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To demonstrate efficacy and safety of an ophthalmic hydrogel formulation of netilmicin/dexamethasone, containing xanthan gum twice a day (b.i.d.) versus netilmicin/dexamethasone eye drops four times a day (q.i.d) to treat inflammation and prevention of infection after cataract surgery.Patients undergoing phacoemulsification with intraocular lens implantation (IOL) were randomised in two groups: group 1, twice daily (b.i.d.) dexamethasone 0.1%/netilmicin 0.3% (Netildex) ophthalmic gel; group 2, four times daily (q.i.d.) dexamethasone 0.1%/netilmicin 0.3% (Netildex) eye drops. Both treatments were administered for 14 days after surgery. Patients were evaluated before surgery, on the day of surgery and at 1, 7, 15 and 60 postoperative days. The primary efficacy endpoint was evaluation of cellularity and flare in the anterior chamber through slit-lamp biomicroscopy 7 days after surgery. Secondary endpoints included: presence of signs/symptoms of postoperative ocular inflammation and incidence of infection.One hundred seventy-three patients were randomised and 168 were evaluable. Flare and cellularity were resolved at day 7 in 92.5% of patients and almost completely by day 15. In both intent to treat (ITT) and per-protocol (PP) populations, the efficacy analysis demonstrated that the gel formulation administered twice a day was non-inferior to the eye drops administered four times a day. For ITT analysis, the lower limit of the 97.5% confidence interval (- 0.0535) was greater than the non-inferiority limit of -0.10. For the PP analysis, the lower limit of the 97.5% confidence interval (- 0.0526) was greater than the non-inferiority limit of - 0.10. The patient's global tolerability and reported symptoms were similar between treatment groups. No microbial load and no safety events were observed.Efficacy of the gel reduced posology (twice a day) is not inferior to four times a day eye drops. Both treatments were well tolerated and efficacious. The new reduced posology hydrogel formulation may improve patient compliance and quality of life.Eudract: 2016-0021138-63; ClinicalTrial.gov: NCT029738880.

Bei mittelschwerem bis schwerem Glaukom ist die Trabekulektomie nach wie vor der «Goldstandard» für die Senkung des Augen­innendrucks (IOP); allerdings erfordert diese Methode eine umfangreiche postoperative Behandlung. Die mikroinvasive Glaukomchirurgie (MIGS) wurde entwickelt, um den intra- und postoperativen Pflegeaufwand zu verringern und gleichzeitig eine akzeptable Senkung des Augeninnendrucks bei Patienten mit leichtem bis mittelschwerem Glaukom zu ermöglichen. Der PreserFlo® MicroShunt (früher InnFocus MicroShunt) ist ein 8,5 mm großes Glaukom-Drainagegerät, das aus Poly(styrol-block-isobutylen-block-styrol) (SIBS), einem äußerst biokompatiblen und bioinerten Material, hergestellt wird. Das Lumen ist eng genug, um eine Hypotonie zu verhindern, aber groß genug, um nicht von Zellschuppen oder Pigmenten verstopft zu werden. Das Gerät wird ab externo, als eigenständiger Eingriff oder in Verbindung mit einer Kataraktoperation, mit intraoperativem Mitomycin C implantiert und ein Sickerkissen unter der Bindehaut und der Tenon-Kapsel erzeugt. Der MicroShunt wurde 2012 mit dem CE-Zeichen versehen und für das primäre Offenwinkelglaukom entwickelt, bei dem der IOP nach maximal verträglicher topischer Behandlung unkontrolliert bleibt. Es wurden mehrere klinische Studien zur Langzeitsicherheit und -wirksamkeit des MicroShunt durchgeführt, die die Wirksamkeit des Geräts über einen längeren Zeitraum und ein erträgliches Sicherheitsprofil belegen. Ziel der vorliegenden Studie ist es, Evidenz für die Wirksamkeit und Sicherheit von PreserFlo fast 10 Jahre nach seiner Einführung zu sammeln und es mit anderen MIGS und der Trabekulektomie, dem Goldstandard in der Glaukomtherapie, zu vergleichen.

