Efficacy of Topical Nepafenac 0.3% in the Management of Postoperative Cystoid Macular Edema.

PURPOSE: To assess the effect of twice-daily nepafenac ophthalmic suspension 0.3% on postoperative cystoid-macular-edema (CME). PATIENTS AND METHODS: In this prospective, clinic-based, non-randomized case-series, 21 patients (21 eyes) were enrolled with either acute or chronic postoperative CME after cataract extraction. Patients were treated with twice-daily nepafenac 0.3% drops, and followed for at least a 4-month period. Best-corrected visual acuity (BCVA) and spectral-domain optical coherence tomography (SD-OCT)-derived central retinal thickness (CRT) were measured. RESULTS: From 21 patients, eight presented with acute postoperative CME and 13 with chronic CME. Mean follow-up was 4.82±1.24 months. No adverse events were reported during the study. Baseline BCVA was 0.49±0.36 logMAR and improved to 0.36±0.42 logMAR at the last follow-up visit (P<0.005). CRT decreased from 450.40±90.74 µm at baseline to 354.60±81.49 µm (P<0.05), following treatment. CONCLUSION: Our outcomes strongly suggest that administrating nepafenac 0.3% drops on a twice-daily regimen could be a promising alternative for the management of postoperative CME. Additional studies are necessary to further validate our results.

Endogenous endophthalmitis: A case of a presumed mixed intraocular opportunistic infection by a fungal species and cytomegalovirus.

BACKGROUND: Endogenous endophthalmitis is a serious sight-threatening disease. Common causes include immunocompromised state and intravenous drug use, permitting opportunistic pathogens to reach the eye through the blood stream. We reported a rare case of a presumed simultaneous opportunistic intraocular fungal and cytomegalovirus (CMV) infection. Case presentation: A 67-year-old male patient with a recent history of hospitalization due to pneumonia, presented to our department with bilateral loss of vision. Ocular examination revealed low visual acuity, signs of vitritis with chorioretinal infiltrations and cotton ball colony-like lesions, bilaterally. A bilateral endogenous fungal endophthalmitis was suspected and topical and systemic antifungal treatment was initiated. Nevertheless, vitreous and blood cultures were negative for fungi and other bacteria, while serological examinations revealed primary infection with CMV. Following vitrectomy, polymerase chain reaction (PCR) of vitreous washings confirmed the intraocular infection with CMV. Treatment was modified, including intravenous administration of Gancyclovir. In the following days, the patient's clinical signs and visual acuity improved remarkably. Conclusions: A case of a presumed mixed fungal and CMV intraocular infection was presented. High level of suspicion with prompt diagnosis and aggressive combination treatment led to a favorable result.

Optical Biometry Derived Axial Length Measurements Following Intravitreal Anti-Vascular Endothelial Growth Factor Treatment for Macular Edema.

PURPOSE: To evaluate axial length (AL) alterations in patients with macular disease over the course of intravitreal anti-vascular endothelial growth factor (anti-VEGF) treatment. METHODS: In this prospective, comparative study, 33 patients with macular edema underwent unilaterally intravitreal anti-VEGF therapy and were followed for two months; the contralateral eyes were considered as controls. Central retinal thickness (CRT) was measured with spectral-domain optical coherence tomography and AL with an IOL-Master optical biometer. RESULTS: CRT of the treated eyes decreased by 35.33 ± 65.59 µm (range, -222.00-67 µm), while AL increased by 0.008 ± 0.062 mm (range, -0.11-0.18 mm). CRT of the control group decreased by 9.82 ± 65.40 µm (range, -203-182 µm), and AL increased by 0.011 ± 0.129 mm (range, -0.20-0.67 mm). No significant correlation was detected between CRT and AL parameters (rhos=0.026, P=0.882). CONCLUSIONS: Anti-VEGF administration has no significant impact on optical biometry-derived AL measurements.

The Effect of LASIK Procedure on Peripapillary Retinal Nerve Fiber Layer and Macular Ganglion Cell-Inner Plexiform Layer Thickness in Myopic Eyes.

