Superficial keratectomy followed by intense pulsed light for Salzmann's nodular degeneration and coexisting meibomian gland dysfunction.

PURPOSE: To describe the clinical course of a case of bilateral Salzmann nodular degeneration (SND) treated with superficial keratectomy (SK) followed by intense pulsed light (IPL) for the treatment of coexisting meibomian gland dysfunction (MGD). CASE DESCRIPTION: A 54-year-old man who presented to us complaining of progressive blurred vision associated with foreign body sensation in both eyes because of SND and coexisting MGD. In view of symptoms and visual acuity (VA) deterioration, bilateral SK was performed. Two months after SK, IPL treatment to the face and meibomian gland expression (MGX) using the E-eye device (E-SWIN, Paris) on days 0, 15, and 45, were performed in both eyes with the aim to avoid recurrence and/or progression of MGD. One year after SK, the patient was asymptomatic and VA was 20/20 in both eyes; however because of worsening of non-invasive tear film break-up time measured on Sirius® Scheimpflug tomograph, IPL and MGX were promptly repeated and scheduled every 6 months. CONCLUSION: In our case, IPL was a safe and effective option to control MGD in a patient with SND requiring SK with no observed recurrence of SND 2 years after surgery.

Effectiveness and safety of intravenous dexmedetomidine sedation for ophthalmic surgery under regional anesthesia.

PURPOSE: To assess the effectiveness and safety of intravenous (IV) dexmedetomidine for sedation in ophthalmic surgery. METHODS: Prospective, observational, uncontrolled, single-center study. Patients were sedated with a continuous dexmedetomidine IV infusion started 15 min before regional anesthesia administration and maintained up to the end of surgery. Effectiveness of dexmedetomidine was assessed by the Modified Observer's Assessment of Alertness and Sedation (MOAA/S) targeted at 5. Safety was assessed by the incidence of patients' movements/snoring and by the incidence of respiratory and haemodynamic complications. An eleven-point numerical rating scale (NRS) was used to assess the level of satisfaction of both the surgeon and the patient. RESULTS: 123 patients (73 males, mean age: 63 ± 13) were included; 81 (81/123; 65.8%) patients reached the requested MOAA/S score of 5. Any intraoperative movement - mostly voluntary - occurred in 34 (34/123; 27.6%) cases with no need for a switch to general anaesthesia; no ocular complications related to the intraoperative movements occurred. Intraoperative snoring occurred in 30 (30/123; 24.4%) patients and it did not affect the surgical manoeuvres. Respiratory drive depression requiring manual or mechanical ventilation never occurred. Bradycardia occurred in 14 (14/123; 11.3%), cases but only 4 (4/123; 3.2%) patients required atropine administration, which was always effective. Intraoperative analgesia was consistently obtained and both the surgeons and the patients reported a high NRS satisfaction score. CONCLUSION: Dexmedetomidine provided adequate sedation in patients undergoing ocular surgery under local anaesthesia and showed a good effectiveness and safety profile. Upper airway obstruction, apnoea and snoring can occur.

The Use of Anterior-Segment Optical-Coherence Tomography for the Assessment of the Iridocorneal Angle and Its Alterations: Update and Current Evidence.

The introduction of anterior-segment optical-coherence tomography (AS-OCT) has led to improved assessments of the anatomy of the iridocorneal-angle and diagnoses of several mechanisms of angle closure which often result in raised intraocular pressure (IOP). Continuous advancements in AS-OCT technology and software, along with an extensive research in the field, have resulted in a wide range of possible parameters that may be used to diagnose and follow up on patients with this spectrum of diseases. However, the clinical relevance of such variables needs to be explored thoroughly. The aim of the present review is to summarize the current evidence supporting the use of AS-OCT for the diagnosis and follow-up of several iridocorneal-angle and anterior-chamber alterations, focusing on the advantages and downsides of this technology.

New ophthalmic dual-viscoelastic device in cataract surgery: a comparative study.