Purpose The aim of this study is to investigate changes in choroidal and optic nerve morphological parameters following MicroShunt PreserFlo implantation. The secondary aim is to investigate how the structural changes relate to the decrease in intraocular pressure (IOP). Methods Prospective observational study on 15 eyes with glaucoma requiring MicroShunt implantation. Optical coherence tomography was used to measure macular choroidal thickness (MCT), peripapillary choroidal thickness (PCT), lamina cribrosa depth (LCD), cup depth and prelaminar tissue thickness (PLT), before and one day after surgery. Results were expressed in median and interquartile range (IQR) and correlated with IOP results. Results The IOP decreased from a median of 25 (IQR = 11) mmHg to 8 (IQR = 2) mmHg the day after surgery. Median MCT increased after MicroShunt implantation from 252.1 (IQR = 156.4) µm to a postoperative value of 318.1 (IQR = 166.6) µm (p p p p = 0.028). On the other side, LCD reduction 24 h after surgery didn’t reach any statistical significance. Conclusion PreserFlo implantation determines retinal structural changes which appear similar to those caused by traditional filtering surgery, confirming the effectiveness of this device, meantime carrying a much smaller complications rate when compared to trabeculectomy.

Purpose: Intravitreal corticosteroid implants based on sustained-release dexamethasone provide effective retinal delivery of drug for around 6 months for the treatment of diabetic macular edema (DME). As current recommendations on the management of patients with DME undergoing cataract surgery are limited, this article aims to highlight issues and provide guidance on the use of dexamethasone intravitreal implants (DEX-DDS) in patients with DME undergoing cataract surgery, based on the consensus findings of a panel of Italian experts. Methods: The panel developed a survey regarding the use of DEX-DDS in patients with DME undergoing cataract surgery, following a comprehensive literature search. The results of the survey were discussed at an experts’ meeting in September 2018, with a structured approach to determining consensus. The routine management of patients with DME undergoing cataract surgery was also developed for use as a basis of discussion to highlight current issues. Results: Eight consensus statements are presented, along with key issues that highlight controversial/outstanding issues in the use of DEX-DDS in DME patients with cataracts. Conclusion: The consensus statements can help provide practical guidance for clinicians in daily practice on the rationale, patient diagnosis and selection, and optimal management of patients with DME undergoing cataract surgery.

Purpose: A prospective, open-label study in 20 professional swimmers evaluated the efficacy and safety of an ophthalmic solution containing crosslinked hyaluronic acid, coenzyme Q10, and vitamin E TPGS in releasing eye irritation and restoring ocular surface damages after prolonged exposure to chlorinated water. Methods: Individually, one eye was instilled with the ophthalmic solution and the other used as a comparator. Eye drops were self-administered three times a day for 2 months. Tear film breakup time (primary endpoint), Schirmer I test, beating of eyelashes/min, tear osmolarity, corneal and conjunctival staining with fluorescein, Ocular Surface Disease Index questionnaire, subject satisfaction, visual acuity (secondary endpoints), and Efron Grading Scale were evaluated at screening/baseline (V1), week 1 (V2), week 2 (V3), week 4 (V4), and week 8 (V5). Results: After 2 months, breakup time test significantly improved in the treated eyes (+1.67 s) compared to control (−3.00 s) ( p = 0.0002). Corneal and conjunctival surfaces of treated eyes recovered significantly compared to control eyes when assessed by fluorescein staining ( p Conclusion: The adequate combination of crosslinked hyaluronic acid, coenzyme Q10, and vitamin E TPGS, contained in the ophthalmic solution VisuXL®, has been shown to protect ocular surface from potential damages originating from prolonged exposure to chlorinated water. VisuXL may represent a compelling treatment in other situations beyond dry eye syndrome.

For moderate-to-severe glaucoma, trabeculectomy remains the "gold standard" intraocular pressure (IOP)-lowering treatment; nonetheless, this method requires extensive post-operative maintenance. Microinvasive glaucoma surgery (MIGS) treatments are designed to lessen intra- and post-operative care burden while offering an acceptable IOP decrease for individuals with mild to moderate glaucoma. The PreserFlo

