The impact of COVID-19 outbreak on urolithiasis emergency department admissions, hospitalizations and clinical management in central Italy: a multicentric analysis. / El impacto de la COVID-19 en las admisiones al servicio de urgencias, hospitalizaciones y manejo clínico de la urolitiasis en el centro de Italia: análisis multicéntrico.

INTRODUCTION AND OBJECTIVES: We aimed to evaluate how the corona virus disease of 2019 (COVID-19) outbreak influenced emergency department (ED) admissions for urolithiasis, hospitalizations and clinical management of the hospitalized patients. PATIENTS AND METHODS: We conducted a multicentric retrospective analysis of ED admissions in three high volume urology departments (one directly involved in COVID-19 patients management and two not involved) in Rome - Italy between March and April 2020 and in the same period of 2019. Statistical analysis was conducted on the number of admissions for urolithiasis, rate of complications, hospitalization and the type of treatment received. RESULTS: 304 patients were included in the analysis. A significant reduction in the global number of patients admitted to ED for urolithiasis between 2019 and 2020 (48.8%) was noted. Moreover, regarding the choice of treatment of hospitalized patients, a statistically significant increase of stone removal procedures versus urinary drainage was reported in 2020 (p = 0.015). CONCLUSIONS: During the COVID-19 pandemic in Rome there has been a significant reduction of emergency admissions for urolithiasis. Patients admitted to ED had more complications, more frequently need hospitalization and regarding clinical management early stone removal was preferred over urinary drainage only. All the urologists should be aware that in the next months they could face an increased number of admissions for urolithiasis and manage more complicated cases.

Intracameral epinephrine without the addition of intracameral lidocaine in the management of tamsulosin associated intraoperative floppy iris syndrome.

OBJECTIVE: Intracameral mydriatics using epinephrine associated with lidocaine have been reported as efficacious in reducing intraoperative floppy iris syndrome (IFIS) complications during cataract surgery. The aim of this study was to verify the efficacy of intracameral epinephrine without intracameral lidocaine as prophylaxis against IFIS in patients on tamsulosin. MATERIALS AND METHODS: This was a retrospective study on the results of cataract surgery in 18 patients on therapy with tamsulosin. Patients had undergone routine phacoemulsification in one eye. Successively, they underwent phacoemulsifcation in the fellow eye using non preserved intracameral epinephrine 1:4000 diluted with BSS. Intraoperative complications during cataract surgery had been documented and IFIS was graded based on iris billowing, miosis or iris prolapse. Follow-up was 3 months. RESULTS: Thirty-six eyes of 18 patients were included in the evaluation. The incidence of IFIS was significantly higher in the eyes where routine phacoemulsificaton had been performed (100%) with respect to eyes where phacoemulsification was carried out using intracameral epinephrine (33%) (Chi Square test =15.12, p<0.001). In routine phacoemulsification 16 eyes showed iris billowing, 14 eyes had some extent of miosis and 14 eyes had tendency to iris prolapse. In phacoemulsification with the use of intracameral epinephrine 5 eyes showed iris billowing, 4 eyes presented some extent of miosis and 2 eyes had tendency to iris prolapse. There were no serious intraoperative complications. CONCLUSIONS: Intracameral epinephrine without the addition of lidocaine was efficacious in the management of IFIS in patients on tamsulosin.

Evaluation of Agreement between HRT III and iVue OCT in Glaucoma and Ocular Hypertension Patients.

Purpose. To determine the agreement between Moorfields Regression Analysis (MRA), Glaucoma Probability Score (GPS) of Heidelberg retinal tomograph (HRT III), and peripapillary nerve fibers thickness by iVue Optical Coherence Tomography (OCT). Methods. 72 eyes with ocular hypertension or primary open angle glaucoma (POAG) were included in the study: 54 eyes had normal visual fields (VF) and 18 had VF damage. All subjects performed achromatic 30° VF by Octopus Program G1X dynamic strategy and were imaged with HRT III and iVue OCT. Sectorial and global MRA, GPS, and OCT parameters were used for the analysis. Kappa statistic was used to assess the agreement between methods. Results. A significant agreement between iVue OCT and GPS for the inferotemporal quadrant (κ: 0.555) was found in patients with abnormal VF. A good overall agreement between GPS and MRA was found in all the eyes tested (κ: 0.511). A good agreement between iVue OCT and MRA was shown in the superonasal (κ: 0.656) and nasal (κ: 0.627) quadrants followed by the superotemporal (κ: 0.602) and inferotemporal (κ: 0.586) sectors in all the studied eyes. Conclusion. The highest percentages of agreement were found per quadrant of the MRA and the iVue OCT confirming that in glaucoma damage starts from the temporal hemiretina.

