A case of bilateral pseudophakic malignant glaucoma treated with a new variant of irido-zonulo-hyaloid-vitrectomy

Purpose: To describe a case of bilateral pseudophakic malignant glaucoma treated with a new variant of irido-zonulo-hyaloid-vitrectomy. Observations: A patient who developed refractory bilateral pseudophakic malignant glaucoma underwent an irido-zonulo-hyaloid-vitrectomy via the anterior chamber in both eyes, one 2-months apart from the other. The procedure involved the use of an 18 Gauge needle to perform a straight vertical irido-zonulo-hyaloidotomy and a 25 Gauge vitreous cutter to complete the vitrectomy. The intraocular pressure was recorded on day 1, day 7, day 14, then monthly until 6 months postoperatively, whereas an ultrasound biomicroscopy of the anterior chamber was performed on day 1 and 6 months after the operation. The malignant glaucoma resolved in both eyes with no intra- nor post-operative complications. At 6 months from the surgeries none of the eyes developed recurrences. Conclusions: The new variant of irido-zonulo-hyaloid-vitrectomy we propose for the management of refractory pseudophakic malignant glaucoma resulted to be a safe and effective technique

Comparative Study of the Effects of 2% Ibopamine, 10% Phenylephrine, and 1% Tropicamide on the Anterior Segment

PURPOSE To assess in normal and glaucomatous eyes the effect of the dopaminergic drug 2% ibopamine on visual acuity, IOP, pupil size and anterior segment geometry, compared with 10% phenylephrine and 1% tropicamide. METHODS Fifteen healthy subjects and 15 patients with primary open-angle glaucoma, aged from 40 to 70 years (mean age: 54.8 +/- 9.6), were recruited into this open prospective study. After instillation of 2% ibopamine, refraction, visual acuity, pupil diameter, IOP, five A-scan ultrasonographic parameters, and 15 ultrasound biomicroscopy parameters were evaluated. The study was repeated with assessment of the same parameters 20 to 30 days later in 10 subjects (5 normal and 5 with glaucoma), using first 10% phenylephrine and then 1% tropicamide. A second group of 15 healthy subjects, aged from 45 to 70 years (mean age: 53.5 +/- 8.6) was examined to evaluate the dose-response effect and time course on pupil diameter, of ibopamine, phenylephrine, and tropicamide. RESULTS After 40 minutes 2% ibopamine induced a marked mydriatic effect (from 5 to 9.1 mm; P < 0.0001) greater than that produced by 10% phenylephrine (from 4.7 to 7.9 mm; P < 0.0001) or 1% tropicamide (from 4.6 to 6.9 mm; P < 0.0001), with no changes in refraction or visual acuity. IOP was significantly increased only in patients with glaucoma after instillation of either 2% ibopamine (from 22.2 to 24.8 mm Hg; P < 0.0001) or 1% tropicamide (from 21.2 to 23.6 mm Hg; P = 0.004), whereas 10% phenylephrine induced no statistically significant changes. Ibopamine (2%) caused a significant increase in iris thickness with a reduction of the sulcus ciliaris and posterior chamber depth. The anterior chamber angle (ACA) showed a mean 5 degrees widening with an increase in scleral-iris angle (SIA) and sclera-ciliary process angle. In 11 (37%) of 30 cases, separation of the pupil border and lens surface occurred, whereas contact was maintained only with the zonule in the other 19 (63%) of 30. The changes after 10% phenylephrine instillation were similar, although only the increase in iris thickness and SIA was statistically significant. Tropicamide (1%) induced a slight but significant increase in SIA. CONCLUSIONS The results confirm the potent mydriatic effect of 2% ibopamine, which is greater than that of either 10% phenylephrine or 1% tropicamide, as well as its ability to induce an increase in intraocular pressure when used in patients with glaucoma alone. These data support the hypothesis that the widening of the ACA induced by 2% ibopamine is due to posterior rotation of the iris plane and ciliary processes. These changes are quantitatively greater than those induced by 10% phenylephrine and 1% tropicamide and are related to the greater mydriatic effect of the drug

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\ub11.0 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

Short-term use of dexamethasone/netilmicin fixed combination in controlling ocular inflammation after uncomplicated cataract surgery