Background:The purpose of this study is to determine the prevalence of diabetes and diabetic macular edema in patients undergoing senile cataract surgery in Italy.Methods:It is a prospective, multicenter, cross-sectional study. Thirteen ophthalmic units equally distributed across the Italian territory have been involved in the study. For a period of 3 months, all subjects undergoing phacoemulsification received an Optical Coherence Tompgraphy (OCT) scan and were screened for the anamnestic presence of diabetes. In addition, five selected units collected blood samples from all their patients to measure glycated hemoglobin (HbA1c) levels and detect the presence of occult diabetes (HbA1c > 6.5%). In diabetic patients, levels of retinopathy were measured and diabetic macular edema was considered significant (clinically significant macular edema) when foveal thickness was above 30% of normal levels.Results:A total number of 3657 subjects have been screened. Among them, 20.4% were diabetics. Prevalence of diabetes was significantly higher in males (24.7%) than in females (17%). Levels of HbA1c were tested in a representative sample of 1216 consecutive subjects, and occult diabetes was diagnosed in 4.8% of cases. No significant differences were observed between age groups or different geographic areas. Among diabetic patients, diabetic macular edema of any kind was present in 27.5% (clinically significant macular edema (6.6%)). No significant differences were seen in the prevalence of diabetic macular edema between males and females or between age groups. Among the 745 diabetic patients, no signs of retinopathy were seen in 537 subjects (76.3%), while 101 patients (14.3%) had nonproliferative retinopathy, 13 (1.7%) had nontreated proliferative diabetic retinopathy, and 53 (7.5%) had laser-treated retinopathy. In the entire sample of 3657 subjects, a normal macula was present in 90.9% of cases, diabetic macular edema of any kind in 5.4%, and other maculopathies in 3.4%.Conclusion:In this large cohort study on patients undergoing cataract surgery, more than one-fourth were diabetics and more than one-fourth of these had diabetic macular edema. These high prevalences suggest the opportunity to plan an adequate preoperative assessment in all patients in order to reduce the risk of postoperative development or worsening of a sight-threatening complication such as chronic diabetic macular edema.

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.

Introduction To evaluate the short-term efficacy and safety of intravitreal dexamethasone implant (IDI) in patients with macular oedema associated with diabetic retinopathy (DR) and retinal vein occlusion (RVO) using enhanced-depth image optical coherence tomography (EDI-OCT) and to estimate the effect of dexamethasone on the choroid and the retinal vascular network using OCT angiography (OCTA). Methods Fifteen eyes in 15 patients with macular oedema secondary to diabetes (DR, n = 8) or retinal vein occlusion (RVO, n = 7) were treated with intravitreal injection of sustained-release IDI. Primary efficacy end points were changes in best corrected visual acuity and central macular thickness (CMT). Secondary end points were changes in choroidal thickness and choroidal and retinal vascular networks as determined by OCTA. Results CMT was significantly reduced from baseline by 3 h after injection (p

Introduction The purpose of this case series was to report the potential role of cyclophosphamide (CY) on bleb survival and to evaluate the safety of the trabeculectomy procedure under immunosuppressant systemic therapy. Case series Five eyes of five patients with unresponsive to intraocular pressure (IOP) lowering medication, progressive glaucoma, underwent mytomicin C (MMC) augmented phaco-trabeculectomy, performed by the same surgeon, A.G., during the period from May 2015 to January 2016. All patients were treated with low doses of systemic CY at the time of surgery, to control their relapsing progressive multiple sclerosis (MS) form. Results During a mean follow-up period of 20.6 ± 8.1 months, for cases of “complete success” (when the IOP was

To analyze Stargardt disease (STGD) by morpho-functional examination and investigate the relationship between morpho-functional measures and reading performance.Observational case series study.Fifteen patients with STGD.Twenty-six eyes of 15 patients underwent complete ophthalmic evaluation. Spectral domain optical coherence tomography, fundus autofluorescence (FAF), best corrected visual acuity (BCVA), and microperimetric examinations were performed. FAF and optical coherence tomography (OCT) overlap on microperimetric images was obtained in order to evaluate both tomographic and FAF features passing through the eccentric fixation area. Both morphologic features and functional data were correlated with magnification of prescribed device and reading rate.Univariable analysis showed a significant correlation between magnification power and greatest linear dimension of both OCT and FAF (r = 0.69 and r = 0.67; p0.05). Magnification power was related to best corrected visual acuity (r = 0.56; p0.05). Retinal sensitivity map (r = 0.57; p0.05) was considered an indicator of reading rate. Magnification levels showed a positive correlation with eccentric preferred retinal location (p = 0.03) and the degree of FAF alteration (normal, dishomogeneous, ipoautofluorescence; p0.0001).As a result of the overlapping of OCT/FAF imaging on microperimetric exam, residual activity of outer retinal layers passing through the eccentric fixation area seems to be related with required magnification and reading rate. Identification of morpho-functional parameters is helpful for designing a customized rehabilitative program.

