Theoretic scientific rationale of double XEN 45 Gel Stent implant in severe glaucomatous ocular hypertension.

PURPOSE: To investigate the theoretical hydrodynamic effects of a single or a double XEN 45 Gel Stent (XEN45) implant in glaucomatous eyes. METHODS: A prospective non-randomized clinical study on 63 glaucomatous eyes of 63 patients. The preoperative intraocular pressure (IOP) values after 14 days of medical therapy washout was correlated to the postoperative IOP values 7 and 45 days after the implant of a XEN45. A mathematical model based on the Hagen-Poiseuille law was designed to assess the residual aqueous humor outflow (AHO) facility in glaucomatous eyes in function of the postoperative IOP reduction. Using XEN45 as unit of measurement, we transformed through equations the residual preoperative AHO in XEN45 equivalent in order to establish theoretical number of stents needed to reach the target IOP. RESULTS: The mean preoperative washout IOP was 28.9 ± 5.4 mmHg, after 7 and 45 days the mean postoperative IOP was 12.6 ± 4.3 and 15.3 ± 4.4 mmHg, respectively (p < 0.001). A significant positive correlation was found between preoperative and postoperative IOP values. We obtained a mathematical relationship to estimate the theoretical number of XEN45 stents needed to reach the target IOP. CONCLUSION: The basal IOP (after medical therapy washout) is a predictive factor for the surgical success after a XEN45 implant. Establishing the residual preoperative AHO it is possible to predict the theoretical number of stents to implant. A double XEN45 implant could be considered a possible further tool to reach the target IOP in patients with severe AHO deficiency.

SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY FINDINGS IN A CASE OF WHIPLASH MACULOPATHY WITH INCOMPLETE RESOLUTION.

PURPOSE: To report spectral domain optical coherence tomography (OCT) findings of a patient who experienced bilateral visual loss after a motorcycle accident. METHODS: A 51-year-old man presented to the emergency department complaining of bilateral visual loss after a motorcycle falling down. A complete ophthalmologic examination and OCT testing were made on the same day of the accident. Follow-up was made at 2 days, 2 weeks, 5 months, and 12 months adding central visual field assessment using Humphrey automated perimetry. RESULTS: At presentation, best-corrected visual acuity was 20/200 in both eyes, anterior segment was normal, and fundus examination showed a bilateral macular edema confirmed by OCT. After 2 days, visual acuity recovered to 20/25. Optical coherence tomography findings showed foveal detachment, hyperreflective clump below external limiting membrane, and hyperreflectivity of Henle layer nasally to the fovea. After 15 days, visual acuity was 20/20, but vision was altered by a paracentral scotoma and some irregularities of OCT findings persisted. At 1 year of follow-up, best-corrected visual acuity was 20/20, and paracentral scotoma was very tiny in the right eye, whereas larger and deeper in the left eye. Optical coherence tomography was normal in the right eye, whereas some fragmentations of interdigitation zone were still evident in the left eye. CONCLUSION: We report a case of bilateral whiplash maculopathy from vitreoretinal traction subsequent to road traffic accident. After 1 year of follow-up, visual acuity was restored but paracentral scotoma persisted. Optical coherence tomography appearance of the left eye was still abnormal.

Floppy eyelid, an under-diagnosed syndrome: a review of demographics, pathogenesis, and treatment.

Floppy eyelid syndrome (FES) is a frequent eyelid disorder characterized by eyelid laxity that determines a spontaneous eyelid eversion during sleep associated with chronic papillary conjunctivitis and systemic diseases. FES is an under-diagnosed syndrome for the inaccuracy of definition and the lack of diagnostic criteria. Eyelid laxity can result from a number of involutional, local, and systemic diseases. Thus, it is pivotal to use the right terminology. When the increased distractibility of the upper or lower eyelid is an isolated condition, it is defined as 'lax eyelid condition' (LAC). When laxity is associated with ocular surface disorder such as papillary conjunctivitis and dry eyes, it can be referred to as 'lax eyelid syndrome' (LES). However, FES is characterized by the finding of a very loose upper eyelid which everts very easily and papillary tarsal conjunctivitis affecting a specific population of patients, typically male, of middle age and overweight. Obesity in middle-aged male is also recognized as the strongest risk factor in obstructive sleep apnea-hypopnea syndrome, (OSAHS). FES has been reported as the most frequent ocular disorder associated with OSAHS. Patients with FES often complain of non-pathognomonic ocular signs and symptoms such as pain, foreign body sensation, redness, photophobia, and lacrimation. Due to these clinical features, FES is often misdiagnosed while an early recognition might be important to avoid its chronic, distressing course and the associated morbidities. This review provides an updated overview on FES by describing the epidemiology, proposed pathogenesis, clinical manifestations, related ocular, and systemic diseases, and treatment options.

