Correction of High Astigmatism after Penetrating Keratoplasty with Toric Multifocal Intraocular Lens Implantation

After penetrating keratoplasty (PK), high astigmatism is often induced, being frequently about 4–6 dpt. According to the entity and typology of astigmatism, different methods of correction can be used. Selective suture removal, relaxing incisions, wedge resections, compression sutures, photorefractive keratectomy, and laser-assisted in situ keratomileusis can reduce corneal astigmatism and ametropia, but meanwhile they can cause a reduction in the corneal integrity and cause an over- or undercorrection. In case of moderate-to-high regular astigmatisms, the authors propose a toric multifocal intraocular lens (IOL) implantation to preserve the corneal integrity (especially in PK after herpetic corneal leukoma keratitis). We evaluated a 45-year-old patient who at the age of 30 was subjected to PK in his left eye due to corneal leukoma herpetic keratitis, which led to high astigmatism (7.50 dpt cyl. 5°). The patient was subjected to phacoemulsification and customized toric multifocal IOL implantation in his left eye. The correction of PK-induced residual astigmatism with a toric IOL implantation is an excellent choice but has to be evaluated in relation to patient age, corneal integrity, longevity graft, and surgical risk. It seems to be a well-tolerated therapeutic choice and with good results

Anterior 360° Synechiolysis in a Case of Late Iridocorneal Adhesions after 25-G Vitrectomy: Surgical and Physiopathogenetic Aspects

We describe the case of an 86-year-old patient, pseudophakic in both eyes and with high myopia, who had previously had a 25-G vitrectomy with 20% C3F8 used as a tamponade due to a total retinal detachment with choroidal hemorrhages and macular hole. At the postoperative 4-month follow-up, we found 360° iridocorneal synechiae with elevated intraocular pressure due to angle closure in all sectors, with an adherent retina and in the absence of choroidal hemorrhage/detachment and of corneal edema or endothelial damage. The patient was, therefore, hospitalized to receive 360° anterior synechiolysis with a single opening to the corneal limbus, like in paracentesis, with topical anesthesia. We have tried to study the possible causes of this case history. However, it should be recognized that the development of iridocorneal synechiae and the rise of intraocular pressure can be a possible complication of air/C3F8 vitrectomy, which cannot be managed with medical therapy. It will be essential to monitor the situation and to hospitalize the patient for surgical synechiolysis to restore the normal anatomy and physiology and to correct the ocular hypertension. During the vitrectomy, we will have to introduce in advance an adequate amount of viscoelastic material in the anterior chamber and to perform a preventive surgical iridectomy, even if the iridocorneal angle is open in all sectors

Use of Intravitreal Dexamethasone in a Case of Anterior Ischemic Optic Neuropathy

Nowadays there is no unique and well-established treatment for nonarteritic anterior ischemic optic neuropathy, despite being the main acute pathology that affects the optic nerve in the elderly population and often resulting in a significant loss of visual acuity. The effectiveness of oral steroids is still under debate in the international literature, although many studies show that patients treated with high doses of systemic corticosteroids have a significantly higher chance of improved visual acuity and visual fields. The authors propose an intravitreal dexamethasone injection/implant as initial and acute therapy. Compared to systemic corticosteroids, intravitreal dexamethasone has the advantage of avoiding any systemic side effects of steroids. On the other hand, a rise in intraocular pressure might occur, manageable with local antiglaucoma drugs, especially in patients at risk, and there is a risk of induced cataract. The pharmacodynamics of the intravitreal dexamethasone slow-release implant is characterized by a first step with high release concentrations and a second following phase with decreasing concentrations. Therefore, the use of emergency dexamethasone (high concentration) intravitreal injection is justified as a treatment after the first detection of an ischemic optic anterior neuropathy

Implantation of a Multifocal Toric Intraocular Lens after Radial Keratotomy and Cross-Linking with Hyperopia and Astigmatism Residues: A Case Report

Radial keratotomy is a refractive surgical technique, widely used in the 80s and early 90s to correct myopia and astigmatism, but now overcome by more recent laser techniques. Important consequences, often in patients with more than 45 years of age, are progressive hyperopic shift and/or an increase in corneal astigmatism, whose main cause seems to be an increase in the curvature radius of the central portion of the cornea. This seems to be due to radial keratotomy incisions – with the consequent need for cross-linking – intraocular pressure, and corneal biomechanical parameters. The authors propose phacoemulsification with a customized multifocal toric intraocular lens implantation to correct the induced shift and hyperopic astigmatism. A decent postoperative visual acuity was observed with good patient satisfaction. A specific protocol must be applied to optimize the correct diagnosis, presurgical evaluation and postsurgical outcomes that are to be maintained over time, without regressions