Purpose: To evaluate the short-term anti-inflammatory effect of dexamethasone/netilmicin fixed combination in the management of ocular inflammation after cataract surgery. Patients and methods: Open-label, randomized, active-controlled, clinical study conducted in 6 sites in Italy; 238 patients were randomized 2:1 to dexamethasone/netilmicin (dexa/net, n=158) or betamethasone/chloramphenicol (beta/chl, n=80). Treatment started the day of surgery and continued 4 times daily for 7 days. The primary efficacy parameter was the anterior chamber (AC) flare. The percentage of patients displaying none or mild (ie, only barely detectable) AC flare was defined as "efficacy rate", whereas the percentage of patients showing a decrease of AC flare score from baseline was defined as "percentage of responders". Additional parameters evaluated were AC cells, conjunctival hyperaemia, corneal and lid oedema, symptoms of ocular discomfort, visual acuity, and intraocular pressure. Dexa/net was considered effective if the efficacy rate was not inferior (by means of 97.5% confidence interval) to that of beta/chl. Results: After 7 days of treatment, no AC flare was observed in 92.8% (dexa/net) and 92.3% (beta/chl) of patients, whereas no AC cells were observed in 91.5% (dexa/net) and 93.6% (beta/chl) of patients, respectively. The "efficacy rate" was 100% in both groups, whereas the "percentage of responders" was 94.1% in the dexa/net and 93.6% in the beta/chl group. The p-value to reject the null hypothesis of inferiority was &lt;0.001. Other efficacy parameters confirmed both treatments as highly effective, despite their difference in steroid content (2 mg/mL for beta/chl vs 1 mg/mL for dexa/net). IOP and visual acuity at the end of the study were comparable. Two cases of allergic conjunctivitis were considered adverse events and were both related to dexa/net. Conclusion: Short-term use of dexa/net fixed combination is safe and effective in the control of post-operative inflammation following uncomplicated cataract surgery

Glaucoma surgery during the first year of the COVID-19 pandemic

Purpose: To summarize the actions taken to give continuity to the surgical treatment of glaucoma patients and to present the volume and characteristics of glaucoma surgery in the first year of pandemic at the Tertiary Glaucoma Center of the University Hospital of Verona (Veneto, Italy). Methods: Demographical and surgical features of patients who underwent glaucoma surgery from March 9th, 2020 to March 8th, 2021 have been collected and compared to the same date range of the previous year. The analyzed data included age, gender, region of origin, glaucoma staging, type of anesthesia and surgical procedure. Results: The surgical volume of glaucoma has dropped by 30.1%. In comparison with the previous year, we found a significant variation in the overall distribution of the performed surgical procedures (p &lt; 0.001). There was a decline in Baerveldt tube implants&nbsp;(- 4.9%), and an increase of non-penetrating surgery (+ 2.6%), cyclo-photo ablative procedures (+ 4.2%) and MIGS (+ 5.7%). Only 24.3% of the procedures were performed under general anesthesia compared to 41.5% in the pre-pandemic period (p &lt; 0.001). The number of procedures performed on eyes affected by advanced or end-stage glaucoma is doubled (p &lt; 0.001). Conclusions: To give continuity to glaucoma surgery, we prioritized interventions on patients with poorer visual fields, rapidly progressing visual field deficit and elevated IOP uncontrolled by maximal medical therapy. Secondly, we have rescheduled the other interventions following the same priority criteria. Finally, we managed some lower priority cases with MIGS, minimizing the need for close post-intervention follow-up. Considering the negative consequences that a delay in the management of glaucoma can have in terms of visual loss, the closure of the operating rooms in the first quarter of the pandemic was detrimental. It appears that glaucoma surgery deserves urgencies that cannot be overshadowed and the greatest effort must be to give continuity to this type of eye surgery

Cytidine 5'-Diphosphocholine (Citicoline): Evidence for a Neuroprotective Role in Glaucoma

Glaucoma, a heterogeneous set of progressively degenerative optic neuropathies characterized by a loss of retinal ganglion cells (RGCs) and typical visual field deficits that can progress to blindness, is a neurodegenerative disease involving both ocular and visual brain structures. Although elevated intraocular pressure (IOP) remains the most important modifiable risk factor of primary open-angle glaucoma (POAG) and is the main therapeutic target in treating glaucoma, other factors that influence the disease course are involved and reaching the optimal IOP target does not stop the progression of glaucoma, as the visual field continues to narrow. In addition to a managed IOP, neuroprotection may be beneficial by slowing the progression of glaucoma and improving the visual defects. Citicoline (cytidine 5'-diphosphocholine) is a naturally occurring endogenous compound that has been investigated as a novel therapeutic agent for the management of glaucoma. Citicoline has demonstrated activity in a range of central neurodegenerative diseases, and experimental evidence suggests a it performs a neuromodulator and neuroprotective role on neuronal cells, including RGCs, associated with improvement in visual function, extension of the visual field and central benefits for the patient. This review aims to critically summarize the current evidence for the neuroprotective properties of citicoline in glaucoma

Optic Nerve Degeneration and Reduced Contrast Sensitivity Due to Folic Acid Deficiency: A Behavioral and Electrophysiological Study in Rhesus Monkeys

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Impact of the COVID-19 pandemic on ophthalmologic outpatient care: experience from an Italian Tertiary Medical Center

