Argon laser trabeculoplasty for congenital ectropion uveae: Case report and review of the literature.

A 18-year-old woman with unilateral glaucoma secondary to congenital ectropion uveae (CEU) in the right eye, without other systemic and ocular associations. Intraocular pressure (IOP) was uncontrolled under topical therapy. The visual field (VF) was within normal limits; retinal nerve fiber layer (RNFL) thickness, as evaluated by Optical Coherence Tomography (OCT), was reduced. The patient refused surgical intervention. After evaluation of the iridocorneal angle, ALT was performed as follows: 95 spots were applied for the 270 ° of visible trabecular meshwork using a laser beam diameter of 50 µm, an exposure time of 0.1 s and a power of 750 mw). Mean IOP in the right eye, as evaluated by diurnal tonometric curve, was 10 mmHg, 16 mmHg and 20 mmHg respectively one month, four months and eight months after ALT, with no additional topical therapy, and 18 mmHg twelve months after ALT with topical therapy. CEU is a rare, non-progressive anomaly characterized by the proliferation of iris pigment epithelium on anterior surface of iris; glaucoma, in this disorder, is often poorly controlled with medical therapy alone. In a phase of initial glaucomatous damage and with a not particularly high IOP, as in this case, ALT could be an alternative therapeutic option at least in the short-term, when surgery is not feasible immediately. In fact, given its limited effectiveness over time, ALT can be used as a temporary control measure of IOP, pending surgery to become feasible.

Diagnostic delay in ADHD: Duration of untreated illness and its socio-demographic and clinical predictors in a sample of adult outpatients.

AIM: To investigate the Duration of Untreated Illness (DUI) and its socio-demographic and clinical predictors in a sample of adult ADHD outpatients. METHODS: The DUI of 150 adult outpatients with a confirmed diagnosis of DSM-IV ADHD was calculated. Non-parametric tests were used to evaluate differences in DUI among subgroups and to build a correlation matrix. Subsequently, a multiple linear regression model was performed. RESULTS: The median DUI was 17 years (interquartile range [IQR] = 14). DUI was longer in employed patients, those with a family history of ADHD, those with a history of major depressive disorder and those who had predominantly inattentive ADHD in childhood. The current age, age at administration of the first proper treatment and education level were correlated with DUI. Current age (63.3% of total variance), family history of ADHD and the presence of a predominantly inattentive type in childhood (together, 2.6% of total variance) were all predictors of DUI. CONCLUSIONS: Information programmes for caregivers and training for health care professionals should be promoted to foster the early recognition of covert inattentive symptoms and shorten DUI.

Survey on centres and procedures for the diagnosis and treatment of adult ADHD in public services in Italy.

Attention deficit/hyperactivity disorder (ADHD) often persists into adulthood. Although its persistence and relative high prevalence, ADHD in adults is often underdiagnosed and undertreated in Italy, leading to poor clinical and functional outcomes, and higher costs of illness. The aims of the study were to identify the Italian mental health services for ADHD in adults, describe the diagnostic and treatment procedures they follow, and compare this offer with the recommendations of the German and English guidelines. The centres, that adopt a clinical and assessment protocol for adult ADHD diagnosis (carried out by specifically trained personnel) and prescribe pharmacological treatment for adult ADHD, were selected from the list of accredited services provided by the Appendix B.2 of the ISTISAN 16/37 Reports of the ISS. An ad-hoc survey including open-ended and close-ended questions was sent to each selected centre in February 2020. The overall picture resulting from the data analysis was compared with the recommendations of the German and English guidelines. The present survey shows that only a few centres are specialised in the diagnosis and treatment of ADHD in adults in Italy. Furthermore, there are no national guidelines for adult ADHD in Italy. The collected data also suggest that there is no a unified practice shared by the Centres both for the patient's transition from child and adolescent to adult mental health services and for the diagnostic-therapeutic process. It is therefore crucial to create specific protocols and develop national guidelines to better identify and diagnose ADHD in adults and provide targeted and more efficient multimodal treatments.

RE-PERG, a new paradigm for glaucoma diagnosis, in myopic eyes.