PURPOSE: To evaluate the effect of applied suction during microkeratome-assisted laser in situ keratomileusis (LASIK) procedure on peripapillary retinal nerve fiber layer (RNFL) thickness as well as macular ganglion cell-inner plexiform layer (GC-IPL) thickness. METHODS: 89 patients (124 eyes) with established myopia range from -3.0 to -8.0 diopters and no associated ocular diseases were included in this study. RNFL and GC-IPL thickness measurements were performed by spectral domain optical coherence tomography (SD OCT) one day before LASIK and at 1 and 6 months postoperatively. RESULTS: Mean RNFL thickness prior to LASIK was 93.86 ± 12.17 µm while the first month and the sixth month postoperatively were 94.01 ± 12.04 µm and 94.46 ± 12.27 µm, respectively. Comparing results, there is no significant difference between baseline, one month, and six months postoperatively for mean RNFL (p > 0.05). Mean GC-IPL thickness was 81.70 ± 7.47 µm preoperatively with no significant difference during the follow-up period (82.03 ± 7.69 µm versus 81.84 ± 7.64 µm; p > 0.05). CONCLUSION: RNFL and GC-IPL complex thickness remained unaffected following LASIK intervention.

Treatment of myopic choroidal neovascularization with intravitreal ranibizumab injections: the role of age.

PURPOSE: The aim of this study was to explore the role of age as a prognostic factor for the outcome of myopic choroidal neovascularization (CNV) treatment with intravitreal ranibizumab injections. METHODS: A retrospective review of charts of patients treated with intravitreal injections of ranibizumab for the treatment of myopic CNV was done. Patients with other ophthalmic disease were excluded. Patients were followed for at least 2 years. The correlation between age and the change in visual acuity and the number of injections during treatment was investigated. RESULTS: Age of the patients was significantly correlated with the number of injections that the patients received (Pearson's r=0.585, P=0.005). Also, it was significantly correlated with improvement in corrected distance visual acuity, defined as the difference between final and initial LogMAR corrected distance visual acuity (Pearson's r=0.614, P=0.003). CONCLUSION: Age significantly affects the visual outcome of myopic CNV treatment with ranibizumab. Younger patients in our study needed fewer intravitreal injections and achieved a more significant improvement in vision.

Variability of different reference bodies in normal, keratoconus, and collagen crosslinked corneas.

PURPOSE: To evaluate the reproducibility of different Scheimpflug imaging-derived reference bodies in normal, keratoconus (KC), and crosslinked (CXL) eyes. METHODS: In this prospective, observational study, 40 participants populated the control group (CG), while 33 and 34 patients formed the KC group and the CXL group, respectively. One eye was randomly selected when both were eligible. Elevation measurements were obtained using Scheimpflug camera, by applying the following reference bodies: the best fit sphere (BFS), the best fit toric ellipsoid (BFTE), the best fit toric ellipsoid with fixed eccentricity of 0.4 (BFTEF), the best fit ellipsoid (BFE), and the best fit torus, by 2 operators in 2 sessions. The variability of different reference bodies' parameters was assessed using intraclass correlation coefficient (ICC). RESULTS: Differences between operators were nonsignificant for all reference bodies' parameters in all study groups (p>0.1). Regarding CG, BFS for both operators and BFTE for operator 1 presented the best intrasession repeatability (majority of ICCs >0.90), while average interobserver reliability was recorded for the majority of reference bodies' parameters. Regarding KC and CXL groups, BFS, BFTEF, and BFE reference bodies demonstrated the best intrasession and interobserver reproducibility (majority of ICCs >0.90) for both groups. Steep and flat radius parameters presented the best overall reproducibility, with the majority of ICCs for all reference bodies ranging above 0.90, in all study groups. CONCLUSIONS: High variability was encountered for most reference surfaces. Ellipsotoric surfaces presented acceptable repeatability in KC and post-CXL corneas.

Mini-monovision versus multifocal intraocular lens implantation.

PURPOSE: To compare the effect of monovision correction and multifocal intraocular lens (IOL) implantation on patient satisfaction, spectacle dependence, visual acuity, and dysphotopsia in cataract patients. SETTING: University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece. DESIGN: Prospective randomized trial. METHODS: Patients with a diagnosis of senile cataract with stage 2 nuclear opalescence were randomly assigned to 2 groups: monovision and multifocal IOL implantation. Uncorrected (UDVA) and corrected (CDVA) distance visual acuity, Visual Function Index-14 (VF-14) scores, and spectacle dependence were assessed prior to surgery and 6 months postoperatively. RESULTS: The monovision group comprised 38 patients and the multifocal IOL implantation group, 37 patients. Both techniques provided excellent refractive outcomes in UDVA and VF-14 scores (all P < .01). No significant intergroup differences were detected in VF-14 scores at the final postoperative examination. The monovision group patients presented significantly more spectacle dependence for near vision but less glare. CONCLUSIONS: Monovision and multifocal IOL implantation provided excellent refractive outcomes for distance vision. Multifocal IOL insertion was associated with less dependence on glasses overall but significantly more dysphotopsia. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Corneal collagen cross-linking in a late-onset graft infectious ulcer: a case report.

