Neurotrophic Keratopathy after wide retinal endolaser and postoperative Ketorolac eye drops: A case series.

PURPOSE: We report a series of 5 cases, happened in a period of 5 months, who developed neurotrophic keratopathy (NK) following pars plana vitrectomy (PPV) and retinal endolaser for rhegmatogenous retinal detachment (RRD). In our several decennary experience of surgical center predominantly based on vitreoretinal surgery, we had rare cases of postoperative NK. These recent cases of post-surgical NK happened contextually to our change of postoperative non-steroidal anti-inflammatory drugs (NSAIDs) drops, based on Ketorolac Tromethamine 0.5% eye drops. CASES PRESENTATION: Five patients with a mean age of 61 ± 7.3 years were treated with one or more PPV with intraoperative peripheral endolaser for RRD. Nobody had previous herpetic keratitis, systemic disease like diabetes mellitus or other predisposing factors for NK. In the postoperative period, all patients received Ketorolac Tromethamine 0.5% eye drops for a mean period of 54 ± 25 days. During follow-up visits they developed NK and they were successfully treated with suspension of Ketorolac eye drops, application of therapeutic contact lens or amniotic membrane patch and topical lubricant therapy. CONCLUSIONS: Postoperative Ketorolac eye drops, in patients who underwent PPV with endolaser, may reduce the corneal sensitivity, predispose to epithelial disruption and NK development. Studies are needed to explore the effect of NSAIDs on corneal sensitivity reduction in patient who will undergo PPV and extensive endolaser.

Pneumatic retinopexy versus scleral buckling for the management of primary rhegmatogenous retinal detachment.

BACKGROUND AND OBJECTIVE: To compare pneumatic retinopexy (PnR) and scleral buckling (SB) for repair of primary rhegmatogenous retinal detachment. MATERIALS AND METHODS: Single-centre retrospective analysis of patients undergoing PnR and SB. Inclusion criteria comprehend phakic patients with a single retinal break or a group of breaks in detached retina in the same quadrant above the 8- and 4-o'clock meridians. A total of 184 patients were included, respectively 106 underwent PnR and 78 SB. Follow-up time was 6 months. RESULTS: Final visual outcome did not differ significantly between the two procedures (P = 0.12). Single-procedure reattachment rate was significantly higher in SB (94%) than in PnR (68%) (P < 0001). Anatomical success rate was not influenced by macular involving. Reattachment rate in repeated PnR was 95% and in these patients visual outcome did not statistically differ compared to those reattached with first attempt (P = 0.196). Total reattachment rate including repeated procedures was 87% in PnR group and 94% in SB group, the difference was not significant (P = 0.06). CONCLUSION: SB has a higher single reattachment rate than PnR. However, final visual outcomes of both procedures are comparable. In selected cases, PnR can be repeated with a high successful rate.

Microscope-assisted pneumatic retinopexy for the management of primary rhegmatogenous retinal detachment.

PURPOSE: Outcomes of pneumatic retinopexy (PnR) using surgical microscope, wide-angle viewing system, and chandelier endoilluminator (microscope-assisted pneumatic retinopexy) for primary rhegmatogenous retinal detachment (RRD). METHODS: Retrospective study. 43 consecutive eyes with RRD undergoing microscope-assisted PnR surgery (MAPR) were analysed. Inclusion criteria comprehend phakic eyes with single retinal break or a group of breaks in detached retina in the same quadrant above 8- and 4-o'clock meridians. Follow-up was at least 6 months. RESULTS: Of the 43 eyes, a total of 25 (58%) presented preoperatively a single retinal break, 15 (35%) had two retinal breaks in the same quadrant and 3 (7%) presented three or more retinal breaks in the same quadrant. Other retinal breaks not observed preoperatively were discovered intraoperatively in 12 eyes (28%). In 9 (21%) the missed retinal breaks were in the same quadrant as the main diagnosed break(s), while 3 (7%) had missed retinal breaks in a different one. These 3 eyes as no longer adhering to the PnR indication criteria switched intraoperatively to other surgical procedures and were excluded in the reattachment rate results. The total primary reattachment rate with MAPR was achieved in 37 eyes (92.5%). No significant BCVA changes were observed postoperatively. CONCLUSION: MAPR is an effective and safe surgical option, it allows to work with both hands free and provides an adequate visualization of the retina during the procedure minimizing the risk of missed retinal breaks potentially leading to surgical failure.

Standardized Flanged Intrascleral Intraocular Lens Fixation with the Double-Needle Technique for Cataract Luxation in the Vitreous Chamber during Phacoemulsification.

