A Treatment Approach in Congenital Fibrosis of Extraocular Muscles.

Background: Congenital fibrosis of extraocular muscles ( CFEOM) is a group of genetically defined eye-moving disorders. The syndrome is clinically characterized by congenital non-progressive ophthalmoplegia caused by dysinervation of the cranial nerves with or without ptosis. As a main sign of a CFEOM, extraocular muscles get shrunken and fibrotic, which makes surgery more technically demanding and the result more unpredictable, which makes the treatment challenging and highly customized. Our paper presents variations of the clinical picture and treatment cases of CFEOM1. Objective: To outline the importance of the clinical examination with the exact measurement of deviations for the patients with ocular fibrosis and passive duction test under general anesthesia, establishing them as the main criteria for treatment. Methods: We treated seven patients (14 eyes) with CFEOM1. The decision of the treatment was based on the measurement of the eye position in the primary position (PP), the severity of compensatory head position (CHP), restriction of motility, and passive motility test performed before surgery in general anesthesia. In 3 cases, patients were treated conservatively with the treatment of refractive error and amblyopia. However, in 4 patients, CHP and position of the eyes in PP were not acceptable, motility was severely impaired, and patients underwent surgery. The first surgery was performed on eye muscles: recession of inferior rectus muscle (IRM), anteposition, and resection of superior rectus muscle (SRM). As a second step procedure, ptosis surgery was performed. When the muscle was too tight, and it wasn't possible to have a satisfying result with conventional surgery, we used a tissue expander to improve the position and motility of the affected eyes. Results: In all operated cases, CHP has significantly improved and the position of the eyes in PP. Conclusion: Exact eye and head position measurements and a passive motility test during general anesthesia should guide the surgery. In the case when conventional surgery is not possible, implantation of a bovine pericard is a safe and effective method.

Pachymetry and Elevation Back Map Changes in Keratoconus Patients After Crosslinking Procedure.

INTRODUCTION: The crosslinking (CXL) procedure using the standard Dresden protocol is established as the gold standard for the treatment of progressive keratoconus. AIM: The aim of this paper is to correlate the pachymetry and elevation back map (EBM) changes in the period from 3 to12 months of keratoconus patients after the CXL procedure. M. METHODS: Forty-four eyes of 34 patients with keratoconus were analyzed after performed standard Dresden protocol CXL procedure. All of them underwent complete preoperative examination with a follow up of 12 months with a focus on pachymetry and EBM changes performed by Oculus Pentacam (Scheimpflug technology) analysis. RESULTS: Pachymetry changed significantly in 12 months post cross-linking, especially in the first 6 months after which it slightly increased. Differences in EBM preoperatively and 12 months postoperatively were not statistically significant. CONCLUSION: Corneal pachymetry in keratoconus patients decreases after the CXL procedure. Differences in pachymetry preoperatively and 3, 6 and 12 months postoperatively were statistically significant, but the value of corneal thickness increased from the third month to 12 months post-op. Differences in EBM preoperatively and 12 months postoperatively were not still statistically significant, which is good, because the increase in elevation, as one of the signs of progression of the keratoconus - did not occur.

Incidence of Keratoconus in Refractive Surgery Population of Vojvodina - Single Center Study.

INTRODUCTION: Keratoconus (KCN) is known to affect all ethnicities but its incidence exhibits geographical variability plausibly due to subclinical forms of the disease, differences in diagnostic methods and criteria, or differences in genetic variations in populations. AIM: To examine the prevalence of keratoconus among the refractive surgery population of Vojvodina, who underwent refractive surgery screening at Eye Clinic Svjetlost Novi Sad, Serbia from September 2018 to September 2019. This is a single-center study. METHODS: Retrospective analysis of 876 patients who presented for refractive surgery evaluation. Corneal tomographers represent the gold standard in the detection and classification of corneal ectatic diseases and screening is an essential part of the preoperative diagnostics before any refractive surgery. The corneal tomographer used in this study was a Scheimpflug imaging device (Pentacam AXL, Oculus Optikgeräte GmbH, Wetzlar, Germany). The device was realigned before each measurement. RESULTS: Out of a total number of patients, 619 (70,7%) were candidates for corneal refractive surgery procedure, and 257 patients (29.3%) were not. Out of 257 patients that were not candidates for the procedure 157 (61,0%) patients had thin corneas, high myopia/hypermetropia or had some retinal disease; 75 patients (29,1) were keratoconus suspect and 25 patients (9,7%) had keratoconus. KCN patients had a mean age of 29.5 ± 7.7 years, 18 patients (72.0%) were male and 7 patients were female (28%). CONCLUSION: The most cited annual incidence of KCN is 2 approximately 1 per 2,000. Recent data from the biggest Netherland study revealed many different epidemiological results which deprive keratoconus of the community of rare diseases. The incidence of keratoconus in Vojvodina refractive surgery population presented in our Clinic was 2.9%.