PURPOSE: To evaluate reliability of steady-state pattern electroretinogram (ssPERG) phase variability in re-test (procedure called RE-PERG) in the presence of myopia, which is known to affect ssPERG amplitude, in glaucomatous patients (GP), normal controls (NC), and myopic patients (MY). METHODS: The procedure was performed on 50 GP, 35 NC, and 19 MY. All subjects were examined with RE-PERG, spectral-domain coherence tomography (SD-OCT), and standard automated perimetry (SAP). Standard deviation of phase (ssPERG SDph) and mean amplitude value (ssPERG Amp) of second harmonic (2ndH) were correlated, by means of one-way ANOVA and Pearson correlation, with mean deviation (MD) and pattern standard deviation (PSD) assessed by SAP and retinal nerve fiber layer (RNFL) and ganglion cell complex (GCC) thickness assessed by SD-OCT. Receiving operating characteristics were calculated in cohort populations with and without myopia. RESULTS: GP showed significant differences from the control group for MD, PSD, RNFL, GCC, ssPERG Amp, and ssPERG SDph; GP also showed significant differences from the MY group for all the parameters except for ssPERG Amp, which is reduced in both groups. In GP group, ssPERG Amp showed a specificity of 82.1% (95% confidence interval [CI]I: 66.5-92.5). In MY group, ssPERG Amp was reduced in 58% of the patients. As a consequence of this, in GP and MY groups, considered as a whole, total specificity dropped to 70.69% (95% CI: 57.3-81.9). In the GP group, ssPERG SDph showed a specificity of 84.6% (95% CI: 69.5-91.1). In both GP and MY groups, considered as a whole, ssPERG SDph total specificity increased from 84.6% to 93.1% (95% CI: 83.3-98.1). CONCLUSION: Intrinsic phase variability of ssPERG is not influenced by myopia, even in the presence of fundus alterations.

RE-PERG, a new procedure for electrophysiologic diagnosis of glaucoma that may improve PERG specificity.

PURPOSE: A significant variability of the second harmonic (2ndH) phase of steady-state pattern electroretinogram (SS-PERG) in intrasession retest has been recently described in glaucoma patients (GP), which has not been found in healthy subjects. To evaluate the reliability of phase variability in retest (a procedure called RE-PERG or REPERG) in the presence of cataract, which is known to affect standard PERG, we tested this procedure in GP, normal controls (NC), and cataract patients (CP). METHODS: The procedure was performed on 50 GP, 35 NC, and 27 CP. All subjects were examined with RE-PERG and SS-PERG and also with spectral domain optical coherence tomography and standard automated perimetry. Standard deviation of phase and amplitude value of 2ndH were correlated by means of one-way analysis of variance and Pearson correlation, with the mean deviation and pattern standard deviation assessed by standard automated perimetry and retinal nerve fiber layer and the ganglion cell complex thickness assessed by spectral domain optical coherence tomography. Receiver operating characteristics were calculated in cohort populations with and without cataract. RESULTS: Standard deviation of phase of 2ndH was significantly higher in GP with respect to NC (P<0.001) and CP (P<0.001), and it correlated with retinal nerve fiber layer (r=-0.5, P<0.001) and ganglion cell complex (r=-0.6, P<0.001) defects in GP. Receiver operating characteristic evaluation showed higher specificity of RE-PERG (86.4%; area under the curve 0.93) with respect to SS-PERG (54.5%; area under the curve 0.68) in CP. CONCLUSION: RE-PERG may improve the specificity of SS-PERG in clinical practice in the discrimination of GP.

Ex-Press Mini-Implant in the Management of Ocular Hypertension Secondary to Silicone Oil Tamponed.