PURPOSE: To assess the visual and refractive outcome of immediate intraoperative vitrectomy and intrascleral intraocular lens implantation using a "standardized" sutureless Yamane technique during cataract luxation in the vitreous chamber as a complication of phacoemulsification. DESIGN: A prospective, interventional, consecutive case series. MATERIALS AND METHODS: Twelve patients underwent vitrectomy and intrascleral intraocular lens fixation using a standardized Yamane technique as the primary procedure during complicated phacoemulsification. Patients were evaluated preoperatively and 6 months postoperatively for best-corrected distance visual acuity, correspondence to the preoperative refractive target in the spherical equivalent, endothelial cell count, and complications. RESULTS: Mean preoperative best-corrected visual acuity was 1.16 ± 0.3 logarithm of the minimum angle of resolution (logMAR), the endothelial cell count was 1910.5 ± 297.64, and target refraction at baseline was -0.197 ± 0.087. Postoperatively, best-corrected visual acuity was significantly improved; the mean value was 0.05 logMAR ± 0.06. Mean baseline target refraction in the spherical equivalent was -0.20 ± -0.09 (range: -0.08 to -0.37), and mean final refraction was -0.44 ± -0.14 (range: -0.25 to -0.75) with no significant difference (p=0.87). No complication was registered intra- and postoperatively. CONCLUSION: Standardization of the Yamane technique seemed a valuable option for patients who had complicated phacoemulsification to achieve a predictable refractive outcome. Synopsis. The predictable refractive outcome could be achieved with the immediate standardized Yamane technique in patients with intraoperative cataract luxation in the vitreous chamber during phacoemulsification.

Curcuma-Based Nutritional Supplement in Patients with Neovascular Age-Related Macular Degeneration.

To investigate effectiveness and safety of a curcumin-based nutritional supplement in neovascular age-related macular degeneration (AMD). We conducted a controlled retrospective study, reviewing the medical records of patients referred to the Eye Center, Humanitas Hospital, Bergamo due to neovascular AMD and treated with antivascular endothelial growth factor (VEGF) intravitreal injections (IVIs) and oral administration of a curcumin-based nutritional supplement vehiculated by enterosoma-I®. We retrospectively collected data of 18 naive patients who received IVI and daily oral nutritional supplement and 24 naive age-matched controls with the same diagnosis undergoing only IVI. All patients underwent a loading-phase of one-per-month IVI for 3 months and then received IVI pro re nata. Median best-corrected visual acuity was significantly improved in treated patients compared with controls (P < .05), while there was no statistical difference in central macular thickness between groups (P > .05). The total number of injections (tIVI) was significantly (P < .05) reduced in the treated group compared with controls. The tIVI in treated group ranged from 3 to 5 with a median of 4 while control group received a tIVI that ranged between 6 and 7 with a median of 7. Treatment with curcumin-based nutritional supplement was safe and effective. Curcumin is a promising adjuvant of anti-VEGF treatment, improves functional outcomes, and prolongs duration.

New perspectives in keratoconus treatment: an update on iontophoresis-assisted corneal collagen crosslinking.

Keratoconus is a bilateral, asymmetric and progressive corneal disease. It usually results in apical thinning and steepening with corneal deformation and impaired vision. Since the early 1990 s, corneal collagen crosslinking (CXL) has remained the primary treatment to stabilize the progression of the disease. Iontophoresis-assisted CXL (I-CXL) has been proposed as a non-invasive alternative to standard epithelium-off technique, showing promising results. In this article, we review up to date literature to provide state of art knowledge and future perspectives of I-CXL.

Evaluating keratoconus progression prior to crosslinking: maximum keratometry vs the ABCD grading system.

PURPOSE: To evaluate the correlation between changes in maximum keratometry (Kmax) and ABC values from the ABCD Progression Display (Pentacam) in progressive keratoconus (KC) and to evaluate whether the ABC changes were able to detect progression earlier than Kmax. SETTING: Humanitas Clinical and Research Center, Rozzano, Milan, Italy. DESIGN: Retrospective study. METHODS: Kmax, ABC values, and thinnest point (ThCT) were recorded at the day of corneal crosslinking (CXL) (T0) and previous follow-up (T-1). In patients without earlier progression in Kmax, follow-up examination (T-2) was used to determine whether any of the ABC parameters reached statistical significance for progression. RESULTS: Seventy-six eyes of 63 patients scheduled for CXL with documented progression (Kmax increase of >1.00 diopter) were included. There was a significant, albeit moderate, correlation between the change in Kmax between T0 and T-1 and the change in both A (ρ = 0.391) and B values (ρ = 0.339). There was no significant correlation between the change in Kmax between T0 and T-1 and the change in either C or ThCT. In patients with T-2 examinations, 16 (51.6%) of 31 patients showed a statistically significant change on the ABCD progression display that was not detected with Kmax. CONCLUSIONS: This study showed a significant, but moderate, correlation between the change in Kmax and the change in A and B values in progressive KC. Moreover, more than half of the cases showed documented progression earlier with the ABCD progression display than that detected by standard Kmax changes. This study suggests possible changes in progression criteria to allow for earlier intervention.

Corneal Cross-linking for Progressive Keratoconus: Up to 13 Years of Follow-up.

