Evaluation and treatment of vitiligo

This thesis considers several aspects of vitiligo; it investigates (i) provoking factors of vitiligo, (ii) the prevalence of thyroid disease, (iii) the efficacy and safety of autologous punch- and cell suspension grafting and (iv) measurement properties of outcome measures for vitiligo. Chapter 2.1 is a retrospective cohort study and gives insight in the patient reported provoking factors of vitiligo including contact with chemicals. In Chapter 2.2 the role of 4-TBP as provoking factor for vitiligo was analysed in a patient with chemically induced contact vitiligo. In Chapter 3.1 current evidence of the prevalence of thyroid diseases in vitiligo is summarised and critically appraised in a systematic review. We found an increased prevalence and an increased risk of (autoimmune) thyroid disease in patients with vitiligo patients compared to non-vitiligo. In Chapter 4.1 the efficacy and safety of different punch depths and punch sizes in autologous punch grafting is compared in an observer blinded randomised controlled trial. We show that 1.5 mm superficial grafts are most beneficial and could be recommended to use in autologous punch grafting in patients with stable vitiligo and piebaldism. Chapter 4.2 determines the efficacy and safety of cellsuspension grafting with a cell harvesting divice (CST-CHD) in vitiligo and piebaldism. The CST-CHD method is found to be an effective, safe and relatively simple technique for CST that allows for the complete transplantation in the operation theatre. Chapter 5 presents the results of a systematic review on outcome measures for vitiligo using the COSMIN checklist. We found that current evidence is insufficient owing to a low number of studies with a poor methodological quality and unclear clinical relevance

The effect of Nd:YAG laser capsulotomy on refraction in multifocal apodized diffractive pseudophakia.

Purpose The primary goal is to evaluate the effect of Neodymium:YAG (Nd:YAG) laser posterior capsulotomy for posterior capsule opacification (PCO) on refraction in multifocal apodized diffractive pseudophakia. The secondary goal is the evaluation of the correlation between automated and subjective refraction in this type of multifocal lenses. Setting: Combined private refractive surgery clinic, Retina Total Eye Care in Driebergen, and tertiary care ophthalmology clinic at the Academic Medical Center, University of Amsterdam, the Netherlands. Methods: This retrospective chart review comprised 75 pseudophakic eyes (55 consecutive patients) with a SN6AD1 or SN6AD3 IOL after cataract surgery or refractive lens exchange, treated for posterior capsule opacification with Nd:YAG laser posterior capsulotomy. Values of monocular uncorrected distance acuity (UCDA), monocular corrected distance acuity (CDVA), spherical equivalent (SE), defocus equivalent (DE), astigmatic power vectors J0 and J45 and overall blurring strength (B) after Nd:YAG posterior capsulotomy were compared with values of before the intervention. The amount of energy used during Nd:YAG posterior capsulotomy and the severity of PCO were evaluated to determine correlation with change in refraction. Values of autorefraction were compared with those of subjective refraction to determine the correlation between the two methods. Results: Visual acuity improved statistically significant in both UDVA and CDVA (P<0.001). There were no statistically significant changes in SE, DE, J0, J45 and B in subjective refraction (P=0.369, P=0.993, P=0.524, P=0.648 and P=0.686). SE changed statistically significant in autorefraction (P=0.008) but this change was small (mean -0.10 ± 0.27) and is clinically not relevant. No statistically significant change is observed in DE, J0, J45 and B in autorefraction (P=0.584, P=0.654, P=0.336 and P=0.338). Four eyes (7,2%) in the SE and 8 eyes (14,5%) in the DE showed a change of >0,5D in subjective refraction. Of those eyes, 3 eyes (5,5%) had a deterioration of the refractive error. The amount of energy used during Nd:YAG posterior capsulotomy shows to have a very weak (J45 rho=-0.29, P=0.033) or no effect (P>0.05 for SE, DE, J0 and B) on subsequent lens movement. The severity of PCO is not related to changes in refraction (P>0.05). Autorefraction and subjective refraction are highly correlated in SE, DE and B (r2>0.59), but are weakly correlated in J0 and J45 (r2<0.14). Conclusions: Nd:YAG laser capsulotomy in multifocal pseudophakic patients mostly results in unchanged refraction. However in ~7% of eyes a change of >0,5D in subjective refraction occurs. Autorefraction can give a good prediction of SE, DE and B in subjective refraction in eyes with apodized diffractive multifocal IOLs, but can not give a good prediction of the astigmatic power vectors.

Ablative 10,600 nm fractional laser for the treatment of scars

Background: Pathologic scars such as hypertrophic or atrophic scars can be highly disfiguring and could have major psychological impact. These scars remain a challenging problem as current available therapies often fail to improve them. Ablative fractional laser therapy (AFLT) is a new treatment modality and is expected to improve scars. The aim of this study is to assess the efficacy and safety of AFLT for the treatment of atrophic and hypertrophic scars. Methods: In a prospective single blinded randomized controlled split lesion trial twenty-one adult patients with hypertrophic or atrophic scars of 1 year or older and Fitzpatrick skin types I-IV were included. AFLT involved three sessions with an interval of 8 weeks. Blinded on-site evaluations were done at every treatment session and 2 months after the final treatment. Primary endpoints were the Physicians Global Assessment (0-3 categorical scale), the Patients Global Assessment (0-3 categorical scale) and the melanin- and erythema index. Secondary endpoints were the Clinical assessment of particular items of the scar (0-3 categorical scale) and adverse events. Results: Because of delay, the study is still running and preliminary results of one laser treatment of 15 patients were available for analysis and are presented in this paper. A significant difference of the PhGA was found between baseline and 8 weeks post treatment (p=0.025). No significant differences were found on the PGA and Clinical Assessment. Both hyperpigmented and hypopigmented scars showed an unfavorable increase of melanin index. In the intervention group the erythema index significantly increased 8 weeks post treatment (p=0.013). Adverse events reported by patients themselves showed 87% erythema, 40% burning, 40% edema, 47% vesicles, 60% crusting, 40% itching and 20% oozing. Five patients reported long lasting eythema, still present 8 weeks post treatment. The physician reported adverse events showed 31% hyperpigmentations and 46% erythema and no hypopigmenations and scar formations. Conclusion: Ablative 10,600 nm fractional laser therapy after one laser treatment is little efficacious and has a considerable risk of erythema and hyperpigmentation. However, no definitive conclusions about the efficacy of AFLT for the treatment of scars can be drawn as preliminary results of one treatment were analysed. The results after the second and third treatment are needed to draw these conclusions. In addition, AFLT is not as safe as expected as more and long term side effects were reported and objectified. Therefore, caution is urged when treating scars with AFLT. Future research of high quality is necessary to strengthen the evidence of the efficacy and safety of AFLT.