Peripapillary pachychoroid syndrome treated with dexamethasone implant: A case report.

PURPOSE: To describe a case of peripapillary pachychoroid syndrome (PPS) in a diabetic patient with cystoid macular edema (CME), treated with intravitreal dexamethasone implant (IDI) injection. This report also illustrates the history of the disease after repeated IDI and dexamethasone topical treatment. METHODS: A case report. RESULTS: A 77-year old male patient with PPS and good diabetic control was treated with dexamethasone implant for CME. After an initial morphofunctional improvement associated with a first IDI, the disease relapsed after the second dexamethasone implant injection. This was associated with a significant increase in both intraretinal fluid and choroidal thickness, with subsequent visual acuity (VA) decrease. At this point, a topical dexamethasone treatment was performed and, despite a morphological improvement, VA worsened compared with baseline, likely because of anatomical damage. CONCLUSION: In this report, the importance of the recognition of PPS is underlined and the possible occurrence of a "rebound" effect due to repeated IDI is described.

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.

In vitro antimicrobial activity of ozonated oil in liposome eyedrop against multidrug-resistant bacteria.

Bacteria are the most common causative agents of ocular infections. Treatment with topical broad-spectrum antibiotics is recommended in severe cases. However, antibiotic resistance has become a major concern in recent years, although antibiotics are generally effective in treating ocular infections. Antibacterial compound screening is performed to identify alternative therapeutic options to antibiotics. The aim of this study was to assess the in vitro antimicrobial activity of an ophthalmic solution containing ozonated oil. Strains of bacterial species with a multidrug resistance profile, which are responsible for a large proportion of ocular infections, were isolated and selected from different biological samples. The bacterial isolates were cultured, and ozonated oil was used to evaluate the inhibition zones at different time points. The treatment exhibited antibacterial activity against all the tested species. The effect was lower against the strains of Pseudomonas aeruginosa and more evident against Staphylococcus and Streptococcus spp. Our results suggest that the administration of ozonated oil may be a candidate agent to treat some infections of the ocular surface with a potential role in antimicrobial prophylaxis.

Pneumomediastinum and Pneumothorax as Relevant Complications of Sub-Intensive Care of Patients with COVID-19: Description of a Case Series.

Lung failure has been the most common cause of hospitalization for COVID-19. Yet, bilateral interstitial pneumonia has not been the only cause of lung failure of these inpatients, and frequently they develop other illnesses associated with COVID-19. Pulmonary embolism has been the most looked for in the world, but rarely other pneumological diseases, such as pneumothorax and pneumomediastinum, have been described and associated with a worsening prognosis. We here report our clinical experience associated with the occurrence of pneumothorax and pneumomediastinum in a cohort of inpatients hospitalized in our division of medicine in a regular ward or in a sub-intensive ward.

Pleural empyema secondary to nephropleural fistula in complicated pyonephrosis.

Pleural empyema of extra pulmonary origin is uncommon and empyema secondary to a fistula between the urinary tract and thorax is extremely rare. We report a case of nephropleural fistula causing massive pleural empyema in a 64-year-old woman with a long history of urological problems, including nephrolitiasis and urinary tract infection. She was admitted with sepsis, fever, chills, tachypnea, productive cough and pyuria. At clinical examination, breath sounds were reduced over the left hemithorax. CT revealed a fistulous connection from the upper left calyceal group and the pleural space. Drainage of thoracic and perinephric collection was carried out, but nephrectomy and pleural decortication were required due to haemopurulent urine and decreased hemoglobin levels during the hospitalization. This case demonstrates the unusual and prolonged evolution of an obstructive hydroureteronephrosis complicated by pyonephrosis, culminating in retroperitoneal abscess that fistulized into the pleural space, leading to empyema.

Heads-up 3D eye surgery: Safety outcomes and technological review after 2 years of day-to-day use.

