Double implantation of Xen 45 gel stent in primary open-angle glaucoma: a pilot study.

PURPOSE: To describe the outcomes of double implantation of Xen 45 Gel Stent (Xen) using an ab externo approach with closed conjunctiva. METHODS: Retrospective single-centre case series of primary open-angle glaucoma patients with at least six months of follow-up after implantation of a second Xen in the same eye via ab externo technique without conjunctival opening. RESULTS: Eight pseudophakic eyes of 8 patients were included. Intraocular pressure (IOP) dropped from 30 ± 2.6 mmHg pre-operatively to 22.4 ± 2.3 mmHg one month after the first Xen implant (mean difference: -7.6 mmHg [95% confidence interval: -9.4, -5.9 mmHg], p = 0.0092). A second Xen was then implanted to achieve the target IOP. The procedure showed no significant intraoperative or postoperative complications. The IOP dropped to 16.1 ± 2.7 mmHg six months following this second implant (mean difference: -6.3 mmHg [95% confidence interval: -7.2, -5.3 mmHg], p = 0.0183); however, 3 patients needed medical therapy to further reduce the IOP towards the target value. CONCLUSION: Sequential implantation of two Xen 45 Gel Stents using an ab externo approach with closed conjunctiva appears a promising procedure that showed a favorable safety and efficacy profile in this small case series. This pilot data might pave the way for further studies to evaluate the safety and efficacy of the procedure.

Refractive error after combined phaco-vitrectomy: A multicentric study.

PURPOSE: To study the post-operative refractive error (RE) of patients undergoing combined phaco-vitrectomy and to find out which intraocular lens (IOL)-power formula had the best refractive outcomes. METHODS: In this retrospective multicentric study we compared the preoperative expected target with the postoperative RE of patients undergoing combined phaco-vitrectomy due to vitreomacular traction, macular pucker, full thickness macular hole or lamellar macular hole. A multinomial logistic regression was performed to compare the postoperative REs and the differences between expected and postoperative REs among the SRK-T, Olsen's and Holladay-2 formulas. The correlation between the difference in REs and IOL-power was also studied. RESULTS: Sixty-seven eyes with a mean axial length of 23.73 ± 1.21 mm were included. Forty-two (63%), 14 (21%) and 11 (16%) eyes were implanted with an IOL that was calculated respectively with SRK-T, Olsen's and the Holladay-2 formula. The mean preoperative expected- and post-operative REs were -0.16 ± 0.12D and -0.48 ± 0.17, respectively (p = 0.045). SRK-T and Holladay-2 formulas led to a significant myopic shift whereas Olsen's caused a significant hyperopic error, independently from the IOL power. CONCLUSION: Independently from the IOL power, none of the analyzed formulas is precise at calculating the post-operative RE.

Influence of the COVID-19 Pandemic on Admissions for Retinal Detachment in a Tertiary Eye Emergency Department.

PURPOSE: To compare the incidence and clinical characteristics of retinal detachments (RDs) diagnosed in a tertiary eye emergency department (EED) during the COVID-19 pandemic and in the corresponding period of the previous 4 years. METHODS: EED consultations performed from February 21, 2020 (first national case of COVID-19 infection) to May 3, 2020 (end of lockdown imposed by national Government) and for the same date range of 2016-2019 (pre-COVID-19 period), and with a confirmed diagnosis of RD were collected and reviewed. The following demographical and clinical features have been analyzed: age, gender, etiology of RD, macular involvement, best corrected visual acuity (BCVA), and duration of experienced symptoms. RESULTS: Eighty-two subjects (20.5±1.0 eyes/year) were diagnosed with RD in the pre-COVID-19 period, compared to 12 patients in the COVID-19 period (-41.5%). During the pandemic, patients complained symptoms for a median of 8.5 days (IQR, 1.7-15 days) before the EED consultation, while in the pre-COVID-19 period, they declared they had been symptomatic for 2 days (IQR, 1-4 days) (p=0.037); macula-off RD raised from 56% to 75% and no one reported trauma as a triggering event. CONCLUSION: During the COVID-19 pandemic, the rate of RD diagnosed in our EED decreased significantly and patients waited longer before asking for an ophthalmologic examination. These findings are probably due to the fear of contracting the COVID-19 infection attending hospital environments. Even if emergency departments are often misused by people suffering non-urgent conditions, patients complaining of sudden visual loss, visual field defects, or phosphenes should always and promptly attend an EED visit to prevent a worse prognosis.

