Long-term visual outcomes and rehabilitation in Usher syndrome type II after retinal implant Argus II.

BACKGROUND: The aim of this article is to describe visual outcomes and posterior rehabilitation of the first Usher syndrome type II (USH2) patient receiving an Argus II (®) prosthesis. CASE PRESENTATION: We present a case of a USH2 patient who underwent Argus II prosthesis surgery at the age of 53. He had hearing loss from birth and presented a very poor visual field with good light perception. He communicated through sign language translated by his interpreter, who explained all the information regarding the surgical procedure and who assisted in the posterior visual therapy. Sixteen months after surgery, the patient communicates more fluently with sign language and is able to identify letters with high contrast over 6 cm and words up to four letters. CONCLUSIONS: This is the first case described in the literature of a USH2 patient receiving an Argus II prosthesis This is an alternative treatment for USH2 patients, whose interpreters are essential in the selection process and subsequent rehabilitation after surgery.

Tratamento cirúrgico da ptose palpebral moderada e grave: análise de resultados / Surgical treatment of moderate and severe ptosis: analysis of results

Introdução: A ptose palpebral é uma afecção comum na prática clínica na qual uma perfeita avaliação torna-se mandatória. Definimos ptose quando a margem palpebral encontra-se abaixo de 2 mm da junção córneo escleral e pode ser classificada em leve, moderada e grave. Existem inúmeras técnicas de reparo e a escolha dependerá da classificação da função do músculo levantador. Métodos: Foram analisados de forma prospectiva, no período de março de 2013 a maio de 2015, quatorze (n = 14) pacientes submetidos ao tratamento cirúrgico de ptose palpebral moderada e grave (n = 21). Inúmeros fatores foram estudados, tais como grau de ptose e função do músculo elevador da pálpebra, tipo de técnica de reparo, complicações imediatas e tardias, etc. Resultados: Quatorze pacientes foram opera-dos, totalizando 21 pálpebras, sendo que, 85% foram de etiologia adquirida e 15% congênita. Com relação ao grau de ptose, 64,3% (n = 9) foram moderadas e 35,7% (n = 5) graves. No que tange à função do músculo levantador, encontramos função boa 28,5% (n = 4), moderada 28,5% (n = 4) e pobre 43% (n = 6). Em relação às com-plicações, 2 casos de hiperemia conjutival e um caso de edema. Obtivemos um alto índice de satisfação com 85,7% (n = 12), com baixas taxas de complicações. Conclusão: A ptose palpebral é uma enfermidade comum na prática clínica e exige por parte do cirurgião um perfeito conhecimento anatômico da delicada estrutura palpebral e também de sua fisiopatologia. Uma perfeita avaliação desse paciente torna-se mandatória para o emprego do tratamento mais adequado.

Introduction: Eyelid ptosis is a common condition in clinical practice for which a complete evaluation is mandatory. Ptosis is defined when the eyelid margin is 2 mm below the corneoscleral junction and can be classified as mild, moderate, and severe. There are numerous repair techniques, and the choice will depend on the classification of the function of the levator muscle. Methods: We evaluated prospectively, from March 2013 to May 2015, 14 patients who underwent surgical treatment of moderate and severe ptosis (n = 21). Several factors were studied, such as degree of ptosis and function of the eyelid levator muscle, type of repair technique, and immediate and late complications. Results: Fourteen patients (21 eyelids) underwent operation. The etiology was acquired in 85% of the cases and congenital in 15%. With respect to the degree of ptosis, 64.3% (n = 9) of the cases were moderate and 35.7% (n = 5) were severe. With respect to the muscle function of the levator, good, moderate, and poor functions were observed in 28.5% (n = 4), 28.5% (n = 4), and 43% (n = 6) of the cases, respectively. With regard to complications, 2 cases of conjunctival hyperemia and one case of edema were observed. We obtained a high satisfaction rate of 85.7% (n = 12), with low complication rates. Conclusion: Eyelid ptosis is a common presentation in clinical practice and requires on the part of the surgeon a detailed anatomical knowledge of the delicate structure of the eyelid and its pathophysiology. A complete evaluation of these patients is mandatory for the employment of the most appropriate treatment.