Floppy eyelid syndrome and ectropion improvement after 1 month of 0.03% Bimatoprost topical therapy.

PURPOSE: To report the clinical improvement observed in a glaucomatous patient affected by floppy eyelid syndrome and ectropion after treatment with Bimatoprost 0.03%. METHODS: Retrospective observational case report of a single glaucomatous patient (caucasian, 82 years old) affected by floppy eyelid syndrome with marked eyelid laxity and ectropion after 1 month of once a day 0.03% Bimatoprost ocular drop administration. RESULTS: We observed a reduction of intraocular pressure (36% in the right eye and 37.5% in the left eye) and an unexpected improvement of eyelid laxity and inferior ectropion after 1 month of therapy with topical 0.03% Bimatoprost. Secondary outcomes were the improvement of the related ocular surface diseases and the decrease of the upper eyelid dermatochalasis. No side effect in terms of conjunctival inflammation and eyelashes growth was observed. CONCLUSIONS AND IMPORTANCE: The first observational clinical case of a possible prostaglandin therapeutic effect on periocular tissue improving the laxity and malposition of the eyelids in a patient with floppy eyelid syndrome associated with inferior eyelid ectropion.

Evaluation of clinical outcomes following implantation of a sub-2-mm hydrophilic acrylic MICS intraocular lens.

PURPOSE: To evaluate clinical outcomes following sub-2-mm microincision cataract surgery (MICS) and intraocular lens (IOL) implantation. SETTING: Five EU clinical sites. DESIGN: Prospective, multicenter, open-label, single-arm, non-randomized. METHODS: Preoperative assessment involved visual acuity (VA), intraocular pressure and biometry measurements. 1.4-mm wound-assisted or 1.8-mm MICS was performed. Follow-up visits were made 1 day, 1-2 weeks, 1-2 and 4-6 months after surgery. The incision size, corrected distance VA (CDVA), uncorrected distance VA, manifest refraction spherical equivalent (MRSE), refraction predictability/stability and IOL decentration were assessed. At 12-, 18-, and 24-month, long-term centration, posterior capsular opacification (PCO) and Nd:YAG capsulotomy rates were investigated. RESULTS: A total of 103 eyes were implanted with the study IOL (INCISE, Bausch & Lomb), 96 of which were included in visual outcome analysis. A mean 6-month CDVA of - 0.02 logMAR (20/20 + 1) was observed and 75 eyes (79.8%) and 93 eyes (98.3%) achieved a visual acuity of at least 20/20 or 20/40. Mean MRSE was - 0.20 ± 0.60 D. Mean absolute predictive error was 0.44 ± 0.36 D, with 90.4% within 1.00 D of target. Mean total decentration was 0.35 ± 0.36 mm at 6 months and 0.32 ± 0.14 mm at 24 months (p > 0.05). 24-month evaluation of posterior capsular opacification score was 0.03 for the central area. A Nd:YAG rate of 3.4% was observed at 24 months. CONCLUSIONS: The new MICS IOL provided excellent visual outcomes and was safe and effective for the sub-2-mm procedure. The MICS IOL demonstrated long-term centration, stability and a low rate of PCO development.

Minimally invasive combined glaucoma and cataract surgery: clinical results of the smallest ab interno gel stent.

