Retromode Imaging in Age-Related Macular Degeneration.

Background and Objectives: Retromode is a relatively new retinal-imaging technique that is based on the transillumination principle and is obtained with a scanning laser ophthalmoscope that uses light in the infrared spectrum. The laser light penetrates into the deep retinal layers and the choroid. Retromode images are captured with a laterally displaced aperture, and the detector captures only the scattered light. The result is a high-contrast pseudo-three-dimensional image. Age-related macular degeneration (AMD) is a disabling retinal disease. AMD is characterized in its early stage by small and intermediate drusen formation, while the signs of intermediate AMD are large drusen and/or pigmentary abnormalities. Late AMD has two forms, geographic atrophy, which is the advanced form of dry AMD, and wet AMD. Most of the lesions of AMD are located in the outer layers of the retina. This new imaging method can provide a glimpse of the deep retinal layers' topographic changes in a non-invasive, fast, and effective way that can match the other imaging tools available. Materials and Methods: The literature review was performed by searching the PubMed database using the following combination of keywords: retromode imaging and age-related macular degeneration. Relevant images similar to the ones in the literature were identified and used as models. Results: The purpose of this article is to highlight the utility of incorporating retromode imaging into the multimodal evaluation of the retina in patients with AMD and to gather and integrate these findings into a brief but comprehensive paper. Conclusions: Retromode imaging is a good screening, diagnosis, and monitoring tool for patients with AMD.

Difficulties in choosing the right intraocular lens in a previously vitrectomized patient - the role of the tear film.

We present the difficulties in choosing the right IOL, when facing a great variability of the keratometric measurements, in the case of a patient operated for epiretinal membrane and lamellar macular hole, who developed complicated cataract in the operated eye. Upon commencing the biometric measurements, inconsistency in keratometric values led to further investigations. Repeated placido disc topography initially showed corneal ectasia, which posed a problem on selecting the right type of intra-ocular lens. Ocular surface pathology was suspected, and after treatment, the topography was repeated with a Scheimpflug topographer, that showed an improved keratometric profile. The surgical solution was to implant an aspheric monofocal IOL, in the bag, with extended depth of focus that enhances intermediate vision, disregarding the previous keratometric measurements. Refractive and functional outcomes were good. In cases of biometric measurements that show inconsistency in keratometric values, ocular surface disease as well as corneal ectasia should be taken into consideration. The right implant should not be chosen based on a single measurement, but rather several measurements should be made and compared and the choice should not be made before treating the ocular surface.

Further advances in the diagnosis and treatment of Leber's Hereditary Optic Neuropathy - a review.

Leber's Hereditary Optic Neuropathy (LHON), is one of the most frequent mitochondrial diseases characterized by Retinal Ganglion Cells degeneration. Pathogenic gene mutations in LHON induces mitochondrial impairment, which in turn leads to insufficient mitochondrial ATP production. The pathologic hallmark of the disease is primary degeneration of retinal ganglion cells, which results in optic nerve atrophy. The paper reviews some of the recent advances in the understanding of LHON: new genetics discoveries and novel therapeutic approaches.

The Diagnosis and Treatment of Fungal Endophthalmitis: An Update.

In recent, large case series of fungal endophthalmitis (FE) that were published by Asian authors, the most frequent etiologic agents for all types of FE are molds (usually Aspergillus species, while Fusarium is the prevalent etiology in keratitis-related FE). Candida was the organism found in most cases of endogenous FE. However, we must keep in mind that prevalence of fungal species varies with the geographical area. Lately, polymerase chain reaction (PCR) was increasingly used for the diagnosis of FE, allowing for very high diagnostic sensitivity, while the costs become more affordable with time. The most important shortcoming of PCR-the limited number of pathogens that can be simultaneously searched for-may be overcome by newer techniques, such as next-generation sequencing. There are even hopes of searching for genetic sequences that codify resistance to antifungals. We must not forget the potential of simpler tests (such as galactomannan and ß-d-glucan) in orienting towards a diagnosis of FE. There are few reports about the use of newer antifungals in FE. Echinocandins have low penetration in the vitreous cavity, and may be of use in cases of fungal chorioretinitis (without vitritis), or injected intravitreally as an off-label, salvage therapy.