[Femtosecond-assisted Ferrara intrastromal corneal ring implantation for treatment of keratoconus: Functional outcomes at one year]. / Anneaux intra-cornéens Ferrara implantés au laser femtoseconde dans le traitement du kératocône : résultats fonctionnels à 1 an.

INTRODUCTION: Intrastromal corneal rings (ICR) have been used for several years for the correction of irregular astigmatism in patients with keratoconus. OBJECTIVE: To evaluate the effectiveness of femtosecond-assisted ICR implantation for treatment of keratoconus and to define predictive factors of success. PATIENTS AND METHODS: We undertook a retrospective study of patients with keratoconus who underwent femtosecond-assisted Ferrara ICR implantation between December 2012 and May 2014 at the University Hospital of Besançon. To determinate predictive factors of success, we divided patients into 2 groups based on the gain of at least two lines of best corrected visual acuity (BCVA) at 1 year after surgery ("good responders") or the gain of only one line of BCVA, no change, or the loss of lines of BCVA ("poor responders"). For each group, we analyzed preoperative refractive and keratometric values. Moreover, to verify if preoperative visual acuity could be a predictive factor of success, four groups were created based on initial visual acuity, and postoperative BCVA was compared. RESULTS: We retrospectively studied 32 eyes of 29 patients with keratoconus who underwent femtosecond-assisted Ferrara ICR implantation between December 2012 and May 2014 at the University Hospital of Besançon. From one month to 1 year postoperatively, we observed a significant improvement in BCVA and a significant decrease in cylinder and keratometry values (P<0.05). In total, 90.6% of patients had an increase in visual acuity (VA) of at least one line within 1 year while 9.4% had a decrease or stability of their VA. The average cylinder value decreased from -4.81±2.45 diopters (D) preoperatively to -2.39±1.94 D (P<0.001) at 1 year postoperatively, and the average of the maximum keratometry from 51.14±3.89 D to 48.52±4.00 D (P<0.05). Four predictive factors of success were statistically significant: type of ectasia (type 1 or 2), stage of keratoconus (Krumeich 1 or 2), implantation of only 1 ICR and a preoperative VA less than 0.4 (decimal scale). Eighty-six percent of patients with an initial VA<0.4 (decimal scale) gained 2 lines of BCVA within 1 year and 80% 3 lines versus 52% and 41%, respectively for patients with initial VA≥0.4 (decimal scale). CONCLUSION: Femtosecond-assisted Ferrara ICR implantation for treatment of keratoconus is a reliable and reversible technique. Implantation results in greater efficiency for patients with moderately advanced asymmetric keratoconus with an initial VA<0.4 (decimal scale).

[Post-surgical management of split-thickness skin grafts in oculoplastic surgery]. / Operatives Management und Nachsorge freier Spalthauttransplantate in der okuloplastischen Chirurgie.

Malignant skin tumours in periocular regions often demand ophthalmo-surgical measures. Split-thickness skin grafts still represent an important treatment alternative when plastic-reconstructive covering through local tissue of the facial area is impossible. Essential technical steps to gain viable split-thickness skin grafts are introduced. Current standards in the after-treatment of split-thickness skin grafts at the receiving location as well as in the after-care of the donor area are presented from interdisciplinary points of view referring to the latest publications. Hydrocolloidal dressings are recommended for the after-treatment of removal areas such as the inside of the forearm since they improve post-surgical management for the ophthalmologist significantly and help in abbreviating healing duration. Pain sensation of the patient as well as the rate of infection are minimal. Throughout the early stages, split-thickness skin grafts at reception areas often demand an intensified local massage treatment with hydrocortisone 2.5 % ophthalmic cream. During the later stages follow-up measures should be stopped neither too soon nor abruptly. Ointments with polysiloxane and silicon dioxide preserve skin suppleness and prevent the occurrence of shrinkage as well as hypertrophic scars.