Double versus single suture stenting to manage hypertensive spikes after glaucoma drainage device implantation.

PURPOSE: To evaluate the safety and efficacy of double compared to single intraluminal suture stenting in reducing early postoperative hypertensive spikes (HS) and hypotony after Baerveldt glaucoma implant surgery. METHODS: For this retrospective study, we reviewed the medical charts of 60 patients (60 eyes) who underwent Baerveldt drainage device surgery between 2017 and 2019. Two groups were formed according to whether a single suture stent was placed within the tube (5-0 polypropylene, 30 eyes, group 1) or a double suture (5-0 and 6-0 polypropylene, 30 eyes, group 2). Intraocular pressure (IOP) was measured at baseline, at 6 h, and on postoperative days 1, 2, 5, 7, 14, 21, 30, 60, 90, 180. The occurrence of HS (IOP ⩾ 30 mmHg), anterior chamber reformation, decompressive paracentesis, anti-glaucoma medication, and adverse events were recorded. RESULTS: There was a greater decrease in IOP from baseline at days 1, 2, and 21 (p < 0.05) and number of HS at 6 h (p = 0.006) and postoperative day 1 (p < 0.001) in group 2. The mean number of decompressive paracentesis, anterior chamber reformation procedures, and topical anti-glaucoma medications was the same in both groups; the need for oral acetazolamide was significantly lower in group 2 at days 1, 21, and 30 (p < 0.05). CONCLUSIONS: While both stenting methods provide a gradual, controlled decrease in IOP, the double stenting technique was associated with a sooner and greater postoperative reduction in IOP and a good safety profile thanks to fewer HS in the early postoperative period and less need for oral acetazolamide.

Role of cysteine in corneal wound healing after photorefractive keratectomy.

AIMS: To evaluate the efficacy of cysteine oral supplements in corneal wound healing after photorefractive keratectomy (PRK). METHODS: A total of 200 eyes (100 patients) underwent PRK. We divided patients into 2 groups; each group was composed of 50 patients (100 eyes). Group 1 patients were assigned to use oral L-cysteine, with a daily dose of 200 mg (100-mg pills to be taken twice a day) for a duration of 14 days, starting from the week preceding the operation; the patients in group 2 were used as a control, and received the oral supplementation of 40-mg placebo pills to be taken twice a day for a duration of 14 days, starting from the week preceding the operation. RESULTS: All the eyes of patients treated with cysteine oral supplements showed shorter times to re-epithelization than the eyes of the control group. The mean time of corneal wound healing observed in group 1 was 102 +/- 15 h, compared to an average of 159 +/- 9 h in group 2. CONCLUSION: Our research showed that oral cysteine supplementation, in a daily dose of 200 mg, reduces mean corneal wound healing time in patients after PRK.

Effect of basic fibroblast growth factor in transgenic mice: corneal epithelial healing process after excimer laser photoablation.