Marcus Gunn Jaw-Winking Syndrome: a Case Report.

INTRODUCTION: Marcus Gunn syndrome is a rare phenomenon with very less number of cases reported in literature. It may be congenital or acquired. AIM: The aim of this case report was to report the clinical characteristics of Marcus Gunn patient from our Clinic. CASE REPORT: A comprehensive opthalmologic examination, CDVA (corrected distance visual acuity), fundus examination and photography, was conducted in Marcus Gunn patient. Clinical findings of patient presented as - chin positioned slightly upwards, extraocular motility normal on both eyes, cover test with normal findings, pupillary examination normal on both eyes. Left upper eyelid was in a lower position than the right one. On right eye, rima interpalpebrarum was 9 mm with upgaze of 13mm. On the left eye, rima interpalpebrarum was 5 mm with upgaze of 6 mm, and with open mouth, left rima interpalpebrarum was 10 mm. Visual acuity on both eyes was 1.0. Cycloplegic refraction on both eyes was +0,75 diopters (D), and Lang test was normal. In the differential diagnosis of patients with ptosis, Marcus Gunn jaw winking syndrome should be considered especially if it improves during feeding, sucking, chewing, smiling or any kind of mouth movement. In case of ptosis always do the jaw test. Have the infant bottle-feed. An older child can chew gum. Have the patient open the mouth, move the jaw from side to side, or protrude the jaw forward. CONCLUSION: Address first to treatment of any amblyopia if present - eyeglasses, patching etc., or strabismus. Think twice before deciding to operate.

Treatment of High Astigmatism with WaveLight Allegretto Eye-Q Excimer Laser Platform.

INTRODUCTION: The WaveLight Allegretto Eye-Q is a flying-spot excimer laser, with a pulse repetition rate of 400Hz, with two galvanometric scanners for positioning laser pulses. The system has an infrared high speed camera operating at 400Hz to track the patient's eye movements that either compensates for changes in eye position or interrupts the treatment if the eye moves outside a preset predetermined range. AIM: The purpose of this study was to investigate WaveLight Allegretto Eye-Q 400Hz laser delivery platform aimed to correct astigmatism by subjecting the pre and postoperative astigmatic values to vector analysis. METHODS: Patients were divided into two groups, depending on the type of astigmatism. Astigmatism was between 2 and 7 diopters (D). A total of 188 eyes (110 patients), 127 eyes (71 patients) with myopic astigmatism and 61 eyes (39 patients) with mixed astigmatism underwent unremarkable LASIK correction on WaveLight Allegretto Eye-Q 400Hz. The preoperative and postoperative sphere, negative cylinder [C] and axis (ø) of manifest refractions were subjected to vector analysis by calculations of the standard J0 (cos [4π(ø-90)/360]xC/2) and J45 (sin[4π(ø-90)/ 360]xC/2). RESULTS: Reporting the key results, we found that J0 significantly reduced after LASIK (p<0.001) but not J45. There was no significant association between individual pairs of pre and postoperative J0 &J45 values. CONCLUSION: WaveLight Allegretto 400Hz showed excellent results for treating patients with high astigmatism, regardless whether it is mixed or myopic astigmatism. The J45 did not reduce significantly possibly because of the low number of eyes with oblique astigmatism. There was no genuine difference postoperatively between groups treated on WaveLight Allegretto platform according to the vector analyses.

Lasik as a Solution for High Hypermetropia.