Femtosecond-LASIK outcomes using the VisuMax®-MEL® 80 platform for hyperopia and hyperopic astigmatism refractive surgery.

The present study evaluated the efficacy, the safety and the predictability of the Femtosecond laser-assisted in situ keratomileusis (Femto-LASIK) procedure for hyperopia and hyperopic astigmatism. We retrospectively analyzed the postoperative 12-month evolution of 593 eyes with hyperopia and hyperopic astigmatism that underwent Femto-LASIK treatment. The procedure was predictable and effective. No eye lost 2 lines of corrected distance visual acuity (CDVA), demonstrating a safety profile of the procedure. Nine percent of the eyes gained at least one line of CDVA. The accuracy of the spherical equivalent after 12 months was 74% within ±1.0 diopter (D) of emmetropia. The refractive outcomes were stable during the follow-up period. There were no significant complications during the procedure. Femto-LASIK using the VisuMax®-MEL® 80 platform was demonstrated to be a suitable option to correct selected cases of hyperopia and hyperopic astigmatism. A longer follow-up period is required to better assess the refractive results and to detect any further regression.

Lens-induced uveitis in a patient with hypermature cataract.

Objective: Our paper aims to report an unusual case of phacogenic uveitis with secondary glaucoma occurring after spontaneous rupture of the lens capsule in a patient with hypermature age-related cataract, to describe its particularities and to review the classification of the lens-induced uveitis. Methods: We described the case of an 83-year-old male with a history of hypermature cataract, who presented to our clinic for right eye pain. Examination revealed circumciliary congestion, diffuse corneal edema, lens debris floating in the anterior chamber, pseudohypopyon and the opacification of the whole lens. An elevated intraocular pressure was also associated. We did not observe any history of previous intraocular surgery or trauma. Results: We diagnosed the case as a phacogenic uveitis with secondary glaucoma and we planned to remove the inflammation trigger, namely the lens and its fragments by the most adequate technique, in order to control the inflammation and the IOP spikes, to alleviate the pain and to improve the patient's visual function and the quality of life. Conclusions: Phacogenic uveitis may present a cloudy cornea and a turbid anterior chamber that mimics endophthalmitis. Careful examination, medical history and ancillary investigations are helpful in establishing an accurate diagnosis and the appropriate treatment can reduce or eliminate the inflammation completely, decrease the intraocular pressure, being able to allow, depending on the particularities of the case, the visual gain.

Endogenous Endophthalmitis: A Review of Case Series Published between 2011 and 2020.

This is a literature review of 31 case series of endogenous endophthalmitis (EE) published in the last ten years, identified from a literature search of several databases (PubMed, EMBASE, and the Cochrane Library). While diabetes mellitus and malignancies remain the most frequently associated medical conditions, intravenous drug use is a significant risk factor (especially in the last years, in studies from Western countries). Ophthalmologic screening is recommended for candidaemia, but not in patients with sepsis of other aetiologies (however, the physician treating patients with sepsis must be well aware of EE). The most frequent Gram-positive microorganisms that cause EE are Staphylococcus and Streptococcus; the most frequent Gram-negative organism is Pseudomonas, and yeasts, probably Candida, usually cause fungal infections. In all-cause EE, prognostic factors of better visual outcomes are initial VA better than counting fingers, performing a pars plana vitrectomy (PPV), performing an intravitreal injection within the first 24 hours after clinical diagnosis, and the presence of a focal type of EE. In endogenous fungal endophthalmitis, more than 1/4 of patients have bilateral involvement. Blood samples have a low rate of positivity. Yeasts remain the most prevalent cause. Many authors report using azoles and echinocandins for systemic therapy (and voriconazole for intravitreal injections). Although PPV was performed in small proportions of eyes, the anatomical success rate is quite high. Klebsiella pneumoniae is an important cause of EE in Southeast Asia (and probably an emergent etiology in other regions), which is frequently associated with diabetes. There is a robust association with pyogenic liver abscess (PLA) (but in up to half of the cases, the diagnosis of EE precedes that of PLA). Blood cultures have a high diagnostic yield, while vitreous samples have a low yield. K. pneumoniae may carry antibiotic resistance. Anatomical and functional success rates are small, but they may be improved with PPV.

Ocular cicatricial pemphigoid (Review).