Propiedades biomecánicas de la cornea con corvis ST y ocular response analyser después de diferentes procedimientos quirúrgicos en pacientes con queratocono / Corneal biomechanical properties with corvis ST and ocular response analyser in eyes with keratoconus which were submitted to different surgical procedures

Introducción. Las opciones quirúrgicas disponibles para el tratamiento del queratocono (QC) se han ampliado y mejorado. Nuestro objetivo es comparar las propiedades biomecánicas de la córnea con dos instrumentos de uso clínico en ojos con QC sin cirugía o intervenidos con diferentes tipos de cirugía corneal (cross-linking (CXL), segmentos intra-corneales (ICSR) y queratoplastia penetrante(QP)). Material e Métodos. Se analizaron 91 ojos de paciente con KC no operados, 22 ojos con ICSR, 16 ojos con QP y 6 ojos con CXL. Se analizó el espesor corneal central (ECC), presión intra-ocular y los parámetros obtenidos con ORA (clásicos, y análisis de señal) y Corvis. Resultados. Tanto los valores de presión intra-ocular (PIO) obtenidos directamente con ORA y Corvis como los valores de PIO corregidos por el ORA (PIOcc) fueron significativamente diferentes entre los distintos grupos. Hasta 9 de los parámetros resultantes del análisis de señal de medida del ORA (p1area, p2area, h2, dive2, path1, aplhf, p1area1, p2area1 y w11) mostraron diferencias estadísticamente significativas entre los grupos. En cuanto al Corvis, A1 Time, A2 Time y Peak Distance fueron significativamente diferentes entre los grupos considerados. Conclusiones. Las nuevas tecnologías de evaluación y análisis de datos de la respuesta biomecánica de la cornea permiten cuantificar y diferenciar el comportamiento biomecánico tras diferentes tipos de cirugía para la estabilización, regularización o substitución corneal en pacientes con queratocono (AU)

Background. Surgical options for the treatment of keratoconus (KC) have been expanded and improved. Our goal is to evaluate the changes in biomechanical properties of the cornea measured with two instruments for clinical use in KC eyes not operated or which undergoing different surgical procedures (cross-linking (CXL), intra-corneal ring segment (ICSR) and penetrating keratoplasty (QP)). Material and methods. The population consisted of 91 eyes with KC not operated, 22 eyes that underwent ICRS implant, 16 eyes that were submitted to PK and 6 eyes that underwent CXL. We analyzed corneal thickness, intraocular pressure and the parameters obtained with ORA (classic and signal analysis) and Corvis. Results. Both the values of intraocular pressure (IOP) obtained directly from ORA and Corvis, as IOP values corrected by the ORA (IOPcc) were significantly different between groups. For 9 of the parameters resulting from ORA analysis of signal (p1area, p2area, h2, Dive2, path1, aplhf, p1area1, p2area1 and w11) showed statistically significant differences between groups. Regarding Corvis, A1 Time, A2 Time and Peak Distance were significantly different between the groups. Conclusions. The new technology assessment and analysis of the biomechanical response of the cornea to quantify and differentiate the biomechanical behavior after different types of surgery for stabilization, regularization or corneal replacement in patients with keratoconus (AU)

The effects of soft contact lens use on cornea and patient's recovery after autograft pterygium surgery.

PURPOSE: To investigate usage of soft contact lens (SCL) on post-operative pain relief and daily, activity due to pterygium surgery. METHODS: Autograft pterygium surgery was performed to 63 eyes of 63 patients. After surgery in 30, eyes of 30 patients in group-1, SCL was placed on the cornea. In 33 patients of group-2, antibiotic, pomade was applied and tightly covered with bandage. Follow-up visits were performed on 24th and, 48th h after the surgery. Re-epithelization time and pain scores were compared. RESULTS: Patients' 24th h pain score was 2.96 ± 0.76 in group-1, and 4.15 ± 0.75 in group-2. The mean, pain score for 48 h was 1.66 ± 0.66 in group-1, and 2.96 ± 0.68 in group-2. Patients' pain scores for, both 24th h and 48th h were lower in group-1 (p<0.01). The mean re-epithelization times in, group 1 and 2 were 48 and 56.7h, respectively. Corneal re-epithelization is improved in patients, with SCL compared to group 2. CONCLUSION: SCL seems effective on reducing post-operative pain and eye stinging, and may accelerate, corneal re-epithelization and maintaining daily activities.