AIM: To evaluate safety and efficacy of Laser in situ Keratomileusis (LASIK) procedure for the correction of high hypermetropia. METHODS: Retrospective study of 160 patients (266 eyes) who underwent LASIK procedure for the correction of hypermetropia between +3.00 and +7.00 diopters(D) and cylinder up to 2.00D from January 2013 and August 2015. All ablations were performed with Wavelight Allegretto Eye-Q400Hzexcimer laser (Alcon, Forth Worth, TX, USA) with aberration free module and were centered on a corneal vertex. All flaps were made with Moria M2 (Moria, Antony, France) mechanical microkeratome (90µm head). Preoperative and postoperative uncorrected and corrected distant visual acuity (UDVA, CDVA), spherical equivalent (SE) and a berrometry for 5mm pupil were measured. Measurements were taken at 1 week, 1,3,6 and 12 months after the surgery. Wilcoxon Signed Ranks Test was used for statistical analysis. RESULTS: Postoperative UDVA was lower than preoperative CDVA at 1 week(p=0.001), at 1 month there was no difference (p=0.099), and at 3,6 and 12 months UDVA was better (p<0.0001). Preoperative SE was 4.69±1.20D (+3.75 to +7.50D). At 1 week SE was 0.03±0.67D (-0.50 to +0.63D), while at 1 year regressed to 0.58±0.56D (+0.25 to +0.88D). Sphere shifted from negative values targeted in treatment planning to compensate for regression to positive values. There was significant difference in SE at every time point (p<0.0005). There was a significant increase in coma (p<0.0001), trefoil (p<0.0001, p=0.0006) and spherical aberration (p=0.022, p=0.0052) at 1 week and 1 month postoperatively, without change throughout the rest of follow up. CONCLUSION: LASIK for high hypermetropia showed satisfactory results in postoperative refraction with reasonable regression without significant loss of lines of visual acuity. However, more test are necessary to asses optical quality.

A Case Study of Choroideremia and Choroideremia Carrier.

AIM: The aim of this case report was to report the clinical and genetic characteristics of choroideremia patient and a family member carrier. CASE REPORT: A comprehensive ophthalmologic examination, BCVA (best corrected visual acuity), fundus examination and photography, optical coherence tomography (OCT), OCT-angiography (OCTA), perimetry was conducted in choroideremia patient and a family member carrier. Clinical findings of choroidermia patient presented as significant atrophy of the choroid and retinal pigment epithelium (RPE) with the exception of a portion of preserved tissue in the macula. OCT showed foveal thickening with parafovoal RPE and fotoreceptor (FR) atrophy. OCTA revealed loss of choriocapillaris vasculature. Clinical diagnosis of CHM mutation was confirmed by multiplex ligation-dependent probe amplification assay (MLPA), followed by sequencing which revealed pathogen variance (c.1584_1587delTGTT). Clinical findings of carrier: small peripheral zones of atrophy and hyper pigmentation, without any symptoms or major visible changes on OCT or OCTA. CONCLUSION: Following new frontiers in gene therapy it is of curtail importance to diagnose patients correctly as well as confirm clinical diagnosis by genetic testing.

Excimer Lasers in Refractive Surgery.

INTRODUCTION: In the field of ophthalmology, laser technology is used in many basic and clinical disciplines and specialities. It has played an important role in promoting the development of ophthalmology. AIM: This article is designed to review the evolution of laser technology in refractive surgeries in ophthalmology, mainly focusing on the characteristics of the excimer laser applied in corneal refractive surgery. METHODS: This article was performed based on a literature review and Internet search through scientific databases such as PubMed, Scopus, Web of Science and Google Scholar. RESULT: The literature on excimer laser technology addresses the technical and physical aspects of excimer lasers including types, characteristics and commercially available lasers on the market. CONCLUSION: The conclusion on this forum aims to help understand the benefits of excimer laser use in ophthalmology, with focus on correction of refractive errors.

Different Surgical Approaches for Treatment of Dissociated Vertical Deviation (DVD).