Ocular cicatricial pemphigoid is a particular form of mucous membrane pemphigoid and it is characterized by a chronic bilateral conjunctivitis with relapsing-remitting periods. Without therapy 75% of the cases develop visual loss due to major ocular complications (e.g. severe dry-eye syndrome, corneal erosions, corneal keratinization, entropion, symblepharon). Pathogenesis remains uncertain and probably linked to an autoimmune type II hypersensitivity response in patients with a genetic predisposition and exposure to different environmental triggers. With a worldwide distribution, no racial predilection and an estimated incidence that largely varies from 1/10,000-1/60,000, ocular cicatricial pemphigoid predominantly affects women aged ~60 years. Conjunctival biopsy with direct immunofluorescence is the gold standard in diagnosis confirmation, but up to 40% of the patients have a negative biopsy result that does not rule out the diagnosis. The skin and many other mucous membranes (e.g. oral, trachea, esophagus, pharynx, larynx, urethra, vagina and anus) may be involved. The disease grading relies on Foster staging system (based on clinical signs) and Mondino and Brown system (based on the inferior fornix depth loss). The differential diagnosis includes atopy, allergies, trauma, chemical burns, radiation, neoplasia, infectious, inflammatory and autoimmune etiologies. The main goals of the treatment are to stop disease progression, to relieve symptoms and to prevent complications. With long-term systemic therapy 90% of the cases can be efficiently controlled. While Dapsone is the first-line treatment in mild to moderate disease in patients without G6PD deficiency, more severe cases require immunosuppressant therapy with azathioprine, mycophenolate mofetil, methotrexate or cyclosporine. Cyclophosphamide, biologics (etanercept or rituximab) and intravenous immunoglobulin therapy are usually reserved for recalcitrant disease and unsatisfactory results to conventional therapy. Dry eye syndrome requires constant lubricating medication and topical steroids, cyclosporine-A and tacrolimus. Surgery should be planed only in quiescent phase as minor conjunctival trauma can significantly worsen the disease.

Intraoperative flap-related complications in FemtoLASIK surgeries performed with Visumax® femtosecond laser: A ten-year Romanian experience.

Incidence and clinical results of intraoperative flap and interface-related complications were investigated after Femtosecond-LASIK surgery, where flap creation was performed with VisuMax® femtosecond laser. A retrospective 10-year cohort study was conducted including all eyes treated for all refractive errors by Femtosecond-LASIK technique. All the flaps were made by the same refractive surgeon with the VisuMax® (Carl Zeiss Meditec) femtosecond laser. We report the intraoperative flap and interface-related complications in these eyes, also describing their management. The study included 4,032 eyes. Flap and interface-related complications were: opaque bubble layer (OBL) 21.18%, suction loss 1.29%, difficult docking 0.69%, difficult dissection of the flap 0.59%, bleeding from limbal blood vessels 0.35%, de-epithelialization of the flap 0.12%, and interface debris 0.025%. These situations were appropriately addressed, with favorable outcomes. Flap creation is an important step in LASIK surgery. The predictability and safety have improved since the flap incision is assisted by a femtosecond laser, but complications of the flap and interface can still occur during the flap creation. Refractive surgeons should be aware and properly manage any unusual situation.

The Management of Lamellar Macular Holes: A Review.

This literature review aims to provide the retina specialist with answers to patient's questions related to the management of lamellar macular holes (LMHs). Most LMHs are stable over time, but 13-21% present an anatomic decline after 18-24 months of follow-up. Nineteen point five percent of the eyes may experience a visual acuity (VA) loss of more than 5 letters after 3 years. Many surgeons choose to perform surgery when there is significant metamorphopsia or documented decline in VA over time. The typical surgery is phacovitrectomy with the epiretinal membrane and the internal limiting membrane peeling in previously phakic eyes (41.9 to 85.3% of the eyes). In the eyes that remained phakic, cataract surgery was often necessary within the first year of follow-up (19.2 to 40% of eyes). After surgery, a VA gain was recorded in 63-94% of eyes, but some eyes (between 0 and 20%) suffered some VA loss. Progression to full-thickness macular hole may occur after surgery, and thus a second surgical intervention may be needed.

Clinical features in toxic coma in children.

