis and linear regression using IBM SPSS Statistics Standard. OUTCOMES: Out of the 70 eyes with primary open angle glaucoma examined that had visual acuity 0,7 or better, 35 were included in stage 1 (MD 0.01dB -> -6dB), 21 in stage 2 (MD -6.01dB -> -12dB) and 14 in stage 3 (MD -12.01dB -> -20dB). A considerable statistic correlation was found between CH and VFI both in the entire group of primary open angle glaucoma patients( r=0.44, p<0.001), and in stages 1 (r=0.44, p<0.009), 2 (r=0.51, p<0.01) and 3 (r=0.52, p<0.05). CONCLUSION: The study shows a moderate correlation, statistically significant, between corneal hysteresis and visual field index in glaucoma patients. Ocular response analyzer can be considered an useful instrument in evaluation of primary open angle glaucoma patients.