INTRODUCTION: DVD is a rare, poorly understood eye motility disorder of unknown etiology. In socially unacceptable deviation, surgical treatment is an option. We present patients operated with three different surgical methods. AIM: To evaluate and compare different surgical approaches for treatment of dissociated vertical deviation (DVD). METHODS: Total amount of 20 patients with DVD of ≥ 20 PD are operated with three different techniques on superior rectus (SR) muscle: Group I with preoperative angle of 20-30 PD was operated with 8 mm recession of SR, Group II with preoperative angle of ≥ 30 PD undergo 3 mm recession with posterior fixation on SR and Group III with preoperative angle of ≥ 30 PD undergo-splitting of SR muscle. Surgeries for associated horizontal deviations were performed before surgery for DVD. Follow up was three years. RESULTS: In all cases amount of DVD deviation was significantly reduced. No binocularity was gained. Although hyperdeviation of affected eye was reduced in all patients, we didn't eliminate deviation completely. Despite smaller preoperative angle, residual angle was bigger (6-12 PD) in the patients in group I where only recession of SR was performed, compared to Group II and III where postoperative angle was 4-8 PD in both groups. CONCLUSION: There are no recommended guidelines for the surgical treatment of DVD and treatment is based more on the surgeon's experience than evidence based data. In our experience recession of the SR should be method of choice in the cases of smaller deviation. SR recession combined with posterior fixation suture and Y-splitting seems to be a safe and effective method for surgical treatment of unilateral DVD with bigger deviation angles. Y splitting with less surgical complications and increasing effect with time can be a good alternative to posterior fixation surgery.

Refractive Outcomes of Posterior Chamber Phakic Intraocular Lens Implantation for Correction of Myopia and Myopic Astigmatism.

OBJECTIVES: The aim was to examine efficacy and safety after Implantable Collamer Lens (ICL) implantation for correction of myopia et myopic astigmatism. METHODS: This prospective clinical study included 28 eyes of 16 patients which underwent implantation of ICL for correction of myopia up to -18,00 diopters (D) and myopic astigmatism up to -6,00 D in the Eye Clinic Svjetlost Sarajevo, from January 2013 to January 2016. Uncorrected distance visual acuity (UDVA), spherical equivalent (SE), corrected distance visual acuity (CDVA), intraocular pressure (IOP), endothelial cell (EC) density were evaluated at one, six and twelve months. For statistical analysis SPSS for Windows and Microsoft Excel were used. RESULTS: Out of 16 patients, with mean age of 28,21 ± 4,06 years, 12 of them had binocular and 4 of them had monocular procedure. After 12 months mean UDVA was 0,76 ± 0,16 compared to UDVA 0,04 ± 0,03 preoperatively. Mean SE preoperatively was -0,21 ± 0,27 D compared to -9,52 ± 3,69 D preoperatively. At 12 months one eye (3,57%) lost 2 Snellen lines. In this study 8 eyes (28,57%) gained 1 line, 5 eyes gained (17,56%) 2 lines, and 3 eyes (10,72%) gained 3 lines. EC loss was 5,50±4.71% after 12 months. There was no significant change of IOP by the end of 12 months follow up period. One haptic crack was reported as the only intraoperative complication. Three postoperative complications were: two lens rotations and one retinal detachment. CONCLUSION: Implantation of ICL is an effective and safe method for reducing or correcting myopia and myopic astigmatism.

One Year Follow-Up After Veriflex Phakic Intraocular Lenses Implantation for Correction of Myopia.

OBJECTIVES: The aim of this study was to evaluate visual and refractive outcomes after Veriflex phakic intraocular lenses (pIOL) implantation in moderately myopic eyes as well as postoperative complications. METHODS: This prospective clinical study included 40 eyes of 26 patients which underwent implantation of Veriflex for correction of myopia from -6.00 to -14.50 diopters (D) in the Eye Clinic Svjetlost Sarajevo, from January 2011 to January 2014. Uncorrected distance visual acuity (UDVA), manifest residual spherical equivalent (MRSE), intraocular pressure (IOP), endothelial cell (EC) density were evaluated at one, three, six and 12 months. Other complications in postoperative period were evaluated. For statistical analysis SPSS for Windows and Microsoft Excel were used. RESULTS: Out of 26 patients 14 had binocular and 12 monocular procedure, with mean age of 29.8±6.5 years. After 12 months mean UDVA was 0.73±0.20. Mean MRSE was -0.39±0.31D and 90% of eyes had MRSE within ±1D. EC loss was 7.18±4.33%. There was no significant change of IOP by the end of 12 months follow up period. The only intraoperative complication was hyphema and occurred in one eye. Few postoperative complications were: subclinical inflammation in three eyes (7,5%), pigment dispersion in four eyes (10%), ovalisation of papilla in 2 eyes (5%) and decentration of pIOL in 2 eyes (5%). CONCLUSION: Implantation of iris-claw phakic lenses Veriflex for treating moderately high myopia is a procedure with good visual and refractive results and few postoperative complications.