Purpose Fabry disease (FD) is a multiorgan X-linked condition characterized by a deficiency of the lysosomal enzyme alpha-galactosidase A, resulting in a progressive intralysosomal deposit of globotriaosylceramide. The aim of this study was to evaluate the macular ultrastructure of the vascular network using optical coherence tomography angiography (OCTA) and to evaluate macular function using focal electroretinography (fERG) in Fabry patients (FPs). Methods A total of 20 FPs (38 eyes, mean age 57 ± 2.12 SD, range of 27-80 years) and 17 healthy controls (27 eyes, mean age 45 years ± 20.50 SD, range of 24-65 years) were enrolled in the study. Color fundus photography, swept-source optical coherence tomography (SS-OCT), OCTA and fERG were performed in all subjects. The OCTA foveal avascular zone (FAZ), vasculature structure, superficial and deep retinal plexus densities (images of 4.5 × 4.5 mm) and fERG amplitudes were measured. Group differences were statistically assessed by Student's t-test and ANOVA. Results In the FP group, the FAZ areas of the superficial and deep plexuses were enlarged (P = 0.036, t = 2.138; P < 0.001, t = -3.889, respectively), the vessel density was increased in the superficial plexus, and the fERG amplitude was reduced (P < 0.001, t = -10.647) compared with those in healthy controls. No significant correlations were found between the structural and functional data. Conclusions OCTA vascular abnormalities and reduced fERG amplitudes indicate subclinical signs of microangiopathy with early retinal dysfunction in FPs. This study highlights the relevance of OCTA imaging analysis in the identification of abnormal macular vasculature as an ocular hallmark of FD.

Many ocular diseases are associated with an alteration of the mechanical and the material properties of the eye. These mechanically-related diseases include macular hole and pucker, two ocular conditions due to the presence of abnormal physical tractions acting on the retina. A complete relief of these tractions can be obtained through a challenging microsurgical procedure, which requires the mechanical peeling of the internal limiting membrane of the retina (ILM). In this paper, we provide the first comparative study of the nanoscale morphological and mechanical properties of the ILM in macular hole and macular pucker. Our nanoscale elastic measurements unveil a different bio-mechanical response of the ILM in the two pathologies, which correlates well to significant differences occurring during microsurgery. The results here presented pave the way to the development of novel dedicated microsurgical protocols based on the material ILM properties in macular hole or pucker. Moreover, they contribute to clarify why, despite a common aetiology, a patient might develop one disease or the other, an issue which is still debated in literature.

Necrotizing fasciitis (NF) is a rare infection that spreads rapidly along the subcutaneous soft tissue planes. NF rarely involves the periorbital region due to the excellent blood supply of this region. We report a case of periorbital necrotising fasciitis following herpes zoster (HZ) in an immunocompromised 70-year-old patient with a dramatically rapid evolution into septic shock. In our patient, the surprisingly rapid spread of the bacterial superinfection led the periorbital cellulitis to turn into frank NF within 2 hours, with an overwhelming evolution. Despite the prompt start of a systemic antibiotic therapy and the immediate surgical intervention, the patient had a septic shock; she was treated in ITU for 31 days and then discharged to a medical ward and eventually died for a mix of complications of the medical treatment and comorbidities. This case is unique because any documented cases of periorbital NF triggered by HZ had never led to a septic shock and death. Ophthalmologists should be aware that even common skin lesions caused by shingles can determine a dramatic clinical picture, in presence of predisposing factors.

Inflammation represents the manifestation of the host's vascular and cellular response to tissue damage, hypersensitivity of the immune system or autoimmunity. As soon as the damage is detected, the mechanisms of localization and removal of foreign substances and damaged tissues are triggered. This response is amplified by the activation of inflammatory cells and by the production of chemical mediators derived from arachidonic acid, vasoactive substances and cytokines.At the ocular level, among the different responses implemented by various inflammation mediators, the action of prostaglandins is mainly expressed in three ways: i) change of intraocular pressure; ii) induction of miosis; iii) increase of protein concentration in the aqueous humor.Ocular inflammation may continue long after the cessation of the initial cause and may also lead to serious consequences, including permanent vision reduction. For this reason, it is essential to establish a correct and effective therapeutic strategy, which allows to control inflammation, the symptoms and the clinical signs associated with it.This article therefore deals with therapeutic strategies to control inflammation, with a particular focus on the role of nonsteroidal anti-inflammatory drugs (NSAIDs) in cataract surgery.