The purpose was to identify rapidly the etiology of toxic coma in children, to appreciate the severity of the coma, to detect elements of gravity based on associated clinical signs and symptoms and to evaluate the initial treatment. Toxic coma is a medical emergency, especially in a Pediatric Emergency Department, requiring rapid and precise evaluation. The key objectives in the evaluation and management of coma in children are: detecting severity characteristics, depth of coma, specific clinical signs and symptoms, etiological and differential diagnostic and also initializing supportive therapy and specific treatment. This is a retrospective study, where we analyzed all patients diagnosed with coma admitted to the 'Grigore Alexandrescu' Clinical Emergency Hospital for Children over a nine-year period from 2003 to 2011. We focused on toxic coma. A prospective component related to tracking certain signs and symptoms associated with toxic coma to diagnose and initiate appropriate therapy as early as possible was also included. In this nine-year study, 750 comatose patients were included. We found that toxicants represent the main cause of coma in children. There were 445 patients diagnosed with toxic coma, representing 59.3% and 305 cases of non-toxic coma, 40.7% of all coma cases presented in ER. The etiology of toxic coma in children is dominated by alcohol and abuse substances, followed by neurologic medication. Clinical manifestations were more frequent and more severe as the coma degree increases. Associating clinical manifestations in patients with altered neurologic status of toxic cause and toxicants has an important role in practice, because it helps us recognize the frequency of association of coma complications such as: aspiration syndrome, arrhythmias and seizures.

Behavior pattern of early-stage ocular surface squamous cell carcinoma in non-HIV patients.

Ocular surface squamous neoplasia (OSSN) is a malignant or dysplastic lesion that has its origins in the epithelial cells at the ocular surface. The structures from which these lesions can arise are the conjunctiva, the limbus, and the cornea. Our study was conducted on a group of seven patients with ocular surface squamous cell carcinoma (SCC). Histopathologically diagnosed SCCs were then assessed as well, moderately and poorly differentiated, depending on which area of differentiation dominated in Hematoxylin-Eosin staining. For the immunohistochemical analysis, the following antibodies (markers) were used: Ki67, p53 and B-cell lymphoma 2 (Bcl-2), E-cadherin, and vascular endothelial growth factor (VEGF). Our study group was composed of seven cases of SCCs of the ocular surface. Three were below in T1 American Joint Committee on Cancer (AJCC) stage, two cases were in T2 AJCC stage, and two cases were in T3 AJCC stage. None of our cases were T4, N1 or M1 AJCC tumors. Four of the cases were histopathologically moderately differentiated SCCs of the ocular surface and three were poorly differentiated SCCs. None of the seven patients present human immunodeficiency virus (HIV) infection. P53 immunostaining was strongly present in our study. Bcl-2 overexpression is not a fact that our study highlights. The expression of Ki67 proliferation marker was low in our study. Our study on ocular surface SCC reveals negative assessment of VEGF immunostaining. E-cadherin expression in our study was positive. Ocular surface SCCs are slow growing tumors, with very low metastasis potential, when HIV-infection is not present.

Leber's Hereditary Optic Neuropathy - Case Discussion.

Purpose. To report a case of a young patient with a clinical condition suggestive of Leber's hereditary optic neuropathy (LHON) confirmed by genetic testing. Material and methods. We present a case of a 21-year-old Caucasian male with bilateral visual loss. The patient complained of visual loss, initially in the right eye and two weeks thereafter in the left eye. Ophthalmological examination revealed visual acuity of 20/ 400 in both eyes, anterior segment of normal appearance, normal direct and consensual pupillary light reflexes, and absence of a relative afferent pupillary defect. Fundus examination demonstrated bilateral protruding, hyperemic, with blurred margins in the nasal quadrant papilla and reduced excavation, tortuous vessels, peripapillary telangiectasias. The optical coherence tomography (OCT) revealed bilateral increase of the retinal nerve fiber layer (RNFL) thickness and ganglion cell layer - inner plexiform layer complex (GCL-IPL complex) severely thinned. Results. The clinical suspicion of Leber's hereditary optic neuropathy was confirmed by the 3460 mutation, which was identified on blood mitochondrial analysis. Meantime, the visual acuity decreased to CF in both eyes. We initiated treatment with idebenone (300 mg T.I.D.). After three months of follow-up, visual acuity was CF in both eyes, bilateral pupillary light reflexes within normal limits and optic disc pallor was noticed in both eyes. Conclusion. No visual recovery was noticed after one year. We recommended that the idebenone treatment was continued and the patient was followed-up further.