An update on intravitreal implants in use for eye disorders.

Advanced biotechnological techniques and new polymers have led to the development of many innovative intravitreal drug delivery systems. Some designs are still in an experimental phase while others have gained widespread acceptance and are commercially available. Since steroids are a mainstay of therapy for uveitis and macular edema, new intravitreal implants have been developed to provide continuous release of corticosteroids over prolonged spans of time with reduced systemic adverse effects. Today, three long-acting corticosteroid implants are commercially available: the fluocinolone acetonide implants Retisert® and Iluvien® and the dexamethasone drug delivery system Ozurdex®. They offer an alternative route in the management of macular edema due to uveitis, retinal vein occlusion, diabetes and pseudophakia. Their advantage over treatment with steroid injections and the anti-vascular endothelial growth factor ranibizumab is the long-term control of inflammation and macular edema with a reduced frequency of administration. Their potential side effects are cataract and glaucoma, therefore, careful patient selection and monitoring is essential. Further studies are warranted to define the relative efficacy and indications for each treatment option. The development of new devices is a future challenge in the strive to improve drug delivery systems.

Intravitreal bevacizumab in the successful management of choroidal metastases secondary to lung and breast cancer unresponsive to systemic therapy: a case series.

PURPOSE: Management of choroidal metastases is commonly with systemic chemotherapy; however, if tumours are refractory to treatment and vision is endangered, local therapy modalities are feasible. A novel option is the use of intravitreal bevacizumab. This report presents three cases of choroidal metastatic tumours secondary to lung and breast cancer treated with intravitreal bevazizumab. PATIENTS AND METHODS: Three patients with choroidal metastases secondary to lung and breast tumours were treated at the Ophthalmology Unit, University of Rome 'Sapienza', S.Andrea Hospital from January 2009 to August 2012. All patients developed vision loss with diagnosis of chorioidal metastasis during systemic chemotherapy. Off label intravitreal bevacizumab treatment was performed with two 1.25 mg injections in two patients and four injections in one patient at 30-day intervals. RESULTS: Vision improved, subretinal fluid resolved, and choroidal tumour regression was obtained in all cases. Follow-up was 6, 9, and 12 months and there were no complications related to treatment. CONCLUSIONS: Intravitreal bevacizumab administration represented an efficacious therapeutic option with rapid effect in the treatment of choroidal metastatic tumours unresponsive to systemic therapy. It can have a role in the management of these tumours by preventing vision loss and improving the quality of life of patients.

Glaucoma and Helicobacter pylori infection: correlations and controversies.

A possible association between Helicobacter pylori infection and eye diseases, including Sjögren syndrome, blepharitis, central serous chorioretinopathy and uveitis, has been proposed. Glaucoma is the second leading cause of blindness in the world, after cataracts, and the leading cause of irreversible blindness, but many aspects of its pathogenesis remain unknown. H pylori infection may influence the pathophysiology of glaucoma by releasing various proinflammatory and vasoactive substances, as well as by influencing the apoptotic process, parameters that may also exert their own effects in the induction and/or progression of glaucomatous neuropathy. It is difficult to understand how H pylori infection can be linked to such varied pathologies. Systemic H pylori-induced oxidative damage may be the mechanism which links oxidative stress, H pylori infection and the damage to the trabecular meshwork and optical nerve head that results in glaucoma.

Standard automated perimetry and algorithms for monitoring glaucoma progression.

Despite increasingly sophisticated techniques for the computerized analysis of the optic nerve and retinal nerve fiber layer, standard automated perimetry (SAP) is still the primary test for assessing functional damage in glaucoma. Most of the diseases affecting the visual field can be studied analyzing the central visual field with a fixed grid of points set at 6 degrees or at a variable density within central 30 degrees, using a III white target stimulus (program 30/2 or 24/2 Humphrey, G1/G2 or 30/2 Octopus). Although there is lack of a true gold standard for glaucoma, SAP results were the primary endpoint in most of the clinical trials in glaucoma. New thresholding strategies allowed a considerable reduction of examination time without substantial loss of accuracy. Moreover, recent findings on structure-function correlation in glaucoma validate the clinical role of this well-known and widespread method of examination.

Visual field damage and progression in glaucomatous myopic eyes.