PURPOSE: To assess the long-term efficacy and safety of epithelium-off corneal cross-linking according to the Dresden protocol (S-CXL) in progressive keratoconus. METHODS: Patients treated with S-CXL from April 2006 to January 2010 at Humanitas Clinical and Research Center, Rozzano, Italy, who completed at least 10 years of follow-up were included. Corrected distance visual acuity (CDVA), refraction, and corneal topography and tomography with Pentacam (OCULUS Optikgeräte GmbH) were evaluated at baseline and 10+ years after the procedure. The definition of progression after S-CXL was two of the following three criteria: increase of "A" value, increase of "B" value, or decrease of minimum thickness evaluated with the ABCD progression display above 95% CI for the post-CXL population. RESULTS: Twenty-seven eyes of 22 patients were included. At a mean of 11 years of follow-up (maximum 13 years), S-CXL was able to maintain CDVA and induce significant regularization of the corneal surface as demonstrated by a significant decrease of the central keratoconus index (P = .035) and a decrease of anterior curvature ("A" value) starting from 2.54 ± 2.46, which reduced to 1.14 ± 1.60 (P = .005) at 10+ years of follow-up. Two of 27 eyes included showed significant progression after S-CXL (7.4%). CONCLUSIONS: S-CXL was confirmed to be a safe and effective treatment for progressive keratoconus with a failure rate of 7.4% at up to 13 years of follow-up. The authors suggest the use of a combined progression system that evaluates anterior and posterior curvature and with thickness map together with the knowledge of the noise level of the testing system. [J Refract Surg. 2020;36(12):838-843.].

OCT changes of idiopathic epiretinal membrane after cataract surgery.

BACKGROUND: We reviewed our experience in the management of cataract and idiopatic epiretinal membrane surgeries at the Humanitas Research Institute-Milan, Italy- over the past 3 years. METHODS: We conducted a single center retrospective observational case series of patients that underwent sequential cataract and idiopatic epiretinal membrane (ERM) surgeries from 2012-2015 in Humanitas Research Institute. Full data was obtained for 53 eyes of 57 patients. Patients with ERM secondary to uveitis or trauma or associated with simultaneous retinal detachment were excluded. Diabetic retinopathy, glaucoma, age-related macular degeneration, and myopia of more than 6 diopters were exclusion criteria as well. RESULTS: Cataract surgery was not associated with an ERM stage progression at one month follow up, but caused retinal inflammation that resulted in a significant increase in central macular thickness (CMT), macular volume (MV), central macular edema (CME), IS/OS disruption (IS/OS) and neurosensory detachment (NSD). However, there was no significant change in Best corrected visual acuity (BCVA). CONCLUSION: We suggest that patients undergoing cataract surgery in the presence of epiretinal membranes need tight follow up to treat and control eventual macular inflammatory changes and eventual prompt vitrectomy if BCVA is threatened.

The use of personal protective equipment in clinical ophthalmology during corona virus disease-2019: a review of international guidelines and literature.

PURPOSE OF REVIEW: The use of nonpharmaceutical interventions can prevent viral spread in COVID-19 pandemic and PPE forms a crucial part of this strategy. However, there are discrepancies in existing guidelines and a lack of consensus among ophthalmic communities. This review aims to identify general consensus and provides recommendation of PPE for most common ophthalmological scenarios. With a global shortage of PPE, extended use and reuse strategies are also discussed. RECENT FINDINGS: In this review, guidelines and resources were selected, based on a three-tier process. The first-tier resources were from international infection control organizations. The second-tier resources were from ophthalmological professional associations and colleges. The third-tier resources involved a PubMed search using the keywords 'COVID-19; coronavirus; personal protective equipment' performed on 1 May 2020. Non-English guidelines and literatures were excluded. SUMMARY: On the basis of our methodology, we included a total of 30 documents, including 5 resources from tier 1, 14 resources from tier 2 and 15 from tier 3. Different levels of protection are necessary. Whenever performing an aerosol generating procedure, maximum protection should be ensured, this includes FFP3 respirator, fluid resistant gown, goggles or face-shield and disposable gloves. Similar protection should be used for handling COVID-19-positive/suspected case but the use of FFP2 respirator is acceptable. During routine outpatient clinic in cases of negative triage, it is recommended to use ASTM III surgical mask, plastic apron, disposable gloves and eye protection with goggles or face-shield. Lastly, patients should be encouraged to wear surgical masks whenever possible.

Facing COVID-19 in Ophthalmology Department.

Purpose: To provide useful guidelines, targeted at ophthalmology professionals, to minimize COVID-19 infection of both health-care workers and patients.Methods: In this review we present updated literature merged with our experience from hospitals in Bergamo, the epicenter of the COVID-19 European outbreak.Results: Non-pharmaceutical interventions, hygienic recommendations and personal protective equipment to contain viral spread as well as a suggested risk assessment for postponement of non-urgent cases should be applied in ophthalmologist activity. A triage for ophthalmic outpatient clinic is mandatory.Conclusion: Ophthalmology practice should be reorganized in order to face COVID-19.