The results regarding changes of choroidal thickness following intravitreal ranibizumab injections in the literature are controversial. Vascular endothelial growth factor A is implicated in pathogenesis of neovascular age-related macular degeneration (AMD). The suspected unchanged choroidal layer thickness after intravitreal injections of ranibizumab suggests a possible protection of the outer blood-retinal barrier in the human eye.The aim was to evaluate choroidal thickness following the first administration of the study drug ranibizumab into the eyes of naïve wet AMD patients (nAMD).In this open label, 3-month, prospective, single-center, interventional, single-arm pilot study, 20 nAMD eyes were included and underwent three consecutive monthly injections of ranibizumab (0.5 mg/0.05 ml). Vital signs (i.e., blood pressure and pulse), ophthalmic examinations, intraocular pressure, best correct visual acuity and subfoveal choroidal thickness as examined with optical coherence tomography using enhanced depth imaging (OCT-EDI) were assessed at each visit. All patients were evaluated at baseline and at 15, 30 60 and 90 days after intravitreal injection. Ten eyes with fibrotic AMD lesions were evaluated as the control group.In all eyes, the choroidal thicknesses (µm) exhibited no significant changes from the baseline visit to the visits at 15, 30, 60 and 90 days post-injection (P 0.05). The intravitreal treatment with ranibizumab was well tolerated, and no adverse events were registered.Choroidal thickness appeared to be unmodified following the intravitreal injection of ranibizumab into nAMD eyes. Intravitreal ranibizumab injections probably elicit a pharmacologic effect only in the choroidal neovascularization and not in the choroid circulation under neovascular lesions. Clinical Trials Eudract Registration #: 2013-005091-17.

Background Mutations in the cytokine receptor-like factor 1 (CRLF1) gene are responsible for Crisponi/Cold-induced Sweat Syndrome, an extremely rare autosomal-recessive multisystem disorder. The protein encoded is a soluble cytokine receptor, involved in the ciliary neurotrophic factor receptor (CNTFR) pathway. The ciliary neurotrophic factor (CNTF) promotes corneal wound healing and patients with Crisponi/CISS1 syndrome suffer from recurrent keratitis. The aim of the study was to report and discuss the corneal alterations in Crisponi/CISS1 rare disease. Materials and methods We evaluated the cornea of both eyes in four Crisponi/CISS1 patients to provide a detailed description of slit-lamp biomicroscopy findings. Corneal sensitivity, tears functionality and blinking video recording at rest were also assessed in all patients. Two patients were also evaluated with in vivo confocal microscopy, completed with a needle electromyography of their orbicularis muscles. Results None of the patients presented a tears dysfunction and video recording documented a prolonged lid excursion in all patients. Slit lamp examination revealed a chronic epithelial impairment in all cases. Needle electromyography of the orbicularis oculi showed a dystonic pattern. The confocal microscopy confirmed the biomicroscopic observed lesions and documented unusual findings of the corneal nerve plexus. Conclusions This is the first report of microscopic cornea alterations explored with confocal imaging in Crisponi/CISS1 patients. The observed corneal findings suggest a possible direct correlation to the CNTFR pathway defect and the blinking imbalance could exacerbate the compromised epithelial wound healing. Topical administrations of lubricating eye drops are strongly recommended in these patients.

To evaluate the corneal topography and the topographic changes after ptosis surgery on patients affected by congenital and acquired blepharoptosis.Twenty eyes of 17 patients affected by acquired and congenital ptosis underwent surgical correction through anterior levator complex tightening. Computerized tomography (Syrius Sistem; CSO) was used to analyze any change in corneal astigmatism (CYL), simulated keratometry, anterior corneal symmetry index front, apical keratometry front, and central corneal thickness. Visual acuity, margin reflex distance, and levator function were also measured.After surgical ptosis repair, corneal topography demonstrated a reduction in average keratometry of 0.15 ± 0.47 diopters (D) and in corneal astigmatism of 0.26 ± 1.12 D. Significant differences were found in apical keratometry front (-1.84 ± 1.76 D) and in best-corrected visual acuity (-0.18 ± 0.06 logMAR) in the postoperative examinations. Central corneal thickness did not show significant differences between preoperative and postoperative examinations. Postoperative topographic maps showed a reduction of symmetry index front (0.10 ± 0.64 D).Eyelid ptosis modifies anterior corneal surface inducing refractive errors and modifying corneal astigmatism in patients, thus affecting the quality of vision. The surgical correction of blepharoptosis induces anterior corneal surface modification, restoring corneal symmetry and regular corneal astigmatism. Postoperative corneal topography showed normal corneal contours.