PURPOSE: To evaluate the role of preparedbasic fibroblast growth factor (bFGF) eyedrops in corneal epithelial healing of transgenic mice after excimer laser photoablation. MATERIALS AND METHODS: In our prospective case series, 60 eyes of 30 mice had uneventful bilateral excimer laser photoablation. In each mouse, 1 eye received the standard topical postoperative therapy with tobramicin, diclofenac and dexamethasone eyedrops, plusbFGF eyedrops 5 microg/10 microl PBS 3 times a day for 1 week, or until corneal reepithelialization was complete. The fellow eye served as the control and received the standard postoperative therapy plus placebo. The mice were monitored daily, commencing the day after surgery and for 7 days, in order to evaluate the corneal reepithelialization rate by using a video slitlamp camera with a cobalt blue light. The mean diameter of the corneal wounds was measured. Videotaped images were recorded and analyzed by computer planimetry. RESULTS: All the eyes treated withbFGF eyedrops healed completely before day 5 after surgery, with a mean reepithelialization time of 90 +/- 12 h (standard deviation); the mean reepithelialization time was 124 +/- 10 h in those eyes receiving placebo. There were no statistically significant differences between the 2 groups in corneal haze presentation during the follow-up, perhaps because the time period was too brief (7 days). However, corneal clarity on slitlamp biomicroscopy was greater in the study group than in the control group. No side effects or toxic effects were documented. CONCLUSIONS: These data suggest that the bFGF significantly accelerates epithelial healing after excimer photoablation. A further clinical study should be performed to prove the results obtained in this study as well as the long-term efficacy of bFGF to prevent corneal haze.

Hess area ratio and diplopia: evaluation of 30 patients undergoing surgical repair for orbital blow-out fracture.

PURPOSE: To determine if the Hess area ratio is effective in predicting postoperative diplopia in patients undergoing surgery for orbital blow-out fracture. METHODS: Our retrospective, interventional case series study involved 30 consecutive cases affected by orbital fractures and diplopia undergoing surgical correction within 7 days after injury. To evaluate ocular motility disturbance, we measured the involved ocular motility range by use of a manual Hess screen test before and 4 months after surgery. The percentage of Hess area ratio % was used to express the range of ocular motility in a numerical value. RESULTS: All patients with preoperative Hess area ratio >85% had no postoperative diplopia, and most patients (57%) having a preoperative Hess area ratio <65% had postoperative diplopia. When the Hess area ratio was between 65% and 85%, surgical outcomes were variable and most patients (55%) described no problematic diplopia in the peripheral visual field. CONCLUSIONS: The Hess area ratio is a useful procedure to convert Hess graphic representation in a numerical value so that Hess chart data can be compared among clinicians and used to predict surgical outcomes in patients undergoing surgery for orbital blow-out fractures.

Comparison of dynamic contour tonometry and goldmann applanation tonometry in deep lamellar and penetrating keratoplasties.

PURPOSE: To compare the measurements of intraocular pressure (IOP) with dynamic contour tonometry (DCT) and Goldmann applanation tonometry (GAT) in eyes with corneal graft and to evaluate the influence of corneal thickness (CCT), corneal curvature (CC), and astigmatism on these methods. DESIGN: Prospective, observational cross-sectional study. METHODS: Eighteen eyes of 18 patients after penetrating keratoplasty (PKP) and 14 eyes of 14 patients after deep lamellar keratoplasty (DLKP) underwent IOP evaluation with DCT and GAT, and measurements of CCT, CC, and astigmatism. Bland-Altman plots were used to evaluate the agreement between tonometers. Multivariate regression analysis was used to evaluate the influence of ocular structural factors and running suture on IOP measurements obtained with both tonometers. RESULTS: IOP values obtained by DCT and GAT were strongly correlated in all eyes (r = .91; P < .001). DCT values measured 2.5 +/- 1.7 mm Hg higher than GAT readings (P < .001). A reduction of the mean IOP difference between DCT and GAT with an increase in IOP values (P < .001) was found. Regression analysis showed no effect of CCT, CC, astigmatism, and running suture on both DCT and GAT readings, either in DLKP or in PKP eyes. CONCLUSIONS: We found a good overall correlation between both tonometers but the agreement between instruments differs in high or low IOP ranges. The wide and varying 95% limits of agreement between DCT and GAT indicates that DCT provides IOP measurements on deep lamellar and penetrating keratoplasties which can be used in the clinical practice.

