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.

Prematurity-Risk Factor or Coincidence in Congenital Glaucoma?

Background and Objective: To correlate the intraocular pressure with the postconceptional age and identify a statistically significant connection between congenital glaucoma and prematurity. Materials and Methods: The current paper is a retrospective, comparative, case-control study. Data collection featured maternal age, gestational age at birth, birth weight, and intraocular ocular pressure (IOP) measurements. Results: Forty-two eyes of 21 children underwent examination. The participants were assigned into two groups. The Preterm-Glaucoma (PG) group included eight preterm-born children diagnosed with glaucoma, whereas the Preterm (P) group was comprised of premature newborns without the aforementioned condition. There was no statistically relevant difference in birth weight (p = 0.691078) nor in mean gestational age (p = 0.752623) between the two groups. The mean IOP in the PG group was 23.813 ± 4.5493, whereas in the P group, it ranged around 13.231 ± 1.0699, p < 0.0001. Using mixed-effects models, we obtained a reduction in IOP of 0.45 mmHg per week in the first month of life. A further weekly reduction of 0.36 mmHg was achieved in the next two months. Conclusions: The mean IOP of prematurely born children decreased with age. Our findings correlate with previously conducted studies, however, the drop in IOP values exceeded any data published so far. We found no correlation between prematurity and the incidence of congenital glaucoma.

The Diagnosis and Treatment of Fungal Endophthalmitis: An Update.

In recent, large case series of fungal endophthalmitis (FE) that were published by Asian authors, the most frequent etiologic agents for all types of FE are molds (usually Aspergillus species, while Fusarium is the prevalent etiology in keratitis-related FE). Candida was the organism found in most cases of endogenous FE. However, we must keep in mind that prevalence of fungal species varies with the geographical area. Lately, polymerase chain reaction (PCR) was increasingly used for the diagnosis of FE, allowing for very high diagnostic sensitivity, while the costs become more affordable with time. The most important shortcoming of PCR-the limited number of pathogens that can be simultaneously searched for-may be overcome by newer techniques, such as next-generation sequencing. There are even hopes of searching for genetic sequences that codify resistance to antifungals. We must not forget the potential of simpler tests (such as galactomannan and ß-d-glucan) in orienting towards a diagnosis of FE. There are few reports about the use of newer antifungals in FE. Echinocandins have low penetration in the vitreous cavity, and may be of use in cases of fungal chorioretinitis (without vitritis), or injected intravitreally as an off-label, salvage therapy.

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.

Correlation between metabolic status and diabetic retinopathy evolution in type 1 diabetes.

Out of the multiple vascular complications of diabetes, retinopathy is the easiest to diagnose and monitor as the examination of the eye fundus is an easy investigation to perform, does not require expensive medical equipment and can be repeated without any risk to the patient. The appearance of the retinal vessels, the optic nerve and the retina can provide useful information on the coronary and cerebral circulation, plasma lipid levels, renal function, and the quality of the arteries of the lower limbs. It is known that visual acuity changes variably depending on the macular alteration and may decrease when edema is installed in the macular region or is altered by the appearance of hemorrhages or the presence of foveolar neovascular tissues resulting from traction retinal detachment. In the absence of proper treatment, diabetes leads to blindness. The lesions that appear are not specific to diabetes, but by combining them they create a clinical picture characteristic of this disease.

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.

Variability of diabetic macular edema in correlation with hypertension retinopathy in patients with diabetes mellitus and essential hypertension.

Objective. This study aimed to determine the possible relationship between variability of diabetic macular edema associated with hypertension retinopathy in patients with type 2 diabetes mellitus and essential high blood pressure, in correlation with contrast sensitivity. Material and Methods. In order to accomplish the objective, this retrospective study evaluated the progression of diabetic macular edema in patients with high blood pressure during day time through measurements of the total macular volume and central macular thickness using optical coherence tomography and contrast sensitivity variations measured through Pelli Robson test, four times a day, along with glycemia and blood pressure measurements. Results. Our results showed a statistically significant correlation between the values of glycemia and central macular thickness, and between contrast sensitivity and macular thickness at every tested hour. Conclusions. The study revealed many statistically significant correlations involving blood pressure, blood glucose levels, Pelli Robson test and central macular thickness. Abbreviations: OCT = optical coherence tomography; DME = diabetic macula edema; SD-OCT = spectral domain optical coherence tomography; LOCS = lens opacities classification system; LE = left eye; ANOVA = analysis of variance.