BACKGROUND: 3D heads-up visualization systems are aimed to improve the surgical experience by providing high-resolution imaging. Objective of our study is to analyze, over a long-time span, the grade of satisfaction and safety of day-to-day 3D surgery compared to standard surgery and to investigate the technical distinctiveness between the heads-up systems currently in use. METHODS: In this retrospective observational case series. we reviewed all surgical records of our ophthalmology-dedicated operatory rooms since the arrival of 3D heads-up viewing system, in November 2017. In particular, we compared the procedural complications of 3D-equipped operatory room (3DR) with the standard microscope operatory room (2DR). Moreover, a satisfaction questionnaire was administered to those surgeons shifting on both rooms to test their preferences on seven specific parameters (comfort, visibility, image quality, depth perception, simplicity of use, maneuverability and teaching potential). RESULTS: 5483 eye surgeries were considered. 2777 (50.6%) were performed in 3DR and 2706 (49.3%) in 2DR. Procedural complication rate was comparable in 3DR and 2DR, also when considering different subtypes of surgery. Twelve surgeons (100% of our surgery team) participated in our satisfaction survey, expressing highest satisfaction score for 3D when applied in retina surgery. For cataract surgery, 3D scored best in all the parameters except for facility in use and depth of field perception. CONCLUSION: Long-term day-to-day use of 3D heads-up visualization systems showed its safety and its outstanding teaching potential in all ophthalmic surgical subtypes, with higher surgeons confidence for retina and cataract surgery.

Covid-19 and acute conjunctivitis: Controversial data from a tertiary refferral Italian center.

PURPOSE: Although acute conjunctivitis has been listed from the beginning as a possible sign of COVID-19, the likelihood of this association remains unclear. The aim of this study was to investigate the relationship between COVID-19 and conjunctivitis. METHODS: In this retrospective, observational study, we recruited all patients with signs and symptoms of acute conjunctivitis seen at the Eye Emergency Department (ED), Turin Eye Hospital, between 01/01/2020 and 12/05/2020 and cross-checked our data with the Piedmont Region online COVID-19 registry in the same period. RESULTS: Among 10,065 patients seen at our ED during the timespan considered, 88 underwent a nasopharyngeal swab (NS) for SARS-CoV-2 detection within 4 weeks before/after our examination. On average, NS was performed -0.72 ± 1.8 weeks before/after eye examination. Of the 77 patients with a negative NS, 26 (33.8%) had a diagnosis of acute conjunctivitis, whereas the remaining 51 (66.2%) had other eye disorders. Among the 11 patients with COVID-19, 7 (63,6%) had a diagnosis of acute conjunctivitis. We found a non-statistically significant increase in NS positivity rate (21.2%) among cases examined at our ED for acute conjunctivitis, compared to the NS positivity rate (7.3%) in patients examined for all other eye conditions (p = 0.092). The Odds Ratio of having a positive NS in patients with acute conjunctivitis was 3.43 (95% I.C. = 0.9-12.8, p = 0.06). Considering online-registry data of Turin population during the same time-span, among 2441 positive NS cases only 27 (1.1%) presented with acute conjunctivitis. CONCLUSION: Our results do not reveal a statistically significant correlation between COVID-19 and acute conjunctivitis. SYNOPSIS: The present study analyzes retrospectively data from a tertiary eye referral center to investigate the relationship between COVID-19 infection and conjunctivitis.

Wide-angle 3D viewing system with valved trocar applied to chandelier-assisted scleral buckling.

INTRODUCTION: Scleral buckling (SB) has been the first technique to repair a retinal detachment (RD) and it is still largely in use. Pars plana vitrectomy (PPV) is currently the most common technique, being more versatile and easier to approach. Here we report on a new SB variant, modified by using some of the latest technological advances borrowed from PPV. METHODS: We retrospectively reviewed all our SB cases from November 2017 to November 2018, all of them performed with a chandelier, mounted on valved trocar, to provide 3D wide-angle viewing. 107 eyes of 107 patients (mean age of 59 ± 8 years, 61 [57%] males) underwent primary uncomplicated RD surgery using this modified SB technique and were enrolled for this study. RESULTS: In this article, the technique is thoroughly described with an online video presentation. Briefly, thanks to valved trocar insertion, it combines the latest breakthroughs in the field of PPV viewing systems with traditional SB surgery. Our first-year data reveal a primary success rate of 94% (101 cases out of 107) at 3 months follow-up. A hidden retinal lesion, undetected at clinical pre-operative evaluation, was found intraoperatively in 12 (8.9%) cases. CONCLUSION: The use of a digital three-dimensional (3D) visualization system, coupled with the positioning of a single 25 gauge valved trocar with chandelier, dramatically simplifies the traditional SB and flattens its learning curve, making this procedure more accessible to young surgeons. In addition, the better visualization capability yields to higher possibility to detect and treat all retinal lesions.

Manual deep anterior lamellar keratoplasty after partial unintentional full-thickness trephination.