Simultaneous bilateral acute angle-closure glaucoma in a patient with subarachnoid hemorrhage.

PURPOSE: To present an unusual case of simultaneous bilateral acute angle-closure (AAC) glaucoma in a patient with subarachnoid hemorrhage due to an aneurysm involving the right middle cerebral artery. METHODS: A 60-year-old woman with a clinically inexplicable bilateral nonreacting mydriasis after brain surgery underwent an ophthalmologic consultancy. The bilateral mydriasis was diagnosed as an unusual clinical presentation of simultaneous bilateral AAC glaucoma. One week after the AAC was bilaterally resolved, the patient underwent echographic examination because of the outbreak of a unilateral relapsed ocular hypertensive attack that required an ultrasound biomicroscopy (UBM) to be accurately diagnosed and treated. RESULTS: The bilateral AAC regressed completely after pharmacologic therapy. UBM evaluation of the eye with recurrence of the angle-closure glaucoma attack was necessary to confirm the diagnosis of unilateral relapsed angle-closure glaucoma due to an unresolved pupillary block. A viscoelastic-aided opening of the angle and peripheral surgical iridectomy were performed. UBM and tonometry were performed intraoperatively to confirm the success of the surgical treatment. CONCLUSIONS: The UBM allowed us to identify the pupillary block as the main mechanism involved in the pathogenesis of this unusual case of simultaneous bilateral AAC glaucoma. Despite the fact that drug-induced supraciliary uveal effusion and mydriasis due to surgical anesthesia have been frequently reported to contribute to this complication, we presumed that simultaneous intravenous administration of sedative drugs and adrenergic agonists, in a patient with individual biometric predisposing factors to the angle-closure, created the anatomic conditions which induced the pupillary block with obliteration of the trabeculum.

Choosing wisely and the use of antibiotics in ophthalmic surgery: There is more than meets the eye.

BACKGROUND:: One of the directions of modern ophthalmology is toward an odontoiatric model, and new settings of eye care are becoming the standard of care: one day surgery and also office-based therapies. METHODS:: Retrospective analysis of three tertiary-care centers in Italy and analysis of the literature. RESULTS:: We provide readers with state-of-the-art measures of prophylaxis in ophthalmic surgery. DISCUSSION AND CONCLUSION:: Role of antibiotics is criticized in the light of stewardship antimicrobial paradigm.

Management of Concomitant Cataract and Glaucoma.

The coexistence of cataract and glaucoma represents a challenge for the ophthalmologist and the issue is still open to debate. The surgical management is based on both the visual field defect and the loss of visual acuity. The surgical options currently available are: (1) cataract extraction alone, (2) sequential glaucoma surgery and cataract extraction, and (3) combined surgery by 1 site or by 2 separate sites. Phacoemulsification alone is suggested when glaucoma can be controlled by medication and the visual field defect is moderate and nonprogressive. In case of a refractory glaucoma (3 or more types of medication required) with associated early-stage cataract, phacoemulsification could be postponed until after glaucoma surgery. The cataractogenous effect of the procedure should be considered in this situation. Moreover, cataract extraction performed after a filtering surgery may lead to a reduction of the bleb function. When both glaucoma and cataract are sight impairing, combined surgery is indicated since it allows a greater intraocular pressure decrease than phacoemulsification alone.

Long-term Outcomes of a Modified Technique Using the Baerveldt Glaucoma Implant for the Treatment of Refractory Glaucoma.