Age-related macular degeneration (AMD) is a complex multifactorial disease and the primary cause of legal and irreversible blindness among individuals aged ≥65 years in developed countries. Globally, it affects 30–50 million individuals, with an estimated increase of approximately 200 million by 2020 and approximately 300 million by 2040. Currently, the neovascular form may be able to be treated with the use of anti-VEGF drugs, while no effective treatments are available for the dry form. Many studies, such as the randomized controlled trials (RCTs) Age-Related Eye Disease Study (AREDS) and AREDS 2, have shown a potential role of micronutrient supplementation in lowering the risk of progression of the early stages of AMD. Recently, low-grade inflammation, sustained by dysbiosis and a leaky gut, has been shown to contribute to the development of AMD. Given the ascertained influence of the gut microbiota in systemic low-grade inflammation and its potential modulation by macro- and micro-nutrients, a potential role of diet in AMD has been proposed. This review discusses the role of the gut microbiota in the development of AMD. Using PubMed, Web of Science and Scopus, we searched for recent scientific evidence discussing the impact of dietary habits (high-fat and high-glucose or -fructose diets), micronutrients (vitamins C, E, and D, zinc, beta-carotene, lutein and zeaxanthin) and omega-3 fatty acids on the modulation of the gut microbiota and their relationship with AMD risk and progression.

Background Von Hippel-Lindau disease is a rare hereditary syndrome caused by germinal mutations in a von Hippel-Lindau tumor-suppressing gene. Retinal hemangioblastoma is the ocular hallmark lesion of von Hippel-Lindau disease. Case presentation A 20-year-old Caucasian woman presented to our institution with painless visual impairment in the right eye. A fundus ophthalmoscopic evaluation and swept-source optical coherence tomographic examination revealed a retinal hemangioblastoma associated with cystoid macular edema. On the basis of the clinical ocular findings and genetic analysis, von Hippel-Lindau disease was diagnosed. Following an intravitreal injection of ranibizumab, off-label administration of intravitreal dexamethasone was considered to reduce the edema. An almost complete resolution of the edema in the macular area was observed 1 week after the injection. Finally, laser photocoagulation and transconjunctival cryotherapy were performed; the patient developed “ablatio fugax” after cryotherapy. Conclusions In our experience, intravitreal dexamethasone administration has proven to be a useful tool for reducing retinal hemangioblastoma-related macular edema in von Hippel-Lindau disease and may be considered a potentially valuable treatment that can be used in combination with other therapies.

Purpose:To assess the 10-year follow-up efficacy and safety of riboflavin ultraviolet A–induced cross-linking (CXL) in a population of pediatric patients aged 18 years and younger with progressive keratoconus (KC).Methods:The prospective longitudinal cohort study included 62 eyes of 47 keratoconic p

To investigate whether topical nonsteroidal antiinflammatory drugs (NSAIDs) are useful, in the absence of concomitant corticosteroid therapy, in limiting postoperative inflammation after uncomplicated cataract surgery.A total of 328 patients were enrolled in a prospective, randomized, double-masked, parallel-group, active-controlled study. Anterior chamber inflammation (ACI) was evaluated as the primary efficacy parameter. Only patients with moderate inflammation (ACI score of=4) the day after surgery were randomized and treated with NSAIDs. A novel topical formulation containing 0.2% sodium naproxen was compared with 0.1% diclofenac. Both were administered three times a day for 14 consecutive days. Ocular inflammation was measured after 7 and 14 days by using slit-lamp biomicroscopy. Safety parameters were also evaluated at the same time.Both treatments were equally effective in controlling postsurgical inflammation. No statistically significant differences between treatment groups were observed for the safety variables. No serious adverse events (AEs) occurred during the course of the study. The most frequent AE reported with naproxen was eye redness.NSAIDs can effectively be used without concurrent administration of corticosteroids to control postoperative inflammation after uncomplicated cataract surgery. In addition, naproxen ophthalmic solution may be considered a suitable alternative to the currently available NSAIDs. (Eur J Ophthalmol 2005; 15: 598-606).

We report the first pilot qualitative confocal microscopic analysis of a laser in situ keratomileusis (Lasik) treatment combined with sequential high-fluence accelerated corneal collagen cross-linking, denominated Lasik XTra, by means of HRT II laser scanning in vivo confocal microscopy after a 6-month follow-up. After obtaining approval from the Siena University Hospital Institutional Review Board, a 33-year-old female patient underwent a Lasik XTra procedure in her left eye. Confocal analysis demonstrated induced slight corneal microstructural changes by the interaction between UV-A, riboflavin and corneal stromal collagen, beyond the interface to a depth of 160 µm, without adverse events at the interface and endothelial levels. This application may be considered a prophylactic biomechanical treatment, stiffening the intermediate corneal stroma to prevent corneal ectasia and stabilizing the clinical results of refractive surgery. According to our preliminary experiences, this combined approach may be useful in higher-risk Lasik patients for hyperopic treatments, high myopia and lower corneal thicknesses.