This study was designed to compare the success of patients with ocular hypertension, secondary to pars plana vitrectomy and silicone oil tamponade, who received an Ex-PRESS Glaucoma Filtration Device P50 (Alcon Laboratories, Inc. Fort Worth, Texas, USA) to those who had conventional trabeculectomy. The records of 10 eyes of 10 consecutive subjects who had Ex-press implants and 9 eyes of 9 consecutive controls who had trabeculectomy procedures were reviewed. Success was defined as the reduction of intraocular pressure (IOP) in patients who did not require further glaucoma surgery in the eye of note during the entire follow-up. IOP was reduced by 10.3 ± 9.7 mmHg (range -31 to 3) in the Ex-PRESS group and by 13.9 ± 11.4 mmHg (range -35 to -4) in the trabeculectomy group. The difference in the percentage of IOP reduction between the standard trabeculectomy group (42.7%) and the Ex-PRESS group (35.9%) was not statistically significant (P = 0.72). The Ex-PRESS device seems to be at least as effective as the standard trabeculectomy in lowering the IOP of patients with hypertension secondary to pars plana vitrectomy and silicone oil tamponade. Even though the data suggested that the Ex-PRESS device did not result in an overall greater reduction in IOP than trabeculectomy, this does not reach statistical significance.

Surgical reposition of a dislocated Ex-PRESS miniature device.

PURPOSE: To present a technique of surgical reposition of the Ex-PRESS miniature glaucoma device when dislocated in corneal limbus. METHODS: A 54-year-old woman diagnosed with glaucoma, with a 3-month history of Ex-PRESS miniature implant, was referred to our department because of progressive intraocular pressure (IOP) rise. Slit-lamp biomicroscopy showed the posterior flange of the implant located in the corneal limbus; IOP was 34 mmHg. Surgical technique consisted of reopening of the conjunctiva and the scleral flap, excision of the corneal tissue covering the flange, and stitching the implant to the sclera with polyprolene suture. RESULTS: Postoperatively, IOP rapidly reduced to 5 mmHg and was balanced to 10 mmHg in the follow-up. CONCLUSIONS: Corneal dislocation of the Ex-PRESS implant, when associated with ocular hypertension, needs surgical treatment. Before considering a trabeculectomy, it could be valuable to attempt an implant reposition.

Ex-PRESS miniature glaucoma device in vitrectomized eyes.

PURPOSE: To evaluate the clinical efficacy and safety of the Ex-PRESS miniature glaucoma device placed under scleral flap for the treatment of ocular hypertension in eyes that underwent vitreoretinal surgery. METHODS: Vitrectomized patients who required glaucoma surgery for persistent ocular hypertension were included. The Ex-PRESS miniature glaucoma device was implanted under scleral flap. Postsurgical clinical outcomes and intraocular pressure (IOP) was monitored for 6 months after surgery. RESULTS: At 6 months, all the patients had an IOP lower than 18 mmHg, 3 of them without topical therapy. CONCLUSIONS: The use of the Ex-PRESS implant under scleral flap in eyes that underwent vitreoretinal surgery was effective for lowering IOP.

Primary open angle glaucoma: an overview on medical therapy.

The purpose of this review is to discuss the topics relevant to the use of intraocular pressure-lowering strategies, which remains the first line in the management of glaucoma. Estimates of blindness from glaucoma and identification of risk factors remain of interest for all ophthalmologists. New functional tests offer promise for better detection and more accurate diagnosis of glaucoma. We finally discuss the impact of various glaucoma therapies, the principles of monotherapy and fixed combinations, which offer benefits of convenience, cost, and safety.

Is there still a clinical use for scanning laser polarimetry with fixed corneal compensator?

PURPOSE: To compare the scanning laser polarimetry device with a fixed corneal compensator (GDx FCC) with the new version with a variable corneal compensator (GDx VCC) in healthy subjects. METHODS: A prospective, nonrandomized, comparative trial was carried out with both the FCC and the VCC systems on 130 healthy volunteers. The FCC measurements were divided into 2 subgroups, in accordance with the appearance of the macula. Subjects with a uniform aspect of the macula were included in the macula-'negative' group (macula-), whereas subjects with an irregular macular appearance with FCC were included in the macula-'positive' group (macula+). Data relative to all the GDx parameters were examined. For each parameter, we compared the data obtained by the FCC to the VCC models. Subsequently we compared each FCC subgroup (macula+ and macula-) to VCC. RESULTS: A total of 67 subjects entered the macula- group and 63 the macula+ group. FCC significantly overestimated the average parameters and underestimated the number, the modulation and also the ratio parameters. The only parameter showing no difference was symmetry. Similar trends were also evident when the subjects were divided into the macula+ and - subgroups. CONCLUSION: Individual variations of corneal birefringence, which are not completely corrected by FCC, result in over- or underestimation of retinal nerve fiber layer parameters. This measurement error cannot be eliminated, not even by only selecting patients with a uniform aspect of macular scan. For this reason GDx FCC does not seem to be an acceptable tool in the early diagnosis of glaucoma, and modern versions of this device should be preferred.