INTRODUCTION: Infectious keratitis following penetrating keratoplasty is a common postoperative complication. Intensive topical and systemic treatments do not always prevent the risk of graft failure. In this report we demonstrate the beneficial anti-microbial effect of corneal collagen cross-linking in a late-onset, sight-threatening, corneal graft ulcer. CASE PRESENTATION: A 57-year old Caucasian man underwent penetrating keratoplasty in his left eye, due to corneal bullosa after cataract extraction surgery. Twelve months after the penetrating keratoplasty, he visited our emergency service complaining of burning and foreign body sensation in his operated eye. Slit-lamp examination revealed a central, round-shaped ulcer of the graft. Due to poor response to the intensive topical antibiotic therapy, corneal collagen cross-linking was applied 3 days after admission, in an attempt to control the infection. Cultures indicated the predominance of methicillin-resistant Staphylococcus aureus infection. Five days after corneal collagen cross-linking treatment, the epithelium was completely re-epithelized, while the transparency of the transplanted cornea was gradually restored within the 12-month follow-up period. No relapses occurred. CONCLUSION: Corneal collagen cross-linking seems to be a safe and effective therapeutic alternative in resistant cases of infectious keratitis following penetrating keratoplasty.

Perceptions of Greek medical students regarding medical profession and the specialty selection process during the economic crisis years.

PURPOSE: To assess the beliefs and preferences of 6th year Greek medical students, regarding medical profession and the specialty selection process, in the years of financial crisis. SETTING: Democritus University of Thrace, Medical School, Alexandroupolis, Greece. MATERIAL AND METHODS: A custom questionnaire based on former similar studies was developed and administered to senior medical students. Further to demographics, the questionnaire gathered information on perceptions and trends regarding medical profession, the specialty and residency selection processes. Total question scores were summed for comparisons among questions. Mean scores and standard deviations were calculated for comparisons between student groups. RESULTS: 111 students responded successfully to the instrument. "Helping patients" and the "scientific basis of medicine" were the fundamental reasons for choosing the medical profession. Compared to women, male students placed greater importance on the "financial allowances" (men: 3.73±1.03, women: 3.05±1.30, p=0.01). Regarding the selection criteria for a certain specialty, "challenging specialty" and "bedside specialty", were the main influence factors. Men more strongly preferred a specialty that could "financially support their desired lifestyle" (men: 3.93±0.88, women: 3.41±1.30, p=0.02). Concerning selection criteria of a residency program, students chose a "well structured" program at a "recognized hospital/department". Regarding the country of preference for their residency, 86% planned to continue abroad, primarily in Germany and the United Kingdom. CONCLUSION: Greek medical students perceive the medical profession and the specialty process in a similar way like their colleagues form Western countries. However, the vast majority identify that migration to another country is the most promising alternative choice for their medical career.

Diagnostic capacity of the keratoconus match index and keratoconus match probability in subclinical keratoconus.