OBJECTIVE: To compare the performance and safety in cataract surgery of two ophthalmic viscoelastic devices (OVDs), each having separate dispersive and cohesive characteristics and different concentrations. METHODS AND ANALYSIS: In this prospective, randomised, controlled clinical study, one eye of each patient was injected with OVD1 (Viscopack14) or OVD2 (DuoVisc) during phacoemulsification and intraocular lens implantation. Endothelial cell count, intraocular pressure (IOP), central corneal thickness (CCT), intraocular inflammation and corrected distance visual acuity (CDVA) were compared 3 months postoperatively. RESULTS: The study enrolled 127 patients. Randomisation assigned 50 eyes of as many patients to each arm of the study. The postoperative mean endothelial cell loss was 14.4% and 7.1% from baseline in the OVD1 and OVD2 groups, respectively (p=0.08). The incidence of IOP spikes at 2 hours was 0% and 8%, respectively (p=0.02). There were intergroup differences in postoperative IOP values, the OVD2 group showed significantly higher values at all of the follow-up visits starting from the 24 hours examination (p<0.05). There was no statistically significant difference in the CCT, intraocular inflammation and CDVA at the end of follow-up. CONCLUSION: Both OVDs showed similar clinical performances and were equally effective during cataract surgery. Viscopack14 showed more corneal endothelial cell reduction, while DuoVisc had more occurrences of IOP values and spikes. Future studies are mandatory to support these preliminary results.

Prevalence of peripapillary choroidal neovascular membranes (PPCNV) in an elderly UK population-the Bridlington eye assessment project (BEAP): a cross-sectional study (2002-2006).

PURPOSE: There is paucity of data on the epidemiology of peripapillary choroidal neovascularisartion (PPCNV). Our aim was to determine prevalence of PPCNV in the elderly UK population of Bridlington residents aged ≥65 years. METHODS: Eyes with PPCNV in the Bridlington eye assessment project (BEAP) database of 3475 participants were analysed. PPCNV outline was drawn, its area measured, and clock-hour involvement of disc circumference recorded. Location and shortest distance from the lesion edge to fovea were recorded. Masked grading for age-related maculopathy (ARM)/reticular pseudodrusen (RPD) within the ETDRS grid was assigned for each eye using a modified Rotterdam scale. Peripapillary retinal pigment epithelial (RPE) changes/drusen were recorded. Visual acuity (VA) and demographic details analysed separately were merged with grading data. RESULTS: PPCNV were identified in ten subjects, and were bilateral in two (20%), a population prevalence of 0.29%, and 0.06% bilaterality. Gender-specific prevalence were 0.36% and 0.19% for females and males, respectively. Age ranged from 66 to 85 years [mean 76.3 (SD 6.4)]. PPCNV were located nasal to disc in 41.7%, measuring 0.46-7.93 mm2 [mean 2.81 mm2 (SD 2.82)]. All PPCNV eyes had peripapillary RPE changes. One subject had no ARM, 1 angioid streaks, and 30% RPD. No direct foveal involvement, or reduced VA attributable to PPCNV was observed. CONCLUSION: PPCNV were infrequent in this population, more common in females, and often located nasal to the disc, without foveal extension. Peripapillary degenerative changes were universal, and strong association with ARM was observed in eyes with PPCNV. Typically, PPCNV were asymptomatic with VA preservation.

Visual performance after bilateral implantation of 2 new presbyopia-correcting intraocular lenses: Trifocal versus extended range of vision.

