Graft Detachment After Descemet's Stripping Automated Endothelial Keratoplasty in Bullous Keratopathy and Fuchs Dystrophy

Descemet’s stripping automated endothelial keratoplasty (DSAEK) is a surgical technique for corneal transplantation in case of corneal decompensation. One of the main complications is graft detachment (GD) recoverable with Air Re-bubbling (ARB). The aim of this retrospective, interventional case series was to identify factors related to this complication in eyes operated for bullous keratopathy (BK) and Fuchs dystrophy (FD). We considered one-hundred patients who underwent DSAEK for BK or FD between January 2016 and October 2017 at Department of Ophthalmology, Policlinico Universitario of Bari, Italy. Studied parameters included physiological and pathological anamnesis of both donors and recipients and properties of donor’s lenticules and of the recipient’s corneas. Data was analyzed using One-way ANOVA with Tukey post hoc test and Chi-square test with Odds Ratio (OR) calculation. We grouped patients according to diagnosis. GD occurred in 9 eyes affected by BK and 19 by FD (p=0.003, OR = 0.25, 95% CI, 0.098-0.62). It was recovered with ARB. In BK, ARB correlated to complicated cataract extraction (p=0.04, OR = 7.83, 95% CI, 1.28 – 47.98) and aphakia (p=0.026, OR = 54.38, 95% CI, 2.51 - 11.76). In FD, ARB was associated to donor’s death for neoplasia (p=0.06, OR= 4.04, 95% CI, 1.06 – 15.37). No other differences were found. In conclusion, we could hypothesize that in FD patients, donor’s cancer therapy may play a role on altered corneal fibroblast metabolism, activating a synergetic effect between chemotherapy and genetic alteration of FD, which may lead to an altered adhesion of donor’s lenticule on recipient's stroma. In BK patients, complicated cataract extraction and aphakic status of recipients’ eye may contribute to altered adhesion of donor’s lenticule post-DSAEK

Graft Detachment After Descemet's Stripping Automated Endothelial Keratoplasty in Bullous Keratopathy and Fuchs Dystrophy

Descemet’s stripping automated endothelial keratoplasty (DSAEK) is a surgical technique for corneal transplantation in case of corneal decompensation. One of the main complications is graft detachment (GD) recoverable with Air Re-bubbling (ARB). The aim of this retrospective, interventional case series was to identify factors related to this complication in eyes operated for bullous keratopathy (BK) and Fuchs dystrophy (FD). We considered one-hundred patients who underwent DSAEK for BK or FD between January 2016 and October 2017 at Department of Ophthalmology, Policlinico Universitario of Bari, Italy. Studied parameters included physiological and pathological anamnesis of both donors and recipients and properties of donor’s lenticules and of the recipient’s corneas. Data was analyzed using One-way ANOVA with Tukey post hoc test and Chi-square test with Odds Ratio (OR) calculation. We grouped patients according to diagnosis. GD occurred in 9 eyes affected by BK and 19 by FD (p=0.003, OR = 0.25, 95% CI, 0.098-0.62). It was recovered with ARB. In BK, ARB correlated to complicated cataract extraction (p=0.04, OR = 7.83, 95% CI, 1.28 – 47.98) and aphakia (p=0.026, OR = 54.38, 95% CI, 2.51 - 11.76). In FD, ARB was associated to donor’s death for neoplasia (p=0.06, OR= 4.04, 95% CI, 1.06 – 15.37). No other differences were found. In conclusion, we could hypothesize that in FD patients, donor’s cancer therapy may play a role on altered corneal fibroblast metabolism, activating a synergetic effect between chemotherapy and genetic alteration of FD, which may lead to an altered adhesion of donor’s lenticule on recipient's stroma. In BK patients, complicated cataract extraction and aphakic status of recipients’ eye may contribute to altered adhesion of donor’s lenticule post-DSAEK

Masquerade Syndrome of Multicentre Primary Central Nervous System Lymphoma

Purpose. In Italy we say that the most unlucky things can happen to physicians when they get sick, despite the attention of colleagues. To confirm this rumor, we report the sad story of a surgeon with bilateral vitreitis and glaucoma unresponsive to traditional therapies. Methods/Design. Case report. Results. After one year of steroidal and immunosuppressive therapy, a vitrectomy, and a trabeculectomy for unresponsive bilateral vitreitis and glaucoma, MRI showed a multicentre primary central nervous system lymphoma, which was the underlying cause of the masquerade syndrome. Conclusions. All ophthalmologists and clinicians must be aware of masquerade syndromes, in order to avoid delays in diagnosis