We report the clinical and confocal microscopic findings of the cornea in a patient with smouldering multiple myeloma (SMM) using in vivo scanning laser confocal microscopy. A 72-year-old female underwent a complete ophthalmological examination including slit-lamp biomicroscopy with digital photography, HRT II laser scanning in vivo confocal microscopy and haematological laboratory assessment. Corneal biomicroscopy revealed the presence of bilateral diffuse microgranular tiny grey opacities. In vivo confocal microscopy showed randomly oriented hyper-reflective needle-shaped crystals throughout all levels of the stroma, sparing epithelium and endothelium. In vivo confocal microscopy was very helpful in the differential diagnosis by allowing the nature of the corneal deposits to be established, revealing the typical aspect of the crystals, and excluding granular dystrophy, leading to a suspected diagnosis of SMM. Crystalline corneal deposits may easily be confused as crumb-like opacities typical of granular dystrophy on slit-lamp examination even by experienced ophthalmologists.

Introduction: Keratoconus is an ectatic disease of the cornea characterized by biomechanical instability of stromal collagen leading to reduction of corneal thickness, variation in posterior and anterior corneal curvatures with associated progressive deterioration of visual acuity mainly due to a secondary irregular astigmatism. Corneal collagen crosslinking (CXL) is a new approach to increase the mechanical strength and biochemical stability of the corneal stromal tissue affected from primary or secondary ectasia. A novel pharmacological series of riboflavin formulations from Avedro, Inc. (Waltham, Massachusetts, MA, USA), were recently granted orphan drug designation by the Food and Drug Administration for the treatment of keratoconus and secondary corneal ectasia. Areas covered: This report reviews the basic concepts concerning the role of riboflavin in crosslinking treatment in order to understand the potentiality of the new VibeX™ and VibeX Rapid™ solutions for riboflavin UVA-induced CXL. The treatme...

This chapter brings together all the current evidence in children for a now well-established procedure for keratoconus (KC) in children. With the aid of research from Caporossi and his group, most recent results of which will be presented in this chapter, the authors will present the similarities and differences found in KC in children.

The opacification of Akreos Adapt (Bausch & Lomb, Rochester; NY) intraocular lens (IOL) has been previously reported in Literature. A metabolic change in aqueous humour was considered as the main trigger factor to IOL opacification. We report our case and discuss the association with Ex-PRESS, highlighting the particular pattern of IOL opacification and its possible relation with the intraocular convective motions of the aqueous. We analyzed our case using both digital slit lamp acquisition and OCT Visante (Zeiss, Germany) images. A literature review was conducted to evaluate our results with that previously reported. The role of a relative stationary flow was reported as suggested concurrent mechanism in IOL opacification phenomenon.

Purpose We evaluated the clinical ability of pattern electroretinogram (PERG) to detect functional losses in the affected hemifield of open-angle glaucoma patients with localized perimetric defects. Methods Hemifield (horizontally-defined) steady-state PERGs (h-PERGs) were recorded in response to 1.7 c/deg alternating gratings from 32 eyes of 29 glaucomatous patients with a perimetric, focal one-hemifield defect, 10 eyes of 10 glaucomatous patients with a diffuse perimetric defect, and 18 eyes of 18 age-matched normal subjects. Standard automated perimetry (SAP) and spectral-domain optical coherence tomography (SD-OCT) for retinal nerve fiber layer (RNFL) thickness also were performed. h-PERG amplitudes and ratios, calculated corresponding hemifield perimetric deviations, as well as hemiretina RNFL thicknesses were analyzed. Results h-PERG amplitudes, perimetric deviations, and RNFL thicknesses showed losses (P < 0.001) when comparing affected with unaffected hemifields of localized glaucomatous eyes. No differences were found in h-PERG amplitudes between hemifields of normal or diffuse glaucomatous eyes. h-PERG amplitude ratios (affected/unaffected hemifield) in localized glaucoma were lower (P < 0.001) than the ratios from normal or diffuse glaucomatous eyes. The areas under the receiver operating characteristic curves for h-PERG amplitude ratios, comparing localized-defect glaucomatous eyes with normal or diffuse glaucomatous eyes, were 0.93 and 0.91, respectively. Conclusions h-PERG assessment showed good diagnostic accuracy to confirm localized glaucomatous defects detected perimetrically. This test may be particularly useful in cognitively impaired patients or young/nonverbal patients unable to provide reliable visual fields. Translational Relevance h-PERG provides a sensitive objective measure to confirm focal losses detected with SAP and/or RNFL thickness analysis.