PURPOSE: To verify the efficacy in intraocular pressure (IOP) reduction and safety of the smallest gel stent (XEN 45 Gel Stent) microincisional glaucoma surgery combined with microincisional cataract surgery (MICS). METHODS: Nonrandomized prospective clinical study. Forty-one eyes of 33 patients with open-angle glaucoma underwent a XEN 45 Gel Stent implantation combined with MICS. Treatment outcomes analyzed included: IOP, medication use, intra- and postoperative complications. At the end of the follow-up, we evaluated the complete success, defined as a postoperative IOP ≥ 6 and ≤17 mmHg without glaucoma medications and the qualified success defined as a postoperative IOP ≥ 6 and ≤17 mmHg, with glaucoma medications. RESULTS: The mean preoperative IOP was 22.5 ± 3.7 mmHg on 2.5 ± 0.9 medication classes. After 12 months, the mean postoperative IOP was 13.1 ± 2.4 mmHg (mean IOP reduction of 41.82%) with a mean of 0.4 ± 0.8 medication classes (P < 0.05 for IOP and medications). The complete success rate was achieved in 80.4% and a qualified success in 97.5%. There were no major intra- and postoperative complications during the first year of follow-up. CONCLUSIONS: This study demonstrated that the smaller diameter XEN 45 gel implant is statistically effective in reducing IOP and medications in glaucoma patients with a low rate of complications.

Safety and efficacy of multiple cyclocoagulation of ciliary bodies by high-intensity focused ultrasound in patients with glaucoma.

PURPOSE: To evaluate long-term efficacy and safety of repeated ultrasonic circular cyclocoagulation (UCCC) in patients with uncontrolled glaucoma. METHODS: Forty eyes of 40 patients affected by primary or secondary uncontrolled glaucoma under maximal tolerated medical therapy were enrolled in this prospective non-comparative case series study. A complete ophthalmic examination was performed before and after each month for 1 year. The UCCC treatment was repeated at 4 months if the intraocular pressure (IOP) was > 21 mmHg without major complications. Complete success was defined as a final IOP > 5 mmHg and ≤ 21 mmHg without hypotensive medication adjunction and no major or vision-threatening complications. RESULTS: The mean preoperative IOP was 32.5 ± 9.9 mmHg. Four months after the first UCCC treatment the overall IOP reduction was 27.8%. Twenty-two of the treated eyes did not achieve the complete success and a second treatment was performed in 20 of these eyes. Four months after the second UCCC procedure, the IOP reduction was 20.3% from preoperative values and 34.7% from baseline. Twelve of the retreated eyes needed a third treatment. Four months after the third UCCC treatment, the overall IOP reduction was 34% and 52.6% from baseline. No major complications occurred during or after any of the procedures. At 12 months, complete success was achieved in 85% (34/40) of treated eyes, with a maximum of three procedures and a significant medication reduction. CONCLUSIONS: Multiple UCCC treatments are safe, and additional treatments increase the overall procedure efficacy.

Unexpected and permanent central visual loss after removal of intraocular silicone oil.

Here we report a case of unexplained sudden visual loss after removal of silicone oil for rhegmatogenous retinal detachment repair. A patient with visual loss in one eye after removal of silicone oil was investigated with best-corrected Snellen visual acuity assessment, fundus biomicroscopy, optical coherence tomography, color fundus photograph, fluorescein angiography, electrophysiologic examination, automated perimetry, and visual evoked potentials. Best-corrected Snellen visual acuity was 20/30 while the silicone oil was in place. Visual acuity dropped dramatically to 20/200 after silicone oil removal. No other complications associated with oil removal were noted. The retina remained attached. Visual evoked potentials revealed decreased amplitude due to a damaged optic nerve, while the earliest central visual field defects disappeared unexpectedly almost 2 years after the last surgical procedure. No other abnormalities were demonstrated. Vision loss is a possible complication of silicone oil and removal. This case was distinguished by the permanent decrease of visual acuity despite the unexplained and quite complete recovery of the foveal threshold with no other relevant visual field defects.

Visual and aberrometric outcomes in eyes with an angle-supported phakic intraocular lens.

PURPOSE: To evaluate the postoperative changes in spherical aberration and the point-spread function (PSF) induced by the implantation of a new angle-supported phakic intraocular lens (pIOL). SETTING: Department of Ophthalmology, St. Bassiano Hospital, Bassano del Grappa, Italy. DESIGN: Prospective nonrandomized cohort study. METHODS: Eyes with high myopia had implantation of an Acrysof Cachet angle-supported pIOL. Preoperative and postoperative total spherical aberration and PSF were measured using a Luneau 80 Wave+ wavefront aberrometer (high-resolution Hartmann-Shack technology) at a fixed entrance pupil scan size of 5.0 mm under pharmacologic mydriasis. Preoperative and postoperative data were analyzed and compared using the Student t test. RESULTS: Thirty-five eyes of 18 patients were included in the statistical analysis. The Student t test for paired data (95% confidence interval) showed a statistically significant difference between preoperative data and postoperative data. The mean preoperative total spherical aberration Z(4,0) was -0.001 µm ± 0.076 (SD) preoperatively and -0.13 ± 0.11 µm postoperatively (P≤.05). The mean PSF was 0.28 ± 0.15 preoperatively and 0.34 ± 0.16 postoperatively (P<.05). CONCLUSION: Implantation of the angle-supported pIOL in eyes with high myopia improved the quality of vision, inducing negative spherical aberration and increasing the PSF under mesopic conditions.