PURPOSE: To make a visual field retrospective analysis on a group of patients with primary open angle glaucoma (POAG) and to evaluate whether different refractive errors could have different progression of the 30 degrees central sensitivity. METHODS: A total of 110 patients with POAG (52 men and 58 women) were included in the study. All the patients were divided into four subgroups based on the refractive error. The visual field of all the included patients was assessed by an Octopus 30 degrees central visual field every 6 months, for a total of 837 visual fields examined. The resulting data were analyzed by PERIDATA for Windows 1.7 TREND function. Mean defect (MD) and loss variance (LV) were considered for the analysis. RESULTS: At the first examination, 82% of eyes showed a global decrease of differential light sensitivity (MD >2 dB) and in 67% the distribution of the defect was nonhomogeneous (LV >6 dB). The analysis of variance for subgroups showed a more significant decrease of MD in highly myopic patients. A linear regression analysis highlighted a statistically significant change in time of MD in 36% and of LV in 34% of the eyes studied. Highly myopic patients had the highest (p<0.01) percentage of change of MD and LV (46% and 42%, respectively). Among the four subgroups, there was no difference in progression of MD decrease in time. CONCLUSIONS: These results showed that after 5 years of glaucoma, the visual field was altered in most of the eyes examined (82%) and that in 67% of cases, its defect was nonhomogeneous and worsened with the increase of myopia. The regression linear analysis of visual field changes in time showed a progressive increase of MD and LV in approximately one third of all the eyes examined.

Ultrabiomicroscopy (UBM) in flap dislocation following LASIK: a case report.

PURPOSE: To describe postoperative laser-assisted in situ keratomileusis (LASIK) flap dislocation occurred after trauma METHODS: Ultrabiomicroscopy (UBM) is used to obtain a high-resolution imaging of the cornea. RESULTS: The UBM results are presented and compared with histologic and confoscan findings CONCLUSIONS: The technique is useful and easy to perform, offering more opportunities to study the anatomical changes in LASK flap dislocation occurred after trauma.

Lisch nodules of the iris in neurofibromatosis type 1.

Neurofibromatosis type 1 (NF1) is a common autosomal dominant disease. The Lisch nodule represents one of the most common NF1 ocular manifestations. Several studies have reported that the Lisch nodule is a melanocytic hamartoma but its pathogenesis is still debated. We have studied the histopathological and ultrastructural features of a Lisch nodule of a 50-year-old woman biopsied during an intracapsular cataract extraction. Our researches revealed that it was composed of three main cytotypes: pigmented cells, fibroblast-like cells and mast cells, showing a pattern similar to a neurofibroma. Furthermore, we hypothesize that Lisch nodules are compatible with neurofibromas.

Effect of brimonidine on patients undergoing uncontrolled IOP with beta-blockers.

The authors evaluated the effect of the replacement of beta-blockers with brimonidine drops in patients taking beta-blockers only or with dorzolamide, having IOP > 20 mmHg. The study was divided into two sections: one group treated with brimonidine b.i.d. (23 patients) and the other group treated with brimonidine + dorzolamide b.i.d. (17 patients). The effect of the substitution showed after 90 days of treatment with a reduction of 8.59 +/- 1.2 mmHg (P < 0.001) in the first group and 6.1 +/- 1.7 mmHg (P < 0.001) in the second group. Three patients in the first group and four patients in the second group presented minor adverse effects which did not justify discontinuation of treatment. Brimonidine was effective treatment as a substitute for beta-blockers only when associated with dorzolamide.

A new method of biofeedback in the management of low vision.

Twenty-eight patients with low vision were enrolled into the study. A preliminary study was carried out on 18 eyes of 13 patients with low vision who underwent visual rehabilitation with a new instrument for biofeedback (BF) applied to vision; improved biofeedback integrated system (Ibis). Successively, eight patients (16 eyes) with bilateral low vision were subjected to biofeedback in one eye. The experimental and control eye were evaluated separately. Then a placebo training was developed on seven patients (12 eyes). Visual acuity, colour vision, automated perimetry, contrast sensitivity and flash VEP were evaluated. A brief review of the literature and the possible mechanisms behind the results are discussed.

Ultrasound biomicroscopy of the peripheral retina and the ciliary body in degenerative retinoschisis associated with pars plana cysts.

