Factors predicting successful customized excimer laser treatment in irregular corneas.

PURPOSE: To identify factors associated with a successful wavefront-guided customized treatment (WG-CT) with an excimer laser in highly aberrated corneas. SETTING: VISSUM Alicante Spain. DESIGN: Retrospective consecutive noncomparative case series. METHODS: Treatment was performed with the WG-CT Amaris excimer laser using the ORK-CAM software for the calculation of the ablation profile. Eyes of patients with significantly aberrated corneas, including postrefractive and keratoplasty procedures or high irregular astigmatism with significant higher-order aberrations (HOAs) that had WG-CT were included. Refractive outcomes, HOAs, and visual outcomes were recorded. Statistical analysis was performed to identify factors associated with technical (based on HOAs) or refractive outcome success. RESULTS: The study included 55 treatments of 51 eyes (35 patients). The postoperative uncorrected distance visual acuity was 0.2 logarithm of the minimum angle of resolution or better in 72% of the eyes, and the postoperative residual manifest refraction spherical equivalent was ±0.50 diopter in 56% of the eyes, whereas 11% of the eyes lost 1 line or more in corrected distance visual acuity. Successful reduction in the total root mean square (RMS) of HOAs occurred in 36 eyes (65%), and these eyes had a significantly higher preoperative RMS of HOAs (1.45 ± 0.93 µ vs 0.91 ± 0.34 µ, P = .003) and preoperative coma-like aberrations (1.09 ± 0.83 µ vs 0.55 ± 0.28 µ, P = .001). In multivariate analysis, posthyperopic treatment eyes were less likely to achieve refractive outcome success (odds ratio = 0.09, P = .02). CONCLUSIONS: WG-CT in highly aberrated corneas had a limited refractive predictability. Eyes with preoperative coma-like aberrations are more likely to benefit from a reduction in HOAs. Posthyperopic treatment is associated with a higher rate of refractive surprises.

Short-term anterior chamber inflammation in phacoemulsification with and without Ex-Press glaucoma implant.

PURPOSE: The aim of this study was to investigate the incidence of clinically significant anterior chamber inflammation in a combined surgery, namely, phacoemulsification and Ex-Press miniature glaucoma device implantation, compared to phacoemulsification alone. METHODS: A retrospective comparative study of a consecutive series of 210 participants above 18 years of age diagnosed with significant cataract and who required glaucoma surgery, namely, Ex-Press miniature glaucoma device implantation or cataract alone in one or both eyes. All were operated on by a single experienced glaucoma surgeon in a single medical center. A total of 231 eyes were included in this study. All cases underwent an uneventful surgery and were examined the day following the surgery for visual acuity, intraocular pressure, and signs of excessive anterior chamber inflammation (Standardization of Uveitis Nomenclature grading ⩾ 3). RESULTS: The combined group included 55 eyes of 51 patients, of whom 15 (27.3%) demonstrated excessive anterior chamber inflammation. The phacoemulsification group included 176 eyes of 159 patients, of whom 12 (6.7%) demonstrated excessive anterior chamber inflammation. Visual acuity and intraocular pressure measurements showed no statistically significant difference between the two groups. CONCLUSION: The Ex-Press glaucoma device is efficient, safe, and known for its inert nature. However, combination of this procedure with phacoemulsification surgery might result in a condition encouraging excessive inflammation, which eventually could lead to excessive anterior chamber inflammations if not treated vigorously. Emphasizing and recognizing the risks, especially in glaucoma patients, is important.

Laser flap enhancement 5 to 9 years and 10 or more years after laser in situ keratomileusis: Safety and efficacy.