Foveal avascular zone area measurements using OCT angiography in patients with type 2 diabetes mellitus associated with essential hypertension.

Objective. This study followed the variability in the foveal avascular zone (FAZ) area measured using optical coherence tomography angiography (OCTA) in patients with type 2 diabetes mellitus and high blood pressure. Material and Methods. This prospective, non-randomized, cohort study evaluated 46 eyes in 26 patients with high blood pressure associated with diabetic non-proliferative retinopathy (mild, medium, and severe forms) and diabetic proliferative retinopathy. Results. Our results showed early macular alterations (microaneurysms, leakage, neovascularizations, intraretinal microvascular abnormalities), a higher class of severity despite a relatively normal clinical aspect and higher values of FAZ associated with neovascularization undetected by SD-OCT (spectral domain-OCT). Conclusion. Measurement of the foveal avascular zone area using OCTA early detects macular alterations that precede classical retinography and SD-OCT determinations. Abbreviations: FAZ = foveal avascular zone; OCTA = optical coherence tomography angiography; IRMA = intraretinal microvascular abnormalities; SD-OCT = spectral domain-optical coherence tomography; OU = both eyes; PD = papillary diameter; ETDRS = early treatment diabetic retinopathy study; BP = blood pressure; OD = right eye.

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 role of clear lens extraction in angle closure glaucoma.

Clear lens extraction can be considered a therapeutic option in angle closure glaucoma (ACG). Even if it does not represent the first choice of treatment, it can be taken into consideration when the topical treatment does not control the intraocular pressure (IOP) and iridotomy does not have a positive effect on the angle closure, especially in appositional angle closure when biometry or ultrabiomicroscopy (UBM) show lens involvement. In angle closure glaucoma, clear lens extraction represents an etiological treatment that takes into account the role of the lens in the pathogenesis of the disease. If we ignore it and we choose a filtrating surgery as therapeutic option we can end up with complications such as prolonged athalamia, corneal damage and lens opacification that will eventually require cataract surgery, but performed late and with higher risks. Before performing a filtrating surgery in ACG, we should take an UBM. We also need to choose the best moment to perform surgery, after topical treatment and iridotomy have been tested, but before trabecular damage appears.

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.

Small eye - a small stump which can challenge and tilt a great surgery.

The small eye suggests an apparently robust anatomy with a more resistant sclera, good trabecular function, good uvea trophicity, a healthy retina, with a full papilla. The volume of these eyes is small. Usually, the volume of the eye is related to the sagittal diameter of the eye. However, the volume of a sphere varies with the third power of the radius of the sphere. These small eyes have a volume smaller than their sagittal diameter suggests. In this volume, highly decreased develop certain anatomical components without having to keep proportions (lens, choroid), and some have a continuous growing volume (lens). On long term, there is a balance inside these eyes despite a disproportion between their components. This internal disproportion inside the small eye can erupt through pressure differences between its structures: pupillary block, angle closure or a disproportionate response in case of typically uncomplicated surgery, which alters the apparent internal balance of these eyes. Seemingly simple surgeries, such as phacoemulsification or filtering surgery can trigger storm (storms occur by differences in atmospheric pressure) with the following characteristics: - intraocular "precipitation" in the form of uveal effusions, massive choroidal hemorrhage exudative retinal detachment, CME - breaks in anatomical barriers, lens posterior capsular tear - deviations courses: aqueous misdirection Surgical operations on these eyes are like a dangerous storm surfing, with risks, incidents, with unpredictable but great experience and courage request.