PURPOSE: The aim of this study was to describe a surgical technique to perform deep anterior lamellar keratoplasty (DALK) despite inadvertent full thickness trephination in one quadrant. METHODS: Case report of a 19-year-old boy who underwent DALK for visually significant post-infectious stromal scar in his left eye. An unintentional full thickness trephination occurred in the upper-nasal quadrant at the beginning of the surgery. After suturing the perforated area, manual DALK was performed, and an air bubble was left in the anterior chamber. Evaluated outcomes included best spectacle corrected visual acuity (BSCVA), residual recipient bed thickness, endothelial cell count (ECC), graft clarity, rejection, and presence/absence of double anterior chamber. RESULTS: The surgery was completed without any further complications. No double anterior chamber or Urrets-Zavalia syndrome was observed on the first postoperative day. Mean residual recipient bed thickness was 72 µm and regular. ECC was 2446 cell/mm2. BSCVA at 18 months of follow-up was 0.9. There were no episodes of rejection, and the graft remained clear at the last follow-up (4 years). CONCLUSION: Inadvertent partial full thickness trephination of the recipient cornea is a largely preventable but possible complication during DALK. Penetrating keratoplasty conversion can be avoided by performing a manual dissection DALK.

Deep Anterior Lamellar Keratoplasty After Previous Anterior Lamellar Keratoplasty to Improve the Visual Outcomes.

PURPOSE: To describe a series of patients who underwent deep anterior lamellar keratoplasty (DALK) after previous anterior lamellar keratoplasty (ALK) to improve their visual outcomes. METHODS: This is a retrospective case series of 9 DALK eyes (9 patients) with a history of previous ALK and an unsatisfactory visual outcome. Surgery was performed in all cases at least 3 years after ALK. Cannula big bubble, air viscobubble, and manual dissection techniques were performed. Preoperative and postoperative best-corrected visual acuity, residual recipient bed thickness, and endothelial cell count were evaluated. Follow-up was at least 24 months for all eyes. RESULTS: Two subtotal anterior lamellar keratoplasties (through 1 type 1 big bubble and 1 air viscobubble) and 7 manual dissection DALKs were achieved. A small rupture of the residual recipient bed occurred during 1 case, and it was managed without penetrating keratoplasty conversion. Mean best-corrected visual acuity improved from 0.64 to 0.09 logMAR. Postoperative residual recipient central bed thickness was less than 80 µm in all cases. No postoperative complications were recorded at the last follow-up (24-36 months postoperatively). CONCLUSIONS: Different DALK techniques can be successfully used to improve visual acuity in previous ALK eyes with an unsatisfactory visual outcome.

Total or subtotal full thickness recipient bed cut to repair donor-recipient curvature disparity in cases of DM rupture with manual DALK.

PURPOSE: To report how to manage a specific type of Descemet's membrane (DM) rupture during manual DALK with a concurrent donor-recipient disparity of curvature. METHODS: Case report of two patients that had DM rupture during manual DALK with a concurrent donor-recipient disparity of curvature; the recipient bed was flatter (post-infectious scar, case 1) and steeper (keratoglobus, case 2) than the donor. Preoperative diagnosis, clinical exam, and best spectacle correct visual acuity (BSCVA) have been reported. A subtotal full-thickness circular cut of the recipient bed was performed to resolve a persistent double AC in case 1 (recipient flatter than donor). A total full-thickness circular cut of the recipient bed, creating a graft made by a DALK allograft and a "DSEK autograft," was performed to avoid a refractory double AC in case 2 (recipient steeper than donor). Evaluated outcomes included postoperative BSCVA, endothelial cell count (ECC), graft clarity, rejection, and presence/absence of double AC. RESULTS: Surgery was successful in resolving/avoiding double AC. VA improved in both cases. No episodes of rejection were recorded. Graft remained clear at the last follow-up (6 years for case 1 and 4 years for case 2). CONCLUSION: The existence of a donor-recipient curvature disparity should be investigated as a possible underlying mechanism of refractory double AC. Total or subtotal full thickness recipient bed cut may be considered to repair donor-recipient curvature disparity in cases of DM rupture occurring during manual DALK. Repairing the DM rupture and avoiding a conversion to PK in high-risk transplant cases are crucial.

Prevalence of diabetes and diabetic macular edema in patients undergoing senile cataract surgery in Italy: The DIabetes and CATaract study.