Purpose: To evaluate the impact the COVID-19-related national lockdown has had on Ophthalmologic Outpatient Care in an Italian Tertiary Medical Centre. Methods: We reviewed all the performances that were carried out as outpatient services at our department between 1 January 2020 and 30 November 2020. We compared data among four different periods: from 1 January 2020 to 17 March 2020 ("Pre-Lockdown"); from 18 March 2020 to 17 May 2020 (Lockdown); from 18 May 2020 to 2 November 2020 (Post-Lockdown) and from 3 November 2020 to 30 November 2020 (Regional Lockdown). Results: The overall number of performed routine outpatient visits per day (ROVs) was 11,871 (Mean \ub1 SD = 35.76 \ub1 17.81), whereas booked appointments (BAs) were 21272 (Mean \ub1 SD = 63.86 \ub1 9.27), meaning a decline in the number of ROVs by 44.01%. (Mean \ub1 SD = 28.10 \ub1 12.11, p&lt;.001). Post-Lockdown and Regional Lockdown clinical activities, dropped respectively by 31 and 25.14% (38.87 \ub1 3.88 vs. 56.34 \ub1 11.06, p&lt;.001 and 6.04 \ub1 4.51 vs. 56.34 \ub1 11.06 p&lt;.001). The number of BAs per day decreased during the pandemic, going from a mean of 77.81 \ub1 2.57 booked appointments per day before the lockdown, to a mean of 53.14 \ub1 4.94, 61.80 \ub1 4.62 and 72.07 \ub1 1.09 appointments per day respectively during the lockdown, the post-lockdown and the regional lockdown periods. Conclusions: During the various lockdown periods, at our institution the volume of outpatient ophthalmological visits drastically dropped. This testifies the dramatic impact the COVID-19 pandemic has had on the supply of ophthalmic care

Femtosecond laser-assisted implantation of corneal stroma lenticule for keratoconus

PURPOSE: To review recent progress, challenges, and future perspectives of stromal keratophakia for the treatment of advanced keratoconus. METHODS: We systematically reviewed the literature in the PubMed database, last update June 30, 2020. No language restriction was applied. The authors checked the reference lists of the retrieved articles to identify any additional study of interest.RESULTS: Several techniques have been proposed for the treatment of keratoconus in order to avoid or delay keratoplasty. This was primarily due to the lack of accessibility to donor corneas in many countries. The ease and predictability of the more advanced femtosecond lasers used to correct ametropias by stromal lenticule extraction lead to hypothesize that generated refractive lenticules could be implanted into corneal stromal layers to restore volume and alter the refractive properties of the cornea in patients with corneal ectasias. At the same time, new techniques for preservation, customization, and cellular therapy of the corneal stromal have been developed, directing to the valorization of otherwise discarded byproducts such as donor corneas unsuitable for either lamellar of penetrating keratoplasty.CONCLUSIONS: Femtosecond laser-assisted stromal keratophakia could be a suitable therapeutic option for the treatment of corneal ectasias, especially in patients with advanced keratoconus, providing biomechanical support recovering the pachimetry to nearly normal value at the same time. The accuracy and predictability of the refractive outcome are yet a critical issue and the patient eligible for the procedure still has to be characterized

Quality of vision and outcomes after bilateral implantation of pseudo-non diffracting beam IOL

Purpose: To analyze the objective and subjective visual performances of a new hybrid refractive/aspheric extended depth of focus (EDOF) intraocular lens (IOL). Methods: In this monocentric prospective study patients with bilateral cataracts underwent cataract surgery and were implanted with a Lucidis IOL (SAV-IOL SA, Neuchâtel, Switzerland) in both eyes, 1 week apart from each other. At 3 months from implantation postoperative evaluations included monocular and binocular uncorrected and distance-corrected distant (4 m), intermediate (80 cm, 67 cm) and near (40 cm) visual acuities (UDVA/DCVA, UI80-67VA/DCI80-67VA, UNVA/DCNVA), binocular defocus curves, halometry, contrast sensitivity and objective quality-of-vision measurements. Also, patients were also asked to complete the national eye institute refractive error quality of life (NEI-RQL-42) questionnaire. Results: Twenty-five patients (50 eyes) were included. The mean postoperative binocular UDVA, UI80VA, UI67VA and UNVA were-0.02 ± 0.13, 0.05 ± 0.09, 0.05 ± 0.08 and 0.03 ± 0.1 LogMar, and did not significantly differ from their corrected counterparts. On binocular defocus curves a VA ≥0.05LogMar was found between +0.50 and - 2.50 D of vergence, whereas the mean distance from the central stimulus on halometry was 1.23 ± 0.01. Mean ocular and corneal radical mean square at 4 mm were 0.31 ± 0.28 and 0.19 ± 0.07, respectively; whereas the mean Strehl ratio was 0.2 ± 0.09. Conclusion: Lucidis IOLs demonstrated excellent visual performances, especially at close distances while maintain good quality of vision, contrast sensitivity, and overall patient-satisfaction