Side-port stabilizer to assist implantation of microincision intraocular lenses.

We describe a new instrument for incision-assisted implantation of microincision intraocular lenses (IOLs). The instrument is a short nail, smooth and oval, that is inserted into the side-port incision to stabilize the eye during IOL implantation. The head prevents deep penetration and escape of the ophthalmic viscosurgical device through the incision. The instrument was safe and effective in its initial use; the 1 failure was due to the close proximity of the side port and the main incision.

Spherical aberration and coma with an aspherical and a spherical intraocular lens in normal age-matched eyes.

PURPOSE: To study optical aberrations in eyes having uneventful cataract surgery and in-the-bag implantation of an aspherical Tecnis Z9000 intraocular lens (IOL) (AMO) or a spherical CeeOn Edge 911 IOL (Pharmacia) and compare the results with those in a group of phakic age-matched eyes. SETTING: Ophthalmic Unit, Hospital and University of Verona, Verona, Italy. MATERIALS: Three groups, each with 30 patients (30 eyes), were examined with the Topcon KR-9000PW topographer/aberrometer. Spherical aberration and coma were analyzed in detail for 4.0 mm optical zone. Internal values were obtained by subtracting corneal aberrations from ocular aberrations. Point spread function and modulation transfer function (MTF) were considered for optical quality. RESULTS: The mean internal spherical aberration Z(4)(0) was -0.048 microm +/- 0.017 (SD) in the Tecnis group, +0.033 +/- 0.026 microm in the 911 Edge group (P<.001), and -0.013 +/- 0.056 microm in the phakic group (P = .149). The mean internal vertical coma Z(3)(-1) was 0.087 +/- 0.056 microm, 0.054 +/- 0.043 microm (P = .005), and 0.044 +/- 0.044 microm (P<.001), respectively. The internal horizontal coma Z(3)(+1) showed a similar pattern; however, total resulting coma was similar in the 3 groups. The mean Strehl ratio was 0.284 +/- 0.166 in the Tecnis group, 0.145 +/- 0.077 in the 911 Edge group (P<.01), and 0.164 +/- 0.097 in the phakic group (P<.01). The MTF curve was better in the Tecnis group (P<.001). CONCLUSIONS: After uneventful implantation, the aspherical IOL yielded better ocular aberration and optical quality results than the spherical IOL. Induced coma was somewhat higher in the Tecnis group; however, the overall results were not affected. Physiologic IOL decentration after correct in-the-bag implantation did not negate the advantages of asphericity.

Optimizing higher-order aberrations with intraocular lens technology.

PURPOSE OF REVIEW: Aspheric intraocular lens technology has been implemented during the past 5 years, and more and more intraocular lenses with different amounts of asphericity are becoming available. Despite the efficacy in the correction of spherical aberration and the good results on implanted eyes, the theoretical advantages of aspheric intraocular lenses are still controversial. RECENT FINDINGS: All investigations showed the ability of the aspheric intraocular lenses to correct the positive spherical aberration of the cornea, with variable impact on the total eye wavefront but with constant advantages in the optical quality of the eyes as measured by the Modulation Transfer Function, the Point Spread Function, and the contrast sensitivity of implanted patients. Theoretical studies on model eyes underlined some possible limitations of aspheric intraocular lenses, especially sensitivity to decentration. In addition, the actual optical quality in implanted eyes is also affected by light scattering, a parameter missed by simple aberration analysis. SUMMARY: Aspheric intraocular lenses effectively reduce spherical aberration in implanted eyes, with improvement in optical quality over the parent spherical intraocular lens. The advantages for implanted eyes could be limited by decentration, by small pupil diameter, and by reduced media transparency.