New perspectives in the use of laser diode transscleral cyclophotocoagulation. A prospective single center observational cohort study.

PURPOSE: The paper intends to present the results of using new methods of a new generation diode laser transscleral cyclophotocoagulation (TSCPC) in patients with different types of glaucoma. PATIENTS, MATERIALS AND METHODS: There have been treated 53 eyes from 59 patients with glaucoma refractory to medical, laser or surgical treatment. We have used the newest generation of 810 nm wavelength diode laser. There have been used two protocols of continuous-wave diode laser emitting radiation for cyclophotocoagulation. The first technique - the standard cyclophotocoagulation (high power and low exposure duration) - has been used for the eyes with limited visual function [visual acuity (VA) extremely low or eyes disorganized]. The second technique - slow coagulation, also named "slow burn" (lower power and greater exposure duration) - has been used for the eyes with apparently better visual prognosis (VA≥20∕400). For evaluation, we followed both subjective parameters (eye pain decrease) and objective parameters [intraocular pressure (IOP) lowering and VA evolution]. Patients have been evaluated before laser intervention and postoperative at one, three and six months. RESULTS: IOP has significantly decreased in both patient groups. In the eyes with better visual function (VA≥1∕20), where we have used the "slow coagulation" technique, we found no decrease of VA. Eye pain has disappeared in almost all treated cases. CONCLUSIONS: The diode laser TSCPC is an efficient method of lowering IOP and decreasing eye pain. The "slow burn" technique has been shown its efficiency for extending the indications of cyclophotocoagulation also in glaucomatous eyes with better functional prognosis.

The management of the oropharyngeal anterior wall cancer.

INTRODUCTION: Anterior wall of the oropharynx or the base of the tongue is the site of different types of cancers, most of them usually diagnosed in advanced stages. The most common histological type of cancer diagnosed in these patients is squamous cell carcinoma (SCC). The treatment methods are multiple, but the optimal therapeutic option with best results on outcome and on the patients' quality life has not been established. The objectives of our study were to evaluate the tongue base SCCs treated by transhyoid approach and the oncological outcomes of the surgery combined with radiotherapy. PATIENTS, MATERIALS AND METHODS: The retrospective study was performed over a period of 10 years (2001-2010) on 37 previously untreated patients. All the tumors were biopsied and after histopathological (HP) diagnosis, the tumors were excised. All the specimens were fixed in 4% (v/v) buffered formalin and sent for the HP evaluation. RESULTS: In the study were included only the patient diagnosed on biopsy with different types of SCC. The mean age was 61 years old, most of the patients (94.59%) being males. We performed a tongue base transhyoid tumor resection in 23 (62.17%) cases followed by epiglottectomy in five (13.51%) cases or horizontal supraglottic laryngectomy in nine (24.32%) cases, respectively. Bilateral neck dissections and postoperative radiotherapy were performed in all cases. The postoperative and post-therapeutic evolution was favorable at three years (81.1%) and five years (75.67%). There were no signs of local or regional recurrences. The tumor specific three-year and five-year survival rates were: pT2 100%, pT3 87.5%, pT4a 71.42% and 57.14%, and pT4b 50% and 25%, respectively. The stage specific three-year and five-year survival rates were: stage II 100%, stage III 85.71%, stage IVA 83.33% and 79.16%, and stage IVB 50% and 25%, respectively. CONCLUSIONS: The prognosis for the SCC of the tongue base is poor. Cancer resection by transhyoid approach is a feasible procedure, which permits a good tumor control with limited postoperative morbidity, with an important benefit on the life quality of the patients.

Femtosecond-LASIK outcomes using the VisuMax®-MEL® 80 platform for mixed astigmatism refractive surgery.