PURPOSE: To study the safety and efficacy of refractive enhancement by flap lifting 5 and 10 years after laser in situ keratomileusis (LASIK). SETTING: Vissum Alicante, Spain. DESIGN: Retrospective case series. METHODS: Eyes with a flap lift at least 5 years after primary LASIK with a 3-month follow-up were evaluated. The primary outcome measures were safety and the complication rate. Moderate epithelial ingrowth was managed with Nd:YAG laser treatment. RESULTS: The primary LASIK procedure was myopic in 45 eyes, hyperopic in 22 eyes, and presbyopic in 3 eyes. The mean time from primary LASIK to the flap lift was 12.3 years ± 3.45 (SD). In 57 eyes, the primary LASIK flap was created at least 10 years before the enhancement. The mean pre-lift spherical equivalent was -1.29 ± 1.23 diopters (D) in the myopia group and +0.65 ± 1.72 D in the hyperopia group. Three months later, 88% of eyes and 74% of eyes, respectively, had an uncorrected distance visual acuity of 20/20 or better; 100% achieved at least 20/25. No eye lost 2 lines or more of corrected distance visual acuity. In the myopia group, the efficacy index was 0.94 and the safety index was 0.98 at 6 months. Mild epithelial ingrowth developed in 31.43% of eyes and clinically significant epithelial ingrowth in 11.42% of eyes; 4.28% required a relift for severe epithelial ingrowth. CONCLUSIONS: Late flap lift for refractive enhancement 10 years or more after LASIK provided good efficacy and safety with fast visual recovery. The rate of surgical intervention for significant postoperative epithelial ingrowth was low.

Corneal Perforation after Nd: YAG Capsulotomy: A Case Report and Literature Review.

BACKGROUND: Nd: YAG capsulotomy is the treatment of choice for posterior capsular opacification after cataract surgery. We report a case of corneal perforation following Nd:YAG capsulotomy in a patient with systemic scleroderma. CASE PRESENTATION: A 69-year-old woman presented with acute onset of blurred vision 2 weeks following Nd:YAG laser capsulotomy for posterior subcapsular opacification. On examination, her best-corrected visual acuity was 1/120, and bio-microscopy revealed a central full-thickness corneal laceration. Conservative treatment consisted of topical ocular antibiotics, cycloplegics, hypotensive drops and a soft therapeutic contact lens. Her final visual acuity improved to 6/18 with resolution of the corneal laceration. CONCLUSION: The possibility of corneal perforation after Nd-YAG capsulotomy in patients with systemic scleroderma and connective tissue disease should be borne in mind when treating such patients.

Clinical Efficacy and Safety of the EX-PRESS Filtration Device in Patients with Advanced Neovascular Glaucoma and Proliferative Diabetic Retinopathy.

BACKGROUND: The prognosis of conventional filtration surgery in eyes with neovascular glaucoma (NVG) is limited due to increased fibrovascular proliferation or bleeding. This study aims to evaluate the safety and efficacy of the EX-PRESS filtration device in the management of NVG associated with proliferative diabetic retinopathy (PDR). METHODS: In this retrospective case series, we reviewed the medical records of patients diagnosed as having NVG associated with PDR who underwent EX-PRESS filtration surgery. The main outcome measures were: postoperative intraocular pressure (IOP), the percent of IOP drop, the number of glaucoma medications, visual acuity, and complications of surgery. Successful surgery was defined as an IOP <22 mm Hg and >5 mm Hg with or without additional glaucoma surgery, and no loss of light perception or less than a 2-line decrease on the Snellen chart of the best corrected visual acuity (BCVA). RESULTS: Five patients (5 eyes) were included in this study. The mean preoperative IOP was 33.4 ± 5.9 mm Hg compared to an IOP of 17.0 ± 3.0 mm Hg at the last follow-up (p = 0.003). The mean number of preoperative anti-glaucoma medications was 3.8 ± 0.4 compared to 2.2 ± 1.5 (p = 0.06) at the last follow-up visit. Final visual acuity improved or stabilized within 1 Snellen line in all 5 patients. Three patients had a "hypertensive phase" (defined as an IOP >21 mm Hg during the first 6 postoperative months) which resolved within 2 months. Two patients developed a hyphema that resolved spontaneously. None of the patients experienced any serious complications. CONCLUSION: EX-PRESS filtration device has a good IOP-lowering effect and a low rate of complications in patients with advanced NVG associated with PDR. In addition, there was no loss of light perception or no line decrease of the BCVA.