PURPOSE OF THE STUDY: The purpose of the study was to evaluate the long-term effectiveness and safety profile of Baerveldt glaucoma implant (BGI) in patients with refractory glaucoma operated using a modified technique to avoid postoperative complications. PATIENTS AND METHODS: A total of 160 eyes from 147 glaucomatous patients were enrolled in a consecutive interventional noncomparative case series. All the patients were treated with a 350-mm BGI using a modified technique. Intraocular pressure (IOP), the number of medications, the complications, and the postoperative interventions were reported preoperatively and during the follow-up. Postoperative IOP and the rate of complications were the primary outcome measures. The complete and qualified surgical success was the second endpoint. RESULTS: BGI obtained a mean IOP reduction from 31.8±6.4 mm Hg (baseline) to 14.4±3.5 mm Hg after a mean follow-up period of 38.4±9.6 months. The mean number of medications reduced between preoperative (n=3.17±1.03) and postoperative period (n=0.58±0.83) (P<0.0001). Cumulative probability of maintaining an IOP between 5 and 21 mm Hg and/or a 25% or greater reduction in IOP was 78.7% at 1 year and 72.1% at 4 years, including 39 eyes (24.4%) in which postoperative interventions were required (qualified success). If we exclude those eyes from the analysis, the probability of complete success was 93.4% at 1 year and 91.4% at 4 years in 75.4% of the eyes. CONCLUSIONS: This modified technique achieved a high percentage of surgical success during the whole follow-up time and was effective in preventing the most serious immediate complications of nonvalved tube shunts.

Adherence to European Society for Cataract and Refractive Surgery recommendations among Italian cataract surgeons: a survey.

PURPOSE: To survey the surgical routines with regards to prophylactic strategies in a sample of Italian hospitals and compare these with European Society for Cataract and Refractive Surgery (ESCRS) guidelines. METHODS: Six private and 18 public hospitals were included in this clinical-based retrospective study. The overall volume of cataract operations in the 24 centers in 2013 was 43,553. Main outcome measure was incidence of endophthalmitis per 1,000. An incidence of less than 0.13% was considered acceptable. RESULTS: Our study provides the first Italian data on the use of intracameral antibiotics in cataract surgery as recommended by the ESCRS. Thirteen centers (54%) used intracameral cefuroxime at the end of surgery. Of the 13 centers that used cefuroxime, 8 (62%) had an incidence of endophthalmitis less than 0.13%. Of the 7 (29%) centers that did not use intracameral cefuroxime, all had an endophthalmitis rate of greater than 0.13%. This difference was statistically significant (p<0.05). Among the 4 centers not included, 2 used vancomycin in the infusion bottle, 1 a fluoroquinolone, and the last a combination of antibiotics. The majority of surgeons (71%) used preoperative antibiotic eyedrops, but this measure was not shown to be significantly protective. CONCLUSIONS: Slightly more than half of the centers surveyed in this study adhered to the recommendations of the ESCRS and routinely employed prophylactic intracameral cefuroxime. An incidence of endophthalmitis greater than 0.13% was encountered significantly more frequently among centers that did not employ intracameral cefuroxime.

Management of concomitant cataract and glaucoma.

The coexistence and management of cataract and glaucoma represents a challenging and unsolved problem. The surgical management of this problem is based on both visual field defect and loss of visual acuity. The surgical options currently available are: (1) cataract extraction alone; (2) cataract extraction followed by glaucoma surgery; (3) glaucoma surgery and afterwards, if necessary, cataract extraction; (4) combined surgery of cataract and glaucoma by one site or by two separate sites. Phacoemulsification alone is suggested when glaucoma can be sufficiently controlled by medication and visual field defect is moderate and not progressive. When glaucoma needs three or more types of medication to reduce intraocular pressure (IOP) or when the offset is unpredictable, phacoemulsification associated with glaucoma surgery at two different times allows a higher IOP reduction than that with a cataract extraction alone. Finally, when glaucoma is prevailing and the surgeon fears that an IOP spike after phacoemulsification may cause significant damage to the optic nerve, combined surgery allows to achieve a greater IOP decrease than phacoemulsification alone and a more predictable low-IOP range in the immediate postoperative period.