AIM: To evaluate the predictability, efficacy and safety of Femtosecond-laser-assisted in situ keratomileusis (LASIK) procedure for mixed astigmatism. PATIENTS, MATERIALS AND METHODS: We prospectively evaluated for 12 months 74 eyes (52 patients) with mixed astigmatism that underwent Femtosecond-LASIK treatment. The preoperative mean refractive sphere value was +1.879±1.313 diopters (D) and the mean refractive cylinder value was -4.169±1.091 D. The anterior corneal flap was cut using the VisuMax® femtosecond laser and then the stromal ablation was done using the MEL® 80 excimer laser. RESULTS: Mean age was 30.22±6.421 years with 61.53% female patients. Postoperative spherical equivalent at 12 months was within ±0.5D of emmetropia in 75.8% of eyes and within ±1D in 97.3% of eyes. Postoperative uncorrected distance visual acuity was equivalent to or better than the preoperative corrected distance visual acuity in 91.9% of eyes. Compared to the preoperative corrected distance visual acuity (CDVA), 8.1% of eyes gained one line, 2.7% gained two lines and 2.7% gained three lines of visual acuity. CONCLUSIONS: Femtosecond-LASIK using the VisuMax®-MEL® 80 platform appears to have safe, effective and predictable results in mixed astigmatic eyes. The results are impressive for high refractive error treatment and for improvement of both uncorrected and corrected distance visual acuity.

Multiple congenital anomalies of carotid and vertebral arteries in a patient with an ischemic stroke in the vertebrobasilar territory. Case report and review of the literature.

The congenital anomalies of the supra-aortic arteries and their branches as potential risk factors for cerebrovascular insufficiency are not yet fully investigated and clarified. This report describes the case of a 68-year-old man who was admitted in our Clinic for an acute ischemic stroke in the vertebrobasilar territory. Extracranial color-coded duplex sonography (CCDS) and computed tomography angiography revealed a combination of congenital anomalies of the neck arteries: left internal carotid artery hypoplasia, left common carotid artery hypoplasia, right vertebral artery hypoplasia and the emergence of the left vertebral artery directly from the aortic arch. The aim of this article is to emphasize the value of CCDS as an accurate, non-invasive method of assessing the neck arteries and, also, the importance of the morphological anomalies of the carotid and vertebral arteries in the cerebral hemodynamics.

Giant cell arteritis with arteritic anterior ischemic optic neuropathy.

Giant cell arteritis (GCA) is an inflammatory vasculitis of unknown etiology that mainly involves large and medium arteries, particularly the cranial branches of the aorta. GCA with consecutive arteritic-anterior ischemic optic neuropathy (A-AION) has rarely been diagnosed in Romania. Recently, we encountered an 83-year-old patient who presented with left eye visual impairment and corresponding optic disc diffusely swollen and pale. He also had typical manifestations of GCA, such as malaise, and temporal headache, and a highly elevated erythrocyte sedimentation rate and C-reactive protein level. Biopsy of his left superficial temporal artery revealed a granulomatous inflammation with multinucleated giant cell infiltration, so he was diagnosed with GCA with consecutive left A-AION. Because without treatment, this affection usually progresses very rapidly, the patient was promptly treated with an adequate dosage of steroids, which was essential to save the visual function of both eyes. Our case report confirms the potential of visual recovery after prompt corticosteroid treatment in GCA with eye involvement.

One year refractive outcomes of Femtosecond-LASIK in mild, moderate and high myopia.

Purpose: To evaluate the safety, efficacy, predictability and stability for a cohort of myopic eyes treated by Femtosecond-LASIK procedure. Methods: 60 eyes (36 patients) with different degrees of myopia that underwent refractive surgery by using the Femtosecond-LASIK technique were prospectively evaluated for 12 months. The mean preoperative spherical equivalent value was -3.827 ± 1.410 diopters (D) (range: -8.125 to -1.375 D). VisuMax® femtosecond laser was used for cutting the corneal flap and then the Mel80® excimer laser for the stromal ablation. Results: Mean age was 30.80 ± 5.745 years (range: 21 to 46 years) with 75% female patients. Postoperative spherical equivalent at 12 months was within ±0.25 D of emmetropia in 90% of the eyes and within ±0.50 D of emmetropia in 100% of the eyes. All the eyes achieved an uncorrected distance visual acuity (UDVA) of 1.0 (decimal scale). No eye lost lines of preoperative corrected distance visual acuity (CDVA). No major intraoperative or postoperative complications were encountered. Conclusions: Femtosecond-LASIK seems to be a suitable option for the correction of mild, moderate, and high myopia, as the procedure showed to be safe, effective, and predictable for the treatment of myopic refractive errors.