[Post-operative rehabilitation of functional amblyopia in primary infantile glaucoma: 11 year-follow-up]. / Rééducation de la part fonctionnelle de l'amblyopie dans le glaucome primitif infantile opéré, recul de 11ans.

PURPOSE: To evaluate the efficacy of functional amblyopia treatment in children having undergone surgery for primary infantile glaucoma. PATIENTS AND METHOD: Parameters studied included: age at surgery, current age, visual acuity (VA) (initial and most recent acuity), refraction, alignment, adherence to amblyopia treatment, condition of the cornea (Haab striae, stromal scarring, pachymetry, cell count), condition of the optic disc (cupping, RNFL OCT) and intraocular pressure. Pearson's p-value was fixed at 5%. RESULTS: Retrospective study of 29 eyes; average age at surgery was four months, mean follow-up was 11.2 years. Initial VA averaged 4.5 over 10, most recent VA 7 over 10, i.e. a gain of 2.3 over 10. Refraction revealed 37.9% myopia, 10.3% emmetropia, 48.2% hyperopia and an average astigmatism of 2.14 D. A negative correlation was found between astigmatism and most recent VA (rho=-0.7; P<0.001). A positive correlation was found between the quality of the occlusion therapy and the recovery of VA with a gain of 3.2 over 10 (P=0.001). A strong positive correlation was found between the cylinder power and the number of Haab striae [rho 0.702, P<0.0001]; final VA is best when the striae show no organized scar formation (P=0.04). CONCLUSION: This study underlines the necessity of prolonged treatment of functional amblyopia in primary infantile glaucoma for the best possible visual rehabilitation.

[Intraocular foreign bodies (IOFB) of the posterior segment: retrospective analysis and management of 57 cases]. / Corps étrangers intraoculaires (CEIO) du segment postérieur : analyse rétrospective et prise en charge à propos de 57 cas.

PURPOSE: To determine the influence of prognostic factors and the type of tamponade agent in surgical management of intraocular foreign bodies (IOFBs) for better visual outcome. PATIENTS AND METHODS: Fifty-seven consecutive cases were retrospectively reviewed at the XV-XX National Hospital (Paris) between 1 January 2004 and 31 December 2007. Univariate and multivariate analyses were performed to identify prognostic variables. Several parameters were measured: pre- and postoperatively: best corrected visual acuity (BCVA), material and size of the foreign body, entry site, time from trauma to surgical removal, IOFB location, initial retinal detachment, choice of vitreous tamponade agent (none, gas, silicone oil), postoperative visual outcome, and complications (siderosis, endophthalmitis, and vitreoproliferative retinal detachment). RESULTS: Metal IOFBs accounted for the majority with 80.7% (n=46). The inferior retinal segment was the most frequent location found: 47.4% (n=27). Initial and final mean BCVAs were, respectively, 1.47 (±0.99) and 1.03 (±0.96) (LogMar scale). The mean follow-up was 20.7 months (range, 12-60 months). Initial retinal detachment was found in 24.56% (n=14), with a statically worse prognosis. The BCVA was better in the group with gas tamponade (n=16) than in the group with silicone tamponade (n=21) and the group without a tamponade agent (n=20). Initial BCVA was the most important predictive factor for final BCVA. Time to surgery was a predictive factor of final visual outcome with a cut-off in the first week. The scleral or corneoscleral entry site had a better prognosis than the corneal site. Five cases of siderosis (8.7%) related to delayed management and two cases of endophthalmitis (3.5%) were found (despite use of prophylactic systemic antibiotics). No statistical difference was found regarding the IOFB location on the retina, its size, or the material. Finally, the retina remained detached in nine cases (15.78%). A final BCVA of 20/40 or more was obtained in 39.3 and 17.5% had light perception or worse. CONCLUSION: The prognosis of an IOFB injury is for the most part uncertain due to a complex combination of parameters. Nevertheless, good postoperative results can be achieved without a silicone tamponade agent. The main prognostic factors related to better visual outcome were initial BCVA, time to surgery (first week), initially attached retina, and the scleral entry site. The main complications were vitreoproliferative retinal detachment, endophthalmitis, and siderosis. The location, type, and size of IOFBs were not statistically significant predictive factors in this study.