PURPOSE: To compare the visual outcomes and quality of vision of 2 new diffractive multifocal intraocular lenses (IOLs) with those of a monofocal IOL. SETTING: Fatebenefratelli e Oftalmico Hospital, Milan, Italy. DESIGN: Prospective case series. METHODS: Patients had bilateral cataract surgery with implantation of a trifocal IOL (Panoptix), an extended-range-of-vision IOL (Symfony), or a monofocal IOL (SN60WF). Postoperative examinations included assessing distance, intermediate, and near visual acuity; binocular defocus; intraocular and total aberrations; point-spread function (PSF); modulation transfer function (MTF); retinal straylight; and quality-of-vision (QoV) and spectacle-dependence questionnaires. RESULTS: Seventy-six patients (152 eyes) were assessed for study eligibility. Twenty patients (40 eyes) in each arm of the study (60 patients, 120 eyes) completed the outcome assessment. At the 4-month follow-up, the trifocal group had significantly better near visual acuity than the extended-range-of-vision group (P = .005). The defocus curve showed the trifocal IOL had better intermediate/near performance than the extended-range-of-vision IOL and both multifocal IOLs performed better than the monofocal IOL. Intragroup comparison of the total higher-order aberrations, PSF, MTF, and retinal straylight were not statistically different. The QoV questionnaire results showed no differences in dysphotopsia between the multifocal IOL groups; however, the results were significantly higher than in the monofocal IOL group. CONCLUSIONS: Both multifocal IOLs seemed to be good options for patients with intermediate-vision requirements, whereas the trifocal IOL might be better for patients with near-vision requirements. The significant perception of visual side effects indicates that patients still must be counseled about these effects before a multifocal IOL is implanted.

Long-term outcomes of limbal relaxing incisions during cataract surgery: aberrometric analysis.

PURPOSE: To compare the final changes in corneal wavefront aberration by limbal relaxing incisions (LRIs) after cataract surgery. METHODS: This prospective cumulative interventional nonrandomized case study included cataract and astigmatic patients undergoing LRIs and phaco with intraocular lens implantation. LRIs were planned using Donnenfeld nomogram. The root mean square of corneal wave aberration for total Z(n,i)(1≤n≤8), astigmatism Z(2,±1), coma Z(3-5-7,±1), trefoil Z(3-5-7,±2), spherical Z(4-6-8,0), and higher-order aberration (HOA) Z(3≤n≤8) was examined before and 3 years after surgery (optical path difference-Scan II [OPD-Scan II)]. Uncorrected distance visual acuity and best-corrected distance visual acuity (CDVA) for distance, keratometric cylinder, and variations in average corneal power were also analyzed. RESULTS: Sixty-four eyes of 48 patients were included in the study. Age ranged from 42 to 92 years (70.6±8.4 years). After LRIs, uncorrected distance visual acuity and best-corrected distance visual acuity improved statistically (P<0.01). The keratometric cylinder value decreased by 40.1%, but analysis of KP90 and KP135 polar values did not show any decrease that could be statistically confirmed (P=0.22 and P=0.24). No significant changes were detected in root mean square of total (P=0.61) and HOAs (P=0.13) aberrations. LRIs did not induce alteration in central corneal power confirming a 1:1 coupling ratio. CONCLUSION: LRIs determined a nonsignificant alteration of corneal HOA. Therefore, LRIs can be still considered a qualitatively viable mean in those cases where toric intraocular lenses are contraindicated or not available. Yet, the authors raise the question of nonpersonalized nomograms, as in the present study, LRIs did not reach the preset target cylinder.

Visual performance of 2 aspheric toric intraocular lenses: comparative study.