Corneal-Committed Cells Restore the Stem Cell Pool and Tissue Boundary following Injury.

During morphogenesis, preserving tissue boundaries is essential for cell fate regulation. While embryonic tissues possess high plasticity and repair ability, the questions of whether and how adult tissues cope with acute stem cell (SC) loss or boundary disruption have remained unanswered. Here, we report that K15-GFP transgene labels the murine corneal epithelial boundary and SC niche known as the limbus. K15-GFP+ basal cells expressed SC markers and were located at the corneal regeneration site, as evident by lineage tracing. Remarkably, following surgical deletion of the SC pool, corneal-committed cells dedifferentiated into bona fide limbal SCs that retained normal tissue dynamics and marker expression. Interestingly, however, damage to the limbal stromal niche abolished K15-GFP recovery and led to pathological wound healing. Altogether, this study indicates that committed corneal cells possess plasticity to dedifferentiate, repopulate the SC pool, and correctly re-form the tissue boundary in the presence of intact stroma.

Oculopharyngeal Muscular Dystrophy and Inherited Retinal Dystrophy in Bukhara Jews Due to Linked Mutations in the PABPN1 and NRL Genes.

AIM: We have previously described two unrelated Bukhara Jews (BJs) with a combination of oculopharyngeal muscular dystrophy (OPMD) and inherited retinal dystrophy (IRD), because of mutations in two linked genes: PABPN1 and NRL. Here we investigated the prevalence of the NRL mutation among BJs with OPMD. MATERIALS AND METHODS: PABPN1 and NRL mutation testing were performed by polymerase chain reaction amplification and direct sequencing on two cohorts of Bukhara Jewish patients: OPMD patients (with or without IRD) and IRD patients (without OPMD). RESULTS: Of 24 unrelated chromosomes from Bukhara Jewish OPMD patients, 19 (79%) harbored the NRL mutation. In contrast, the NRL mutation was not detected in Bukhara Jewish patients diagnosed with IRD but without OPMD. CONCLUSIONS: Our findings provide an explanation for the reoccurrence of IRD in Bukhara Jewish OPMD homozygotes. Moreover, they indicate that Bukhara Jewish OPMD patients are at high risk for carrying the NRL mutation, and should be offered appropriate genetic counseling and testing.

Homozygosity for a Recessive Loss-of-Function Mutation of the NRL Gene Is Associated With a Variant of Enhanced S-Cone Syndrome.

PURPOSE: To investigate the genetic basis for severe visual complaints by Bukharan Jewish patients with oculopharyngeal muscular dystrophy (OPMD). METHODS: Polymerase chain reaction amplification and direct sequencing were used to test for NRL, PABPN1, and NR2E3 mutations. Complete ophthalmic examination included best-corrected visual acuity, biomicroscopic examination, optical coherence tomography, and fundus autofluorescence. Detailed electroretinography (ERG) testing was conducted including expanded International Society for Clinical Electrophysiology of Vision protocol for light-adapted and dark-adapted conditions, measurements of S-cone function, and ON-OFF light-adapted ERG. RESULTS: The index patients were homozygotes for both a dominant mutation of the PABPN1 gene, (GCN)13, and a recessive mutation of the NRL gene, p.R31X, on chromosome 14q11.1, leading to early-onset OPMD accompanied by night blindness and reduced visual acuity. No mutations were found in the NR2E3 gene. Both patients were of Bukharan Jewish origin, but from unrelated families. Electroretinography responses of both patients were dominated by short-wavelength-sensitive mechanisms, with no detectable rod function, similar to the ERG responses of individuals with enhanced S-cone syndrome (ESCS) due to NR2E3 mutations. Heterozygotes for the PABPN1 and NRL mutations demonstrated normal fundi and ERG responses. CONCLUSIONS: Homozygosity for the recessive NRL mutation described here appears to be associated with a distinct retinal phenotype, demonstrating ERG characteristics similar to those of ESCS patients. This report expands the spectrum of NRL recessive mutations, as well as the genetic spectrum of ESCS, and indicates a new syndrome of OPMD with an ESCS-like phenotype.