Topical versus peribulbar anesthesia in non-penetrating deep sclerectomy. A cost-effectiveness analysis.

AIM: To assess the costs and cost-effectiveness ratio of topical and peribulbar anesthesia in non-penetrating deep sclerectomy for the surgical treatment of open-angle glaucoma. PATIENTS AND METHODS: We evaluated the associated direct costs with both topical and peribulbar anesthesia. Effectiveness was defined as the proportion of patients that experienced no pain during the surgical procedure and was obtained from the literature. Cost-effectiveness was defined as direct cost of anesthesia per patient with no pain. We also calculated the incremental cost-effectiveness ratio (ICER) in order to determine which intervention was dominant. RESULTS: Direct costs were US$ 45.60 and US$ 49.18 for topical and peribulbar anesthesia respectively. The great majority of patients experienced no pain with any of the procedures (91.7% for the topical group and 69.7% for the peribulbar group). Cost-effectiveness ratio was US$ 49.73 for topical anesthesia and US$ 70.56 for peribulbar anesthesia. The ICER was negative and topical anesthesia was dominant over peribulbar anesthesia. CONCLUSION: Topical anesthesia was less costly and more effective than peribulbar anesthesia in avoiding pain in non-penetrating deep sclerectomy.

Pharmacokinetics of pirfenidone after topical administration in rabbit eye.

PURPOSE: Pirfenidone (5-methyl-1-phenyl-2-[1H]-pyridone) is a new, broad-spectrum agent that has an inhibition effect on the proliferation, migration, and collagen contraction of human Tenon's fibroblasts, and thus modulating the wound healing process of glaucoma filtering surgical site. This study investigated the pharmacokinetics of topically administered pirfenidone (0.5%) in rabbit eyes. METHODS: Pirfenidone solution (50 µl) was instilled into the rabbit's conjunctival sac. The rabbits were quickly sacrificed at 2, 5, 8, 10, 15, 20, 30, 60, 90, and 120 min after the administration and ocular tissues were obtained. The concentrations of pirfenidone in conjunctiva, sclera, cornea, aqueous humor, and vitreous were determined by high performance liquid chromatography. RESULTS: After topical administration, there was wide distribution and fast clearance of pirfenidone among the various ocular tissues. The mean maximum concentrations (C(max)) of pirfenidone in cornea, conjunctiva, sclera, aqueous humor, and vitreous were 9.64 mg/g, 9.62 mg/g, 2.13 mg/g, 34.88 mg/l and 0.52 mg/l, respectively. The half-life for these tissues was 18.26, 34.16, 15.71, 70.91, and 39.48 min, respectively. CONCLUSIONS: Measurable concentrations of pirfenidone are achieved in ocular tissues after topical application in rabbit model. Topical administration of pirfenidone may be an effective approach for modulation of wound healing responses in glaucoma filtration surgical site.