PURPOSE: To evaluate the diagnostic capacity of the Ocular Response Analyzer's keratoconus match index (KMI) and keratoconus match probability (KMP) classification in keratoconus-suspect eyes. SETTING: Department of Ophthalmology, University Clinics Saarland, Homburg, Germany. DESIGN: Comparative case series. METHODS: The KMI and KMP parameters in keratoconus-suspect eyes and normal eyes (control group) were compared. The quantitative keratoconus percentage index was calculated for all suspect eyes. According to the thinnest corneal thickness (TCT), keratoconus-suspect eyes were divided into 2 subgroups: subgroup 1 (TCT <520 µm) and subgroup 2 (TCT >520 µm). The KMI's overall predictive accuracy was assessed using receiver operating characteristic (ROC) curves. The relationship between KMI and a series of Scheimpflug-derived keratoconus-related indices was evaluated using Spearman analysis. RESULTS: The mean KMI was 0.41 ± 0.29 (SD) in the keratoconus-suspect group (50 eyes) and 0.94 ± 0.29 in the control group (50 eyes) (P<.001). Nonsignificant KMI differences were detected between the keratoconus-suspect subgroups (subgroup 1, 27 eyes; subgroup 2, 23 eyes) (P=.059). Nonsignificant correlations were found between Scheimpflug indices and the KMI. The KMP identified 27.65% of control eyes as keratoconus suspect and 10.71%, 28.57%, and 3.57% of keratoconus-suspect eyes as being normal, having mild keratoconus, or having moderate keratoconus, respectively. The ROC analysis for the KMI indicated a predictive accuracy of 94% (cutoff point 0.72). CONCLUSIONS: The KMI seems to be a valuable index in the early diagnosis of keratoconus-suspect eyes. The KMP identified a significant percentage of topographically defined keratoconus-suspect eyes as normal or keratoconic. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Contribution of reference bodies in diagnosis of keratoconus.

PURPOSE: To evaluate the contribution of reference bodies for elevation maps in diagnosis of keratoconus (KC) and forme fruste keratoconus (FFK). METHODS: Study groups included (1) 80 eyes with KC, (2) 55 eyes with FFK, and (3) 95 eyes as control eyes. The maximum elevation value at the central 5 mm of the posterior cornea (MEL) and the elevation value at thinnest corneal point (TEL) were evaluated for their diagnostic capacity using receiver operating characteristic curves under the following reference bodies: sphere, ellipsoid, toric ellipsoid, and torus, with autodiameter and fixed 8-mm-diameter settings. Moreover, characteristic parameters for each reference body and the root mean square (RMS) were evaluated for their diagnostic capacity. RESULTS: Significant differences were detected in TEL, MEL, and RMS parameters among groups, for almost all reference bodies. The highest predictive accuracy (KC group, >99.97%; FFK group, >90.9%) was estimated for the TEL and MEL parameters using the toric ellipsoid (8 mm) reference body with a fixed eccentricity of 0.4. Moreover, the RMS parameter demonstrated sufficient diagnostic capacity (KC group, 99.95%; FFK group, 85.1%). The cutoff points for the TEL parameter were found to be 7 and 3 µm in the KC group and the FFK group, respectively; for the MEL parameter, they were 11 and 6 µm, respectively; and for the RMS parameter, they were 6.87 and 7.19 µm, respectively. CONCLUSIONS: The posterior corneal elevation values and the RMS parameter can effectively discriminate KC from normal corneas, although measured values and cutoff points depend on the selection of reference body. Moreover, the use of a toric ellipsoid reference body, with a fixed eccentricity of 0.4, seems to be an effective tool even in diagnosis of FFK.

Diagnostic capacity of biomechanical indices from a dynamic bidirectional applanation device in pellucid marginal degeneration.

PURPOSE: To evaluate the diagnostic capacity of the keratoconus match index (KMI) and keratoconus match probability (KMP) classification from a dynamic bidirectional applanation device (Ocular Response Analyzer) in eyes with pellucid marginal degeneration (PMD). SETTING: Department of Ophthalmology, University Clinics Saarland, Homburg, Germany. DESIGN: Cross-sectional study. METHODS: Pellucid marginal degeneration eligibility was confirmed by inferior peripheral thinning, corneal protrusion, and irregular astigmatism. The KMI and KMP parameters in PMD eyes (study group) were compared with those in normal eyes (control group). The KMI's overall predictive accuracy was assessed operating characteristic (ROC) curves. The relationship between KMI and corneal hysteresis (CH), the corneal resistance factor (CRF), and a series of Scheimpflug camera indices was evaluated with Spearman analysis (r). RESULTS: The mean KMI in the study group (40 eyes) and control group (40 eyes) was 0.34 ± 0.43 (SD) and 0.95 ± 0.30, respectively (P<.001). The KMI correlated significantly with the CH, CRF, and most Scheimpflug camera indices. Regression analysis indicated that the index of height decentration (r = -0.877, P<.001) was the primary determinant of the KMI. Moreover, the KMP index identified 50.0%, 29.16%, and 20.83% of PMD eyes as ectatic, suspect for ectasia, and normal, respectively. The ROC curve analysis of the KMI parameter indicated a predictive accuracy of 94.8% (cutoff point 0.626; sensitivity 85.71%; specificity 90.1%). CONCLUSIONS: The KMI seems to be a promising diagnostic index for PMD. In contrast, the KMP index identified a significant percentage of topographically defined PMD eyes as normal, limiting its diagnostic value in PMD. FINANCIAL DISCLOSURES: No author has a financial or proprietary interest in any material or method mentioned.