Topical nonsteroidal anti-inflammatory drugs as adjuvant therapy in the prevention of macular edema after cataract surgery

Purpose: The purpose of the study was to assess adjuvant treatment with topical nonsteroidal anti-inflammatory drugs (NSAIDs) (0.9 % bromfenac, 0.1 % nepafenac, 0.5 % indomethacin, or 0.1 % diclofenac) in addition to topical steroidal treatment with 0.1 % dexamethasone and 0.3 % netilmicin for prevention of cystoid macular edema (CME) after uneventful small incision cataract extraction with foldable intraocular lens (IOL) implantation. Setting: Institute of Ophthalmology, Department of Scienze Mediche di Base, Neuroscienze ed Organi di Senso, Aldo Moro University, Policlinico Consorziale di Bari, Bari, Italy. Design: A retrospective 6-month single center study. Methods: Patients were divided into groups according to treatment with topical drugs for 2 weeks, after phacoemulsification with foldable IOL implantation. CME incidence was evaluated by assessing retinal foveal thickness changes using spectral domain optical coherence tomography. All patients were treated with a fixed combination of dexamethasone and netilmicin, and some patients were additionally treated with NSAIDs (bromfenac, nepafenac, indomethacin, or diclofenac). Results: Fourteen patients were treated with bromfenac, 15 with nepafenac, 12 with indomethacin, and 14 with diclofenac; ten patients were treated with dexamethasone and netilmicin alone. At the end of the follow-up, macular thickness, evaluated at 1-week post-surgery, was reduced only in the group treated with nepafenac (−1.3 %, p = 0.048), was increased in the group treated with dexamethasone and netilmicin alone (+4.3 %, p = 0.04), and did not change in the groups treated with bromfenac (−1.1 %, p = 0.3), indomethacin (+0.1 %, p = 0.19), or diclofenac (+1.2 %, p = 0.74). There were no side effects in any group. Conclusions: Topical treatment with nepafenac, bromfenac, and indomethacin enhanced the efficacy of steroids to reduce postoperative macular edema. Diclofenac did not improve steroids efficacy

Ex-Press Mini-Implant in the Management of Ocular Hypertension Secondary to Silicone Oil Tamponed.

This study was designed to compare the success of patients with ocular hypertension, secondary to pars plana vitrectomy and silicone oil tamponade, who received an Ex-PRESS Glaucoma Filtration Device P50 (Alcon Laboratories, Inc. Fort Worth, Texas, USA) to those who had conventional trabeculectomy. The records of 10 eyes of 10 consecutive subjects who had Ex-press implants and 9 eyes of 9 consecutive controls who had trabeculectomy procedures were reviewed. Success was defined as the reduction of intraocular pressure (IOP) in patients who did not require further glaucoma surgery in the eye of note during the entire follow-up. IOP was reduced by 10.3 ± 9.7 mmHg (range -31 to 3) in the Ex-PRESS group and by 13.9 ± 11.4 mmHg (range -35 to -4) in the trabeculectomy group. The difference in the percentage of IOP reduction between the standard trabeculectomy group (42.7%) and the Ex-PRESS group (35.9%) was not statistically significant (P = 0.72). The Ex-PRESS device seems to be at least as effective as the standard trabeculectomy in lowering the IOP of patients with hypertension secondary to pars plana vitrectomy and silicone oil tamponade. Even though the data suggested that the Ex-PRESS device did not result in an overall greater reduction in IOP than trabeculectomy, this does not reach statistical significance

TREATMENT OF RECURRENT RETINAL ANGIOMATOUS PROLIFERATION WITH INTRAVITREAL TRIAMCINOLONE ACETONIDE FOLLOWED BY PHOTODYNAMIC THERAPY WITH VERTEPORFIN: A RETROSPECTIVE CASE SERIES