Custo social de duas técnicas de cirurgia de catarata no Brasil / Social costs of two cataract surgical techniques in Brazil

OBJETIVO: Comparar os custos sociais pós-operatórios da cirurgia de catarata segundo as técnicas de facoemulsificação (Faco) e extração extracapsular (EECP). MÉTODOS: Estudo prospectivo, intervencionista e randomizado com 205 pacientes: 101 submetidos à Faco e 104 à EECP, no sistema público em São Paulo, SP, em 2002. Para avaliação do impacto socioeconômico dessas cirurgias, foi considerado o custo no período pós-operatório para os pacientes, empregadores e Sistema Previdenciário. As comparações entre os grupos foram feitas pelo teste do qui-quadrado ou por Mann-Whitman, quando apropriado. O nível de significância estabelecido foi de 5 por cento. RESULTADOS: Considerando os gastos com os retornos hospitalares e aquisição de lentes corretivas (óculos), o paciente submetido à Faco obteve uma economia média de US$ 16,74, comparado ao paciente submetido à EECP. Quanto aos custos com licença médica, na primeira quinzena de afastamento do paciente, e os gastos com a ausência no trabalho do acompanhante, nos retornos pós-operatórios, o sistema empresarial obteve uma economia média de US$ 0,18 no grupo dos pacientes submetidos à Faco em relação ao grupo submetido à EECP. O gasto do Sistema Previdenciário por paciente foi estimado em US$ 6,57 no grupo Faco e US$ 51,15 no grupo EECP. CONCLUSÕES: A técnica de Faco representou economia média de US$ 61,5 para empregadores, pacientes, acompanhantes e Sistema Previdenciário, quando comparada à técnica de EECP.

Correçäo de pterígio recidivado com enxerto córneo-limbo-conjuntival / Corneal-limbus-conjuntival graft procedure to treat recurrent pterygium-A four a half years experience

Os autores apresentam sua experiência de quatro anos e meio com a técnica cirúrgica em que se realiza um enxerto ceratolomboconjuntival para o tratamento de pterígios recidivados e pseudopterígios, associados ou näo a simbléfaro. Foram realizadas 19 cirurgias, obtendo-se um bom resul;tado sem recidivas em 16 procediemntos 88,9 (por cento). O tempo de observaçäo pós-operatória variou de 1 a 63 meses (média de 18 meses). Concluímos que esta é uma técnica confiável, quando indicada em casos de pterígio recidivado ou com várias cirurgias prévias que apresentam comprometimento cicatricial e retracional

Cálculo do poder dióptrico de implantes intraoculares: aplicaçäo da fórmula de Sanders, Retzlaff e Kraff / Posterior chambers implant pourer choice: use of Sanders, Retzlaff and Kraff formula

O autor apresenta dados colhidos de 100 facectomias extra-capsulares programadas com implante intra-ocular de câmara posterior. Em todos os casos, a escolha do valor dióptrico do implante foi baseada na fórmula de Sanders, Retzlaff e Kraff (SRK), que utiliza o comprimento axial do globo ocular e o valor dióptrico da córnea. O erro refratométrico encontrado variou de 3,30 dioptrias para o lado miópico a 1,69 dioptrias para o lado hipermétrope, com um valor médio igual a 0,87 dioptria. Em 66% dos casos näo superou 1,0 dioptria e em 93% dos casos näo superou 2,0 dioptrias. O autor chama a atençäo para o grande risco que representa usar uma lente ou partir da refraçäo pré-operatória do paciente para a escolha do valor dióptrico do implante intra-ocular a ser utilizado, já que ambos os métodos podem dar margem a erros grosseiros e altamente desfavoráveis no que diz respeito à refraçäo pós-operatória do paciente pseudo-fácico. Ressalta, ainda, a necessidade de se conhecer os principais componentes da refraçäo do globo ocular, principalmente o comprimento axial e o valor dióptrico da córnea e aplicá-los em uma das fórmulas existentes para o cálculo do valor dióptrico do implante a ser utilizado. A fórmula de Sanders, Retzlaff e Kraff (SRK), por ter sido desenvolvida a partir de dados eminentemente empíricos, por ser de fácil aplicaçäo e por oferecer razoável margem de segurança quanto à refraçäo pós-operatória a ser alcançada pelo paciente é, na opiniäo do autor, de grande utilidade...