Visual acuity and contrast sensitivity comparison between Tecnis and AcrySof SA60AT intraocular lenses: A multicenter randomized study.

PURPOSE: To evaluate best corrected visual acuity (BCVA) and photopic and mesopic contrast sensitivity in pseudophakic patients implanted either with the aspheric intraocular lens (IOL) designed to correct for corneal spherical aberration or with a conventional IOL. SETTING: Three surgical centers participated this prospective randomized masked comparative study. METHODS: Thirty eyes of 30 patients after aspheric lens implantation (Pfizer/Pharmacia Tecnis Z9000) were compared with 30 eyes of 30 age-matched patients after conventional lens implantation (Alcon AcrySof SA60AT). Two to three months after surgery, best spectacle corrected distance visual acuity was measured using the Early Treatment Diabetic Retinopathy Study chart. Contrast sensitivity was measured by sinusoidal grating charts for distance at photopic (85 cd/m(2)) and mesopic (6 cd/m(2)) luminance level with optical correction in place. Tested spatial frequencies were 1.5, 3, 6, 12, and 18 cycles per degree (cpd). RESULTS: The mean BCVA was -0.053 +/- 0.044 logMAR in eyes with the aspheric Tecnis IOL and 0.006 +/- 0.059 logMAR in eyes with the conventional AcrySof IOL (P=.0001). Eyes with the aspheric IOL showed better contrast sensitivity at spatial frequencies of 3 cpd (P<.05) and 6, 12, and 18 cpd (P<.01) in photopic and in mesopic conditions. Peak improvement occurred at 18 cpd and was 36% (0.29 log units) in photopic and 54% (0.27 log units) in mesopic conditions. CONCLUSIONS: The aspheric Tecnis IOL yielded better BCVA and better distance contrast sensitivity than the conventional IOL. The differences were clinically significant for higher spatial frequencies. The results give some suggestions for further studies.

Reverse flap dissection for glaucoma surgery.

A modified reverse dissection of scleral flaps for glaucoma surgery is described. A conventional square or rectangular flap is designed with deep scleral incisions, the two radial incisions crossing the limbus. A horizontal tunnel is created parallel to the limbus within the peripheral cornea, joining the two radial incisions. This tunnel is then enlarged toward the sclera, gradually dissecting the whole scleral flap. This centrifugal cutting is opposite to the common centripetal cutting employed for scleral flaps. Advantages over conventional dissection include more precise dissection within the limbal area, smoother surfaces, and reduction of disturbing bleeding.

Comparison of wavefront aberrations and optical quality of eyes implanted with five different intraocular lenses.

PURPOSE: We compared corneal and total higher order wavefront aberrations in 25 pseudophakic eyes implanted with five different types of intraocular lenses to obtain an objective evaluation of the optical quality of these pseudophakic eyes. Five IOLs per type were studied. METHODS: Implanted lenses were the Pharmacia Tecnis Z9000 with negative spherical aberration, Pharmacia 911 Edge, Alcon Acrysof SA60AT and MA60BM, and Allergan Sensar AR40e. Eyes were examined using the Topcon KR-9000PW topographer/aberrometer, which obtains simultaneous coaxial measurements of corneal and ocular aberrations, and displays the calculated Point Spread Function (PSF) and Modulation Transfer Function (MTF). RESULTS: Corneal spherical aberration was positive in all tested eyes. For a 4-mm optical zone, ocular spherical aberration was 0.0054+/-0.0172 microm root-mean-square (RMS) in eyes implanted with the Tecnis lens, and was 0.0562 to 0.0974 microm RMS in eyes implanted with the four other conventional IOLs. A myopic refractive shift with mydriasis of -0.08 D occurred with the Tecnis IOL; it was -0.57 to -0.90 D with the conventional IOLs. Coma did not show a substantial reduction with any of the IOLs. Total wavefront aberrations showed nonsignificant reduction with the Tecnis lens. The PSF and the MTF also showed nonsignificant improvements over conventional IOLs. CONCLUSIONS: The optical quality of pseudophakic eyes can be measured in vivo by aberrometers. Different IOLs resulted in measurably different outcomes. In this preliminary study, compensation of the spherical aberration observed with the Tecnis lens confirmed the theoretical predictions associated with this lens and resulted in no myopic shift in refraction with mydriasis.