AIM: To evaluate the ciliary body and peripheral retina in degenerative retinoschisis associated with pars plana cysts using ultrasound biomicroscopy (UBM). METHODS: 18 eyes of 12 patients with degenerative retinoschisis associated with pars plana cysts were selected through binocular indirect ophthalmoscopy and Goldmann three mirror lens examination, both with scleral depression. These patients were studied in detail with UBM. RESULTS: Study of the ciliary body with UBM showed pars plana cysts of different size and uneven shape. In cross sections the morphology of pars plana cysts in detail and the close relation of the cysts with the oral region and the peripheral retina, where areas of cystoid degeneration and retinoschisis were present, were observed. In transverse sections three main morphological aspects of pars plana cysts could be differentiated ("isolated," "confluent," and "clustered" cysts). Furthermore, ultrabiomicroscopy allowed differential diagnosis between retinoschisis and associated retinal detachment in six eyes. CONCLUSIONS: The study of peripheral degenerative retinoschisis and pars plana cysts is possible in vivo by means of UBM, showing the detailed morphology of the lesions (not otherwise evident through ophthalmoscopic examination) and the close relation between pars plana cysts, cystoid degeneration, and peripheral retinoschisis.

Ocular alterations in alopecia areata.

PURPOSE: To determine the ocular alterations occurring in alopecia areata with regard to the lens and fundus. METHODS: Seventy-five patients with alopecia areata were examined. Seventy healthy control patients unaffected by skin, ocular or systemic disorders were also studied. RESULTS: Symptomless punctate lens opacities were found in 38 (51%) patients, whereas only 2 (3%) control patients had similar lens changes. Fundus alterations were found in 31 (41%) cases of alopecia areata and in only 16 (23%) controls. CONCLUSIONS: These ocular alterations and their prevalence are reported and some theories regarding the possible aetiopathogenetic mechanisms are discussed.

Sturge-Weber syndrome associated with naevus of Ota.

The association of Sturge-Weber syndrome with naevus of Ota is an infrequently reported phenomenon and there are only four previously described cases in the literature. In this paper we briefly review the literature regarding the coexistence of vascular and pigmentary naevi and present an additional patient with the association of the Sturge-Weber syndrome and naevus of Ota.

Branch retinal artery occlusion in a young woman with Ménière's disease.

An unusual case of a 32-year-old woman with branch retinal artery occlusion is presented. The patient was affected by Ménière's disease and had a history of occasional migraine headaches. A thorough clinical and laboratory investigation showed a high cholesterol level. Retinal arterial obstruction is rare in young people and it is difficult to establish the precise cause. The presumed multifactorial etiologic factors are discussed.

Structural evidence for membrane lipid changes in human cataract.

Lipid changes in relationship to cataractogenesis were studied with histochemical methods (topoptical reactions) of polarization microscopy. Frozen section of formaldehyde-fixed human lenses were used for these studies. Six lenses were transparent and 14 lenses presented early to confluent cortical opacities. Cell membrane lipids of transparent lenses showed 8.0 +/- 2.7 nm light retardation. In the early cataractous lenses the light retardation of cell membranes was 23.3 +/- 5.0 nm and that of the fusiform and globular lipids was 37.7 +/- 4.0 nm and 48.5 +/- 6.9 mn, respectively. In the non transparent cortical regions of cataractous lenses, membrane lipids were not observed. Similar to other cell membranes, normal lens membranes are composed of loosely organized lipids. In early cataract lipid density uniformly increased along the cell membranes at the clinically transparent areas, while at the areas with clinically evident fine opacities, small fusiform and globuler lipid drops were formed by even more dense lipids. Confluent cortical cataracts were associated with disappearance of membrane lipids. In our study our findings demonstrated intramembrane lipid changes associated with cataractogenesis.

Fox's modified technique using the Mersilene mesh sling in the management of blepharoptosis.

BACKGROUND AND OBJECTIVE: Frontalis suspension is the best surgical procedure for severe ptosis with poor or absent levator muscle function. In addition to autologous fascia lata, a variety of materials are available for suspension. The authors describe the use of Mersilene mesh slings developed to overcome the problems of failure, slippage, and extrusion commonly associated with various suspensory materials. PATIENTS AND METHODS: Brow suspension was performed in 20 ptotic eyelids of 14 patients. All patients had severe ptosis with levator function of 4 mm or less. The surgical technique used was a modified version of the method originally described by Fox using the Mersilene mesh sling. RESULTS: The improvement in lid height was evaluated by preoperative and postoperative vertical aperture measurements and ranged from 2 to 5 mm (average 3.5 mm). The results were maintained in all cases during a follow-up period of 18 months. CONCLUSION: The good functional and cosmetic results suggest that Fox's modified technique using the Mersilene mesh sling has a definite place in ptosis management.