One-year clinical results of photorefractive keratectomy with a solid-state laser for refractive surgery.

PURPOSE: To investigate the safety, efficacy, and stability of photorefractive keratectomy (PRK) performed with a newly developed solid-state laser after 1-year follow-up. METHODS: The all-solid-state, Q-switched, frequency-shifted laser (LaserSoft; Katana Technologies, Berlin, Germany) with a Gaussian spot diameter of 0.2 mm and repetition rate of 1 kHz was used. Eleven eyes of six patients were treated with PRK. The mean outcome measures were uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), corneal topography, and corneal transparency. All patients were evaluated at 1, 3, 6, and 12 months postoperatively. RESULTS: At 12-month follow-up no eye lost lines of BSCVA and UCVA improved in all eyes. All eyes were within +/- 1.00 diopters (D) and 8 (73%) eyes were within +/- 0.50 D of emmetropia. CONCLUSIONS: Clinical results at 1 year were promising, with good safety, efficacy, and stability of the visual and refractive outcome.

Combined radial optic neurotomy, internal limiting membrane peeling, and intravitreal triamcinolone acetonide for central retinal vein occlusion.

To evaluate the efficacy of radial optic neurotomy, internal limiting membrane peeling, and intravitreal triamcinolone acetonide for central retinal vein occlusion. Eight consecutive eyes with central retinal vein occlusion with a duration of less than 6 months, cystoid macular edema, and best-corrected visual acuity (BCVA) of less than 20/200 were enrolled. BCVA, intraocular pressure, fluorescein angiography, and optical coherence tomography were evaluated. After 4.75 +/- 0.7 months, BCVA significantly improved, intraocular pressure was well controlled, and fluorescein angiography showed perfused state and reduction of the number of retinal hemorrhages in all eyes. Optical coherence tomography revealed significant reduction of macular thickness. Bleeding in the neurotomy site occurred in 3 cases. Radial optic neurotomy, internal limiting membrane peeling, and intravitreal triamcinolone acetonide may be useful in the management of central retinal vein occlusion with macular edema.

Experimental and clinical investigation of efficiency and ablation profiles of new solid-state deep-ultraviolet laser for vision correction.

PURPOSE: To investigate the efficiency and ablation profiles of a newly developed, all-solid-state laser platform. SETTING: Experimental investigations performed at Katana Technologies GmbH, Kleinmachnow, Germany, and clinical study, at the Ophthalmology Clinic, University of Messina, Messina, Italy. METHODS: Experimental studies were performed on poly(methyl methacrylate) (PMMA) and in porcine eyes using an all-solid-state, Q-switched, frequency-shifted laser (LaserSoft, Katana Technologies GmbH) with a Gaussian spot with a diameter of 0.2 mm in the target plane, a peak fluence of 350 mJ/cm2, and a repetition rate of 1 kHz. The ablation profiles were determined using a profile meter (MicroProf, Fries Research and Technology GmbH), corneal topography was analyzed with a TMS 2N (Tomey Inc.), and corneal thickness was measured with an ultrasound pachymeter (DGH Technology). In the clinical study, 9 human eyes were treated with photorefractive keratectomy. The mean outcome measures were uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), corneal topography, and corneal transparency. The follow-up was 1 month for all eyes and 3 months for 4 eyes. Safety, efficacy, and predictability were evaluated. RESULTS: Smooth profiles were found in the PMMA and the porcine eyes. The topographic maps showed central steepening after the hyperopic ablation and slight central flattening of the surface after the myopic treatment. No eye lost lines of BSCVA; the UCVA improved in all eyes. All eyes were within +/-1.00 diopter (D) of emmetropia, and 89% were within +/-0.50 D. CONCLUSION: The efficacy of the ablation was good, with the profile meter results confirmed by the topographic measurements.