PURPOSE: To compare the visual and aberrometric outcomes of 2 aspheric toric intraocular lenses (IOLs). SETTING: Fatebenefratelli e Oftalmico Hospital, Milan, Italy. DESIGN: Prospective randomized comparative study. METHODS: Astigmatic patients had cataract surgery with implantation of an Acrysof SN6AT IOL (Group A) or an AT Torbi 709M IOL (Group B). The uncorrected (UDVA) and corrected (CDVA) distance visual acuities, net refractive astigmatism, spherical equivalent (SE), IOL misalignment, and optical quality were evaluated 3 months postoperatively. RESULTS: The study included 72 eyes. No statistically significant difference was found in UDVA, CDVA, residual refractive astigmatism, intraocular or total higher-order aberrations (Z(n,i) (order of aberrations calculated: 3≤n≤8), coma Z(3,±1), or trefoil Z(3,±2). The UDVA was 0.3 logMAR or better in all eyes and 0.1 logMAR or better in 55.5% of eyes in Group A and in 61.1% of eyes in Group B. Considering polar value analysis, 94.4% of eyes in both groups had a refractive astigmatism value within ±0.50 diopter at KP90 (polar value along 90-degree meridian). The SE was closer to emmetropia in Group A (P=.01). Intraocular lens misalignment of less than 5 degrees was present in 61.1% of cases in Group A (maximum 9 degrees) and in 66.6% in Group B (maximum 11 degrees). Spherical aberration Z(4,0) was significantly lower in Group B. CONCLUSIONS: Both IOLs had similar clinical effectiveness in term of astigmatism correction, rotational stability, and optical quality. Eyes in Group A appeared significantly nearer to emmetropia, while the IOL in Group B induced significantly less spherical aberration. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Imported Loa loa filariasis: three cases and a review of cases reported in non-endemic countries in the past 25 years.

OBJECTIVES: The aim of this study was to highlight the increasing chance of Western physicians encountering patients (both immigrants and expatriates/travelers) seeking help for loiasis. METHODS: We describe three cases of imported loiasis observed at two hospitals in Italy and France, and present a review of all previously published cases in the medical literature in the last 25 years (1986-2011). The search was performed using PubMed and Scopus databases using the terms "Loa loa" AND "loiasis". RESULTS: We reviewed 101 cases of imported loiasis of which 61 (60.4%) were reported from Europe and 31 (30.7%) from the USA. Seventy-five percent of infestations were acquired in three countries: Cameroon, Nigeria, and Gabon. Overall, peripheral blood microfilariae were detected in 61.4% of patients, eosinophilia in 82.1%, eye worm migration in 53.5%, and Calabar swellings in 41.6%. However, Calabar swellings and eosinophilia were more common among expatriates/travelers, whereas African immigrants were more likely to have microfilaremia. Eye worm migration was observed in a similar proportion in the two groups. Only 35 patients (including the three described here) underwent clinical follow-up for a median period of 10.5 months (range 1-84 months); clinical relapse occurred in three of these patients and persistence or reappearance of blood microfilaria in another two. CONCLUSIONS: Due to increasing travel and the migration of people from the endemic countries of West Africa to Europe and the USA, we speculate on the possible emergence of loiasis. Western physicians should be aware of the typical (eye worm migration and Calabar swellings) as well as unusual clinical presentations.

In vivo assessment of higher-order aberrations after AcrySof toric intraocular lens implantation: a comparative study.

PURPOSE: To compare higher-order aberrations (HOAs) and optical quality in eyes implanted with AcrySof SN60TT toric intraocular lens (IOL) or with non-toric AcrySof SN60AT IOL (Alcon Laboratories, Inc., Fort Worth, TX). METHODS: This was a prospective, consecutive, nonrandomized, interventional, comparative study. One hundred eyes with cataract in 56 patients were included (SN60TT group, n=50; SN60AT group, n=50). Patients underwent phacoemulsification through a 2.2-mm temporal corneal incision. Postoperative HOAs, point spread function (PSF) and modulation transfer function (MTF), residual objective refractive astigmatism, and IOL alignment were evaluated using Optical Path Difference (OPD)-Scan II (Nidek, Gamagori, Japan). A novel technique to calculate IOL axis alignment was introduced. RESULTS: One year postoperatively, no statistical difference in corneal, intraocular, and total HOAs, Strehl ratio, and MTF based on HOAs was found between groups. Toric IOL patients had a net residual refractive astigmatism (M) of 0.44 D±0.47; the difference between expected and obtained astigmatism (M) was 0.043 D (p=0.16). Toric IOL axis misalignment was 2.65±2.39 degrees and no correlation with HOAs was found. CONCLUSIONS: AcrySof SN60TT determines HOAs comparable to the non-toric version providing a good optical quality, and predictably corrects corneal cylinder with a stable postoperative alignment. The OPD-Scan II might be regarded as a fast and reliable method of toric IOL analysis.