Biodegradable nanoparticles for controlled subconjunctival delivery of latanoprost acid: in vitro and in vivo evaluation. Preliminary results.

Purpose of the study was to develop and assess a novel controlled drug delivery system of latanoprost acid (LA). Poly(lactide)/Monomethoxy-poly(ethyleneglycol) (PLA-PEG) nanoparticles (NPs) were prepared using an emulsification-solvent evaporation technique. NPs were characterized in vitro according to their size, ζ-potential, drug entrapment efficiency and LA release. LA-loaded NPs (equivalent to 8.5 µg LA) were administered into the subconjunctival space of normotensive rabbits (group A). A free LA solution of the same drug content was subconjunctivally injected in a second rabbit group (group B), while blank NPs were administered in a third group (group C). A group of untreated animals (group D) served as the control. Intraocular pressure (IOP) was monitored for 8 consecutive days, using the Tono-pen XL. Aqueous humor (AH) levels of LA were evaluated for 6 days post-administration, by means of HPLC. Mean nanoparticle size was 80 nm. The drug entrapment efficiency was 18.3%. NPs sustained the release of LA over several days in vitro. Non-significant differences in baseline IOP were found between groups (p = 0.22). LA-loaded NPs exerted a significant hypotensive effect on group A, while IOP values remained significantly lower compared to the rest groups, throughout the study (p = 0.04). LA AH concentrations in group B continuously decreased with time, while LA levels in group A steadily increased. On day 6, LA levels were higher in group A compared to group B (344 ± 73.5 ng/ml and 228 ± 41.01 ng/ml, respectively). No adverse effects were observed. In conclusion, after subconjunctival administration, the LA-loaded NPs provided sustained LA delivery in vivo. They appear to be a promising system for the controlled subconjunctival delivery of LA.

Biomechanical diagnosis of keratoconus: evaluation of the keratoconus match index and the keratoconus match probability.

PURPOSE: To evaluate the diagnostic capacity of the Ocular Response Analyser's keratoconus match index (KMI) and keratoconus match probability (KMP) classification in a sample of keratoconus (KC) patients. METHODS: Keratoconus match index and KMP from 114 KC eyes, randomly selected from 114 patients with bilateral keratoconus (KCG), were compared with the corresponding ones from 109 normal eyes (CG). Keratoconus match index's predictive accuracy was assessed by receiver operating curves (ROC). Keratoconus match probability level of agreement was evaluated at the different KC stages of the Amsler-Krumeich classification. Correlations were estimated with topographic keratoconus classification (TKC), keratoconus index (KI), index of surface variance (ISV), vertical asymmetry (IVA), height asymmetry (IHA), height decentration (IHD), minimal radius (Rmin), central corneal thickness (CCT), thinnest corneal thickness (TCT) mean keratometry (Km) and intraocular pressure (IOPg). RESULTS: Mean KMI in KCG and CG was 0.20 ± 0.38 and 0.98 ± 0.25, respectively (p < 0.01). Significant KMI differences (p < 0.01) were detected in different KC groups [range: 0.62 ± 0.38 (KC 1), -0.62 ± 0.04 (KC 4)]. Significant correlation was detected between KC staging and KMI (r = -0.56, p < 0.0001). Keratoconus match probability identified 22.03% of the CG eyes as suspect. Moreover, KMP identified 7.01% and 23.68% of the KCG eyes as normal and suspect, respectively. Receiver operating curves analysis for KMI parameter indicated a predictive accuracy of 97.7% (cut-off point: 0.512, sensitivity: 91.18%, specificity: 94.34%). CONCLUSIONS: Keratoconus match index seems to be a reliable index in keratoconus diagnosis and staging. Keratoconus match probability identifies a significant percentage of topographically defined KC and CG eyes as suspect. Diagnostic capacity of these novel indexes needs to be further explored.