Hospitalization of children with down syndrome.

INTRODUCTION: Children with Down syndrome present with multiple medical problems in a higher prevalence compared with the general population, which may lead to hospitalizations. METHODS: Analysis of 560 hospitalizations of 162 children aged 0-16 years with Down syndrome at Hadassah Medical Center during the years 1988-2007 compared with data on children in the general population, hospitalized at the same period. Data was collected from patient files and statistical data from the Ministry of Health. RESULTS: Respiratory infections were the leading cause for hospitalization of children with Down syndrome. The number of hospitalizations of children with Down syndrome compared to the number of all children, who were hospitalized was surprisingly similar to their proportion in the general population. Eleven children died during their hospitalization (five heart failure, three sepsis, one respiratory tract infection, and one due to complication after surgery). Nine of the 11 had a congenital heart anomaly. CONCLUSION: Children with Down syndrome can present with complex medical issues and we support the concept of a multidisciplinary team that has experience and knowledge to serve as a "one stop shop" for these individuals and their families, with timely visits in which a comprehensive evaluation is performed, problems attended to and prevention plans applied. In this way, we may prevent morbidity, hospitalizations, and mortality.

Unilateral angle-closure glaucoma with ciliochoroidal effusion after the consumption of cannabis: a case report.

A 35-year-old male patient, diagnosed with acute angle-closure glaucoma, did not improve despite intensive treatment with antiglaucoma medications. Ultrasound biomicroscopy revealed a ciliochoroidal effusion. Due to his past history of drug abuse, a urine test was analyzed and found to be positive for cannabis. After topical cycloplegia and oral steroid therapy, his symptoms improved substantially. The present case highlights the role of ultrasound biomicroscopy in evaluating patients with acute angle-closure glaucoma and the role of cannabis abuse in the development of ciliochoroidal effusion.

Synthesis and preliminary in vitro biological evaluation of 7α-testosterone-chlorambucil hybrid designed for the treatment of prostate cancer.

The synthesis of 7α-testosterone-chlorambucil hybrid is reported. This compound is made from testosterone in a 6 step reaction sequence and with 23% overall yield. An alternative convergent reaction sequence yielded the same hybrid through a Grubbs metathesis reaction between chlorambucil allyl ester and 7α-allyltestosterone with 35% overall yield. MTT assays showed that the hybrid is selective towards hormone-dependent prostate cancer cell line (LNCaP (AR+)) and shows similar activity than the parent drug, chlorambucil. Thus, the new hybrid shows promising potential for drug targeting of hormone-dependent prostate cancer through its capacity of delivering chlorambucil directly to the site of treatment. This could extend the use of chlorambucil to prostate cancer in the future.

Importance of 3-D image reconstruction of spectral-domain OCT on outcome of grid laser photocoagulation for diffuse diabetic macular edema.