Effects of osmoprotection on symptoms, ocular surface damage, and tear film modifications caused by glaucoma therapy.

PURPOSE: To determine the effects of 2 artificial tear formulas on the ocular surface in patients with glaucoma using topical preserved beta-blockers (BB) or prostaglandins (PG). METHODS: This was a prospective, comparative, randomized, double-blind study with a crossover design. Twenty patients with dry eye were divided into 2 groups based on glaucoma treatment: BB (10 subjects) or PG (10 subjects). Each group was administered a 4-week course of unpreserved isotonic (300 mOsm/L) solution containing 0.2% sodium hyaluronate (SH) or a preserved isotonic (295-305 mOsm/L) solution containing 0.5% carboxymethylcellulose and 0.9% glycerin as compatible solute (CMCs) administered QID. After a 2-week washout period, the course of treatment was reversed. The primary efficacy criteria consisted of assessing symptoms according to the Ocular Surface Disease Index© (OSDI); the secondary efficacy criteria consisted of evaluating tear film confocal microscopy, central corneal thickness (CCT), and lissamine corneal and conjunctival staining (Oxford Grading System Score [OGSS]). RESULTS: Within each group, only CMCs induced a significant improvement in OSDI and OGSS compared to baseline values: OSDI -20.5, p<0.0001; OGSS -0.9, p<0.0001. Tear film confocal microscopy improved after treatment, especially in case of patients who were administered CMCs. No difference in CCT was noticed for any subject. CONCLUSIONS: This study demonstrates for the first time that the use of concomitant CMCs in the management of glaucoma undergoing treatment with BB or PG may assist in tear film production and could lead to better compliance with intraocular pressure-lowering medication and ultimately better prognosis.

Congenital iris ectropion associated with juvenile glaucoma.

Congenital iris ectropion is an uncommon malformation and no reports exist about the use of modern technologies in this pathology. The authors describe a case of unilateral and isolated congenital iris ectropion associated with juvenile glaucoma in a healthy and completely asymptomatic 6-year-old girl with an unusual form of anisocoria. Optical coherence tomography and confocal scanning laser tomography showed a progressive glaucomatous neuropathy. A trabeculectomy without antimetabolites was performed and intraocular pressure normalized without other medications during a follow-up of 2 years. The authors assert the utility of various diagnostic technologies to recognize congenital iris ectropion early to prevent blindness in young patients and improve their prognosis.

Effect of hypotonic 0.4% hyaluronic acid drops in dry eye patients: a cross-over study.

PURPOSE: The aim of the study is to evaluate the short-term effects of 2 kinds of artificial tears, both containing 0.4% hyaluronic acid in an aqueous solution yet having different osmolarity, on the typical symptoms of patients suffering from dry eye and on the vitality of corneal and conjunctival epithelial cells. METHODS: A cross-over, randomized, balanced, single-blind study involving 28 patients was divided into 2 treatment groups: group A (unpreserved 0.4% hyaluronic acid eye drops 300 mOsm/L) and group B (unpreserved 0.4% hyaluronic acid eye drops 150 mOsm/L). Both treatments were administered for 7 days, being dosed as a 1 solution drop 4 times daily. After a 1-day wash-out period, the patients in group A passed over to group B and vice versa. RESULTS: Treatment with hypotonic solution gave better results in relieving symptoms, along with a statistically significant improvement (P < 0.001) in the state of the corneoconjunctival epithelium, than the isotonic solution. At the end of the study, 60.7% of the patients declared that they preferred hypotonic solution and only 10.7% preferred isotonic solution; the remaining 28.6% did not notice any difference between the 2 treatments. CONCLUSIONS: By reducing the osmolarity of tear film, the hypotonic solution not only improves the characteristics of tear film and the vitality of the epithelial cells of the cornea and conjunctiva but also proves to be effective in reducing dry eye symptoms.