Objective: The aim of this study was to report the effect on tolerability of combined treatment with intravitreal triamcinolone acetonide (IVT) and photodynamic therapy (PDT) with verteporfin in patients with stage II retinal angiomatous proliferation (RAP) who had been treated previously with PDT and presented with recurrent RAP (R-RAP). Methods: This was a retrospective case series of patients with R-RAP after PDT (1–5 treatments) treated once with IVT followed 1 month later by PDT. A visual acuity test, fluorescein and indocyanine green angiography, and optical coherence tomography were performed at baseline and at 1, 3, and 6 months. Results: Five patients (4 men, 1 woman; mean [SD] age, 76.8 [3.9] years) with 6 eyes diagnosed with stage II R-RAP who had previously been treated with PDT and who received an IVT injection and PDT within 1 month were included in the study. Best corrected visual acuity (BCVA) remained stable after IVT in 5 eyes (83%) and deteriorated in 1 eye (17%). After PDT, BCVA remained stable in 2 eyes (33%) and deteriorated in 4 eyes (67%). IVT treatment combined with PDT also reduced fluorescein leakage. Median lesion size increased 24% before PDT and 61% at 6 months after PDT. One eye had intraocular hypertension at 3 months, and 1 eye developed a pigment epithelial tear after PDT. Conclusion: The results were limited by the number of eyes and relatively short follow-up, but in this study, PDT after IVT did not appear to be as effective or well tolerated in 5 patients who had already been treated with PDT and presented with R-RAP

RE-PERG, a new procedure for electrophysiologic diagnosis of glaucoma that may improve PERG specificity

Purpose: A significant variability of the second harmonic (2ndH) phase of steady-state pattern electroretinogram (SS-PERG) in intrasession retest has been recently described in glaucoma patients (GP), which has not been found in healthy subjects. To evaluate the reliability of phase variability in retest (a procedure called RE-PERG or REPERG) in the presence of cataract, which is known to affect standard PERG, we tested this procedure in GP, normal controls (NC), and cataract patients (CP). Methods: The procedure was performed on 50 GP, 35 NC, and 27 CP. All subjects were examined with RE-PERG and SS-PERG and also with spectral domain optical coherence tomography and standard automated perimetry. Standard deviation of phase and amplitude value of 2ndH were correlated by means of one-way analysis of variance and Pearson correlation, with the mean deviation and pattern standard deviation assessed by standard automated perimetry and retinal nerve fiber layer and the ganglion cell complex thickness assessed by spectral domain optical coherence tomography. Receiver operating characteristics were calculated in cohort populations with and without cataract. Results: Standard deviation of phase of 2ndH was significantly higher in GP with respect to NC (P<0.001) and CP (P<0.001), and it correlated with retinal nerve fiber layer (r=−0.5, P<0.001) and ganglion cell complex (r=−0.6, P<0.001) defects in GP. Receiver operating characteristic evaluation showed higher specificity of RE-PERG (86.4%; area under the curve 0.93) with respect to SS-PERG (54.5%; area under the curve 0.68) in CP. Conclusion: RE-PERG may improve the specificity of SS-PERG in clinical practice in the discrimination of GP

Scedosporium apiospermum contact lens-related keratitis: A rare case report and a literature review

Background: Scedosporium apiospermum (SA) is commonly present in temperate climates. It can induce cutaneous and subcutaneous tissue infections as well as disseminated infections in immunocompromised or immunocompetent hosts. The eye is rarely involved. Keratomycosis is usually caused by plant-related injuries. Here, we describe a patient with a severe and sight-threatening corneal abscess caused by SA, which was associated with contact lens wear and was successfully treated with a combination of surgical and medical therapies. Case Presentation: An otherwise healthy 22-year-old woman, with history of contact lens wearing, was referred to the Ophthalmic Department of Bari University, Bari, Italy for evaluation of a corneal abscess and hypopyon in her left eye. Intensive topical and systemic antibiotic therapy was initiated after obtaining conjunctival swabs. Within 2 days, her ophthalmic condition had worsened, and her best-corrected visual acuity (BCVA) dropped to counting fingers. She underwent penetrating keratoplasty, after which her ophthalmic condition improved. Microbiological culture, obtained from the explanted cornea, revealed SA infection. This was addressed with specific topical and systemic therapy using voriconazole. Two weeks later, the condition of her left eye was stable, with mild corneal edema and no sign of acute graft rejection. Her BCVA improved to 20/25, and all medications were discontinued, except for the steroid eye drop. The patient was scheduled for a 1-month follow-up. Conclusions: Prompt identification of the etiological agent is mandatory to perform appropriate therapy in cases of keratomycosis. Surgery to remove the infected cornea is helpful in patients with deteriorating condition, in whom the initial medical therapy has failed. Topical and systemic antimycotic therapy, based on microbiological culture, is recommended as an adjunctive therapy for the surgical management of severe corneal mycotic abscesses