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.

Ocular disorders in multiple myeloma patients: cross-sectional study of prevalence and association with treatment.

Multiple myeloma (MM) therapy is evolving, and several new drugs are now available, extending patients' life and exposure to different compounds and toxicities. We conducted a cross-sectional observational study enrolling 93 consecutive patients on active treatment for MM, aiming to assess their ocular complications. All the patients underwent a comprehensive ophthalmic evaluation. In our cohort, prevalence of low visual acuity was in line with similar age healthy population reported in registry studies. Interestingly, we recorded a higher prevalence of lens opacities (46%) and dry eye syndrome (53%). Nevertheless, we did not find any significant association between ocular disorders and anti-myeloma treatments, even steroid therapy. This observation suggests that other factors besides treatments, such as M-protein deposition in eye structures, may have a role in developing ocular toxicities. Since MM patients are elderly patients at higher risk of age-related eye disorders, we recommend periodic ophthalmic assessment in daily practice.

Premacular membrane formation after scleral buckling for primary rhegmatogenous retinal detachment: prospective study and pathophysiological insights.

PURPOSE: To investigate the incidence, clinical features and risk factors of premacular membrane (PMM) formation after primary rhegmatogenous retinal detachment (RRD) repair with scleral buckling (SB) alone. METHODS: This institutional, prospective and consecutive case series included phakic eyes with RRD, treated with SB alone within 7 days from the occurrence of symptoms, with a follow-up of 6 months. Spectral-domain optical coherence tomography images were reviewed. The association of PMM development and morphology with preoperative and intraoperative RRD features was analysed. RESULTS: Ninety-two patients with a mean age of 56±13 years completed the 6 months follow-up period. Postoperatively, eyes with any PMM stage were 30 out of 92 (32.6%) at 1 month and 47 out of 92 (51,1%) at both 3 months and 6 months. Over the follow-up period, 17 out of 47 PMMs (36.2%) progressed to later stages. Progression of PMMs to later stages were observed only in RRDs involving the macular region (17 out of 35 eyes, 48.5%), while none of the PMMs in macula-sparing detachments progressed to later stages (p=0.020). The risk factors significantly associated with postoperative new onset of PMM were preoperative RRDs involving the macular region (p=0.001), cryopexy time (p=0.045), presence of horseshoe tears (p=0.003), worse preoperative visual acuity (p=0.004) and subretinal fluid drainage (p=0.047). CONCLUSION: The incidence of postoperative PMM formation after RRD repair with SB alone was high. In retinal detachments involving the macular region PMM were more severe, tending to anatomical progression and functional deterioration. Activation of foveal Müller cell in detachments involving the macula may be a key factor in PMM progression.

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.

Spectral domain OCT and autofluorescence imaging of unilateral acute idiopathic maculopathy.

PURPOSE: To report imaging findings of unilateral acute idiopathic maculopathy (UAIM). METHODS: In this observational case report, the Spectralis acquisition system (Heidelberg Engineering, Germany), which includes spectral domain optical coherence tomography (OCT), multiple autofluorescence (AF), fluorescein angiography (FA), and indocyanine green (ICG) angiography, was used for monitoring onset and evolution of UAIM. RESULTS: A well-defined, bullous macular lesion was evident on color pictures, infrared imaging (IR), and AF. Fluorescein angiography and ICG similarly showed early hypofluorescence of the lesion and, exclusively on FA, mild staining. Notably, the definition and limits of the detachment were clearly identifiable on late-phase ICG, and formed a hypocyanescent area. Spectral domain OCT disclosed severe retinal pigment epithelium (RPE) but not neurosensory detachment; the distinction between the photoreceptors inner/outer segment line was nonapparent for the entire length of the lesion. At 7-week follow-up, visual acuity improved to 20/20, with resolution of the exudative detachment. Autofluorescence and FA imaging indicated normalization, and only IR showed the boundaries of the lesion as still identifiable. Infrared imaging also showed a central granular feature, suggesting persistent choroid and pigment alteration. Indocyanine green angiography still evidenced the early hypofluorescent halo that became more evident in the late phases without any staining of the dye. Tomography depicted a reconstituted fovea, in which the outer limiting membrane and the inner/outer segment junction returned detectable. CONCLUSIONS: Comprehensive evaluation of UAIM by AF, FA, ICG, and spectral domain OCT disclosed involvement of RPE, the neuroretina, and the choroid in the pathogenesis of the disease. Despite functional recovery, choroidal rather than retinal alteration could persist.

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.