BACKGROUND: The purpose of this study is to determine the prevalence of diabetes and diabetic macular edema in patients undergoing senile cataract surgery in Italy. METHODS: It is a prospective, multicenter, cross-sectional study. Thirteen ophthalmic units equally distributed across the Italian territory have been involved in the study. For a period of 3 months, all subjects undergoing phacoemulsification received an Optical Coherence Tompgraphy (OCT) scan and were screened for the anamnestic presence of diabetes. In addition, five selected units collected blood samples from all their patients to measure glycated hemoglobin (HbA1c) levels and detect the presence of occult diabetes (HbA1c > 6.5%). In diabetic patients, levels of retinopathy were measured and diabetic macular edema was considered significant (clinically significant macular edema) when foveal thickness was above 30% of normal levels. RESULTS: A total number of 3657 subjects have been screened. Among them, 20.4% were diabetics. Prevalence of diabetes was significantly higher in males (24.7%) than in females (17%). Levels of HbA1c were tested in a representative sample of 1216 consecutive subjects, and occult diabetes was diagnosed in 4.8% of cases. No significant differences were observed between age groups or different geographic areas. Among diabetic patients, diabetic macular edema of any kind was present in 27.5% (clinically significant macular edema (6.6%)). No significant differences were seen in the prevalence of diabetic macular edema between males and females or between age groups. Among the 745 diabetic patients, no signs of retinopathy were seen in 537 subjects (76.3%), while 101 patients (14.3%) had nonproliferative retinopathy, 13 (1.7%) had nontreated proliferative diabetic retinopathy, and 53 (7.5%) had laser-treated retinopathy. In the entire sample of 3657 subjects, a normal macula was present in 90.9% of cases, diabetic macular edema of any kind in 5.4%, and other maculopathies in 3.4%. CONCLUSION: In this large cohort study on patients undergoing cataract surgery, more than one-fourth were diabetics and more than one-fourth of these had diabetic macular edema. These high prevalences suggest the opportunity to plan an adequate preoperative assessment in all patients in order to reduce the risk of postoperative development or worsening of a sight-threatening complication such as chronic diabetic macular edema.

Cataract surgery in corneal transplantation.

PURPOSE OF REVIEW: Corneal diseases are often associated with lens opacity. The present article reviews the recent advances in the management of cataract and corneal transplant. RECENT FINDINGS: Thanks to the development of lamellar transplant techniques and the evolution of cataract surgery, we now have several strategies to address corneal diseases and cataract including 'lamellar triple procedure'. Numerous precautions have been identified to have a successful surgery with good visual recovery. SUMMARY: Corneal diseases associated with cataract can be successfully managed using separate or combined surgical procedures, as appropriate. In most cases the intraocular lens power can be calculated with a predictable outcome.

Vitreous Substitutes: Old and New Materials in Vitreoretinal Surgery.

Recent developments in vitreoretinal surgery have increased the need for suitable vitreous substitutes. A successful substitute should maintain all the physical and biochemical properties of the original vitreous, be easy to manipulate, and be long lasting. Substitutes can be gaseous or liquid, both of which have associated advantages and disadvantages related to their physical properties and use. Furthermore, new surgical techniques with smaller vitreoretinal instruments have driven the use of more viscous substitutes. In this review, we analyze and discuss the most frequently used vitreous substitutes and look ahead to future alternatives. We classify these compounds based on their composition and structure, discuss their clinical use with respect to their associated advantages and disadvantages, and analyze how new vitreoretinal surgical techniques have modified their use.

Surgical approach in thymectomy: Our experience and review of the literature.

AIM: Thymectomy is the main treatment for thymoma and patients with myasthenia gravis (MG). The traditional approach is through a median sternotomy, but, recently, thymectomy through minimally invasive approaches is increasingly performed. Our purpose is an analysis and discussion of the clinical presentation, the diagnostic procedures and the surgical technique. We also consider post-operative complications and results, over a period of 5 years (May 2011-June 2016), in thymic masses admitted in our Thoracic Surgery Unit. METHODS: We analyzed 8 patients who underwent surgical treatment for thymic masses over a period of 5 years. 6 patients (75%) had thymoma, 2 patients (25%) had thymic carcinomas. 2 patients with thymoma (33%) had myasthenia gravis. We performed a complete surgical resection with median sternotomy as standard approach. RESULTS: One patient (12%) died in the postoperative period. The histological study revealed 6 (75%) thymoma and 2 (25%) thymic carcinomas. Post-operative morbidity occurred in 2 patients (25%) and were: pneumonia in 1 case (12%), atrial fibrillation and pleural effusion in 2 patients (25%). One patient with thymoma type A recurred at skeletal muscle 2-years after surgery. CONCLUSIONS: Thymic malignancies are rare tumors. Surgical resection is the main treatment, but a multimodal approach is useful for many patients. Radical thymectomy is completed removing all the soft tissue in the anterior mediastinum between the two phrenic nerves and this is the most important factor in controlling myasthenia and influencing survival in patients with thymoma. Open (median sternotomy) approach has been the standard approach for thymectomy for the better visualization of the anatomical structures. Actually, video-assisted thoracoscopic surgery (VATS) thymectomy and robotic video-assisted thoracoscopic (R-VATS) approach versus open surgery has an equal if not superior oncological efficacy, better perioperative complications and survival outcomes.