AIM: To present the outcome of modified grid laser photocoagulation (GLP) in diffuse diabetic macular edema (DDME) in eyes without extrafoveal and/or vitreofoveal traction. METHODS: Inclusion criteria for the retrospective study were DDME eyes of patients with type II diabetes mellitus that had ≥4 months of follow-up following GLP. Only one eye per patient was analyzed. Using 3-D spectral-domain optical coherence tomography (3-D SD-OCT), eyes that had either extrafoveal or vitreofoveal traction, or had been previously treated by an intravitreal medication(s) were excluded. Treated DDME eyes were divided into 4 groups: A) "Classic" DDME that involved the central macula; B) edema did not involve the macular center; C) eyes associated with central epiretinal membrane (ERM); D) DDME that was associated with macular capillary dropout ≥2 disc-diameter (DD). RESULTS: GLP outcome in 35 DDME eyes after 4-24 (mean, 13.1±6.9) months was as follows: Group A) 18 eyes with "classic" DDME. Following one or 2 (mean, 1.2) GLP treatments, best-corrected visual acuity (BCVA) improved by 1-2 Snellen lines in 44.4% (8/18) of eyes, and worsened by 1 line in 11.1% (2/18). Central macular thickness (CMT) improved by 7%-49% (mean, 26.6%) in 77.8% (14/18) of eyes. Causes of CMT worsening (n=4) were commonly explainable, predominantly (n=3) associated with emergence of extrafoveal traction, 5-9 months post-GLP. Group B) GLP(s) in DDME that did not involve the macular center (n=6) resulted in improved BCVA by 1-2 lines in 2 eyes. However, the central macula became involved in the edema process after the GLP in 3 (50%) eyes, associated with an emergence of extrafoveal traction in one of these eyes 4 months following the GLP. Group C) GLP failed in all 5 eyes associated with central ERM. Group D) GLP was of partial benefit in 2 of 6 treated eyes with macular capillary dropout ≥2DD. CONCLUSION: Eyes with DDME that involved the macular center were found to achieve favourable outcomes after GLP(s) during mid-term follow-up, unless complicated pre-GLP or post-GLP by vitreoretinal interface abnormalities, often extrafoveal traction or ERM, or by capillary dropout ≥2DD. Prospective studies with larger cohorts are required.

[Goal analysis and goal operationalisation: a group intervention for the enhancement of work motivation]. / Zielanalyse und Zieloperationalisierung (ZAZO): Evaluation eines Gruppentrainings zur Förderung beruflicher Motivation.

BACKGROUND: Work motivation, mental well-being and competencies of self-regulation are linked to successful job-related reintegration after rehabilitation. Based on the Diagnostical Instrument to assess Work motivation (Diagnostikinstrument für Arbeitsmotivation DIAMO) and existing training programs, a new group intervention, the goal analysis and goal operationalization, was developed and evaluated. The objective of this intervention, designed for participants of a rehabilitation program was to enhance work motivation and volitional control processes (self-regulation and self-control), to encourage job-related goal orientation and to thereby increase the probability of goal achievement. PATIENTS AND METHODS: In a quasi-experimental longitudinal design 207 patients (111 experimental group/96 control group) were tested. The experimental group took part in the job-related training (ZAZO) in addition to the usual rehabilitation. The evaluation was conducted through various scales at t0 (beginning) and t1 (end of the training). Scales for the measurement of work motivation, mental well-being, status of rehabilitation, competencies of self-regulation and the subjective prognosis of the ability to work were used. As direct effects of the training an enhancement of work motivation and of an improved subjective prognosis of the ability to work were expected. Accordingly, a positive influence on the subjective well-being as indirect effects, were anticipated in the long run, the experimental group should also show an enhanced job-related reintegration. RESULTS: Participants of the experimental group showed significantly higher values on particular scales of the Diagnostical Instrument of Work motivation as opposed to the control group (curiosity motive, attitudes to work and contact motive). Most notably, significant interactional effects could be found on the scale for the subjective prognosis of the ability to work, which is a highly reliable instrument and important predictor for prospective job-related reintegration. The training ZAZO led to an enhancement of work motivation and subjective prognosis of the ability to work, both having positive effects on job-related orientation. CONCLUSIONS: First evaluation results of the training ZAZO document the positive effect on both work motivation and subjective prognosis of the ability to work. The results of the evaluation present the good acceptance of the participants (93.3% = rather content to very content). The implementation of the group intervention in existing programs of rehabilitation can benefit job-related reintegration and will thereby contribute to lower costs for pension regulatory authorities in the long run.