Changing trends in corneal graft surgery: a ten-year review.

AIM: To review indications and corneal tissue use for penetrating and lamellar surgery between 2002 and 2011. METHODS: The surgical reports of corneal grafts performed during 2002-2011, using tissues supplied by the Eye Bank of Piedmont (Italy), were reviewed retrospectively. Patient demographic data, date of intervention, indication for surgery, and surgical technique used were recorded. Surgical techniques included penetrating keratoplasty (PK), deep anterior lamellar keratoplasty (DALK) and endothelial keratoplasty (EK). The χ (2) test was used to compare the distribution of indications and types of surgical technique used, for corneal grafts done during 2002-2006 versus those done during 2007-2011. RESULTS: The number of corneal grafts increased by 30.7% from 2002-2006 to 2007-2011 (from 1567 to 2048). Comparing the two periods, both main indications and surgical techniques changed significantly. In 2007-2011, the proportion of interventions for aphakic/pseudophakic bullous keratopathy (from 16.8% to 21.3%), graft failure (from 16.4% to 19.1%) and Fuchs endothelial dystrophy (from 12.8% to 16.7%) all increased significantly (P<0.05), while those for keratoconus decreased significantly (from 35.6% to 27.3%; P<0.001). In 2007-2011, the proportion of PK decreased significantly (from 92.4% to 57.2%; P<0.001) while that of EK and DALK went from 0.4% to 30.2% (P<0.001) and from 7.2% to 12.6% (P<0.001) respectively. CONCLUSION: During 2002-2011 the number of interventions increased significantly for corneal endothelial diseases and graft failure. The growing demand for interventions for these diseases corresponded to the widespread adoption of EK techniques. The use of DALK also increased, but more moderately than EK procedures.

Adherence to European Society for Cataract and Refractive Surgery recommendations among Italian cataract surgeons: a survey.

PURPOSE: To survey the surgical routines with regards to prophylactic strategies in a sample of Italian hospitals and compare these with European Society for Cataract and Refractive Surgery (ESCRS) guidelines. METHODS: Six private and 18 public hospitals were included in this clinical-based retrospective study. The overall volume of cataract operations in the 24 centers in 2013 was 43,553. Main outcome measure was incidence of endophthalmitis per 1,000. An incidence of less than 0.13% was considered acceptable. RESULTS: Our study provides the first Italian data on the use of intracameral antibiotics in cataract surgery as recommended by the ESCRS. Thirteen centers (54%) used intracameral cefuroxime at the end of surgery. Of the 13 centers that used cefuroxime, 8 (62%) had an incidence of endophthalmitis less than 0.13%. Of the 7 (29%) centers that did not use intracameral cefuroxime, all had an endophthalmitis rate of greater than 0.13%. This difference was statistically significant (p<0.05). Among the 4 centers not included, 2 used vancomycin in the infusion bottle, 1 a fluoroquinolone, and the last a combination of antibiotics. The majority of surgeons (71%) used preoperative antibiotic eyedrops, but this measure was not shown to be significantly protective. CONCLUSIONS: Slightly more than half of the centers surveyed in this study adhered to the recommendations of the ESCRS and routinely employed prophylactic intracameral cefuroxime. An incidence of endophthalmitis greater than 0.13% was encountered significantly more frequently among centers that did not employ intracameral cefuroxime.

Pearls and pitfalls in diagnosis and management of coats disease.

PURPOSE: To review current literature on Coats disease and provide a structured framework for differentiating challenging clinical features in Coats disease patients. METHODS: We critically reappraise historical and current literature and present clinical methods for developing a thorough differential diagnosis and management strategy for Coats disease. RESULTS: Coats disease is a sporadic, usually unilateral condition typically occurring in young males. When untreated, this disorder can lead to total exudative retinal detachment and secondary glaucoma. CONCLUSIONS: Anti-VEGF agents are currently a treatment option in combination with ablative therapy of telangiectatic vessels. Anti-VEGF agents appear particularly useful for patients with extensive areas of exudative retinal detachment, and are an effective treatment option for total retinal detachment.