We present a case of keratoconus in which the association with posterior polymorphous corneal dystrophy was established by confocal microscopy. Confocal microscopy enable us to assess the differential diagnosis between posterior corneal dystrophies, essential for a prognosis and therapeutic decision.

Purpose To evaluate the long-term results of air-guided manual deep anterior lamellar keratoplasty (DALK) and to perform confocal microscopy on postoperative DALK corneas. Methods Seven postoperative consecutive DALK corneas were evaluated 1 year after suture removal. All patients underwent a complete ophthalmologic examination evaluating visual acuity, astigmatism, corneal thickness, and endothelial cell count. Confocal microscopy was performed to examine the corneas of the seven eyes and to obtain the measured interface depth. Results Eighteen months after surgery, the mean postoperative uncorrected visual acuity was 20/38 and the mean best-corrected visual acuity was 20/23. Postoperative mean value of residual recipient stroma thickness was 65.57 μm ± 28.74. Conclusions Maximum depth DALK can lead to significant advantages for quality of vision when compared to other types of anterior lamellar keratoplasty. Still, it remains a challenging procedure. These results show that a deep dissection without baring Descemet membrane makes good visual results possible, preventing corneal perforation and conversion to penetrating graft.

Pseudoexfoliation (PEX) syndrome is a common ocular disease that also affects the cornea. A case of clinical PEX syndrome, studied by in vivo corneal confocal microscopy is reported. The morphological analysis of the confocal images demonstrated hyper-reflective deposits and several dendritic cells in the basal epithelial layer. A fibrillar subepithelial structure was also found. The endothelial layer showed cell anomalies (polymegathism and pleomorphism) and hyper-reflective small endothelial deposits. Confocal microscopy is an in vivo imaging method that may provide new information on corneal alterations in PEX, and detect early corneal features.

To compare two different postcataract surgery antibiotic/steroid therapeutic combinations, for clinical results as well as patient satisfaction.Prospective randomized clinical trial of patients with bilateral operative cataract. Postoperatively, for 15 days one eye was randomly assigned to therapy with the combination chloramphenicol 0.25%-betamethasone 0.13% gel three times a day (Group 1) and the other to the combination tobramycin 0.3%-dexamethasone 0.1% eyedrops four times a day (Group 2).A total of 142 patients (284 eyes) completed the study. The authors could not detect any significant difference between Group 1 and Group 2 concerning preoperative evaluation, surgical procedure, and complications. Pertaining to the two therapeutic regimens, efficacy, side effects, and clinical findings such as uncorrected visual acuity, intraocular pressure, edema or hyperemia of eyelids and/or conjunctiva, conjunctival and/or ciliary vessels congestion, decreased corneal transparency, corneal edema, Descemet folds, anterior chamber Tyndall and depth, and posterior synechiae were also comparable. Postoperative subjective pain and dry eye sensation were comparable between the two groups, while the gel preparation elicited a significantly more pleasant sensation in the patients (p=0.04).The motivation for use of a gel is to prolong the permanence of associated drugs on the ocular surface, increasing potency and decreasing concentration of the drug and rate of administration. This in order to improve compliance and decrease potential side effects. Chloramphenicol 0.25%-betamethasone 0.13% gel combination proved to have comparable efficacy, tolerance, and better acceptance by the patients than an aqueous tobramycin 0.3%-dexamethasone 0.1% preparation.

Purpose. To report the risk of methicillin-resistantStaphylococcus aureus(MRSA) ocular infection after UVA-riboflavin corneal collagen cross-linking in a patient with atopic dermatitis.Methods. A 22-year-old man, with bilateral evolutive keratoconus and atopic dermatitis, underwent UVA-riboflavin corneal cross-linking and presented with rapidly progressive corneal abscesses and cyclitis in the treated eye five days after surgery. The patient was admitted to the hospital and treated with broad-spectrum antimicrobic therapy.Results. The patient had positive cultures for MRSA, exhibiting a strong resistance to antibiotics. Antibiotic therapy was modified and targeted accordingly. The intravitreal reaction is extinguished, but severe damage of ocular structures was unavoidable.Conclusion. Riboflavin/UVA corneal cross-linking is considered a safe procedure and is extremely effective in halting keratoconus’ progression. However, this procedure is not devoid of infectious complications, due to known risk factors and/or poor patients’ hygiene compliance in the postoperative period. Atopic dermatitis is a common disease among patients with keratoconus andStaphylococcus aureuscolonization is commonly found in patients with atopic dermatitis. Therefore, comorbidity with atopic dermatitis should be thoroughly assessed through clinical history before surgery. A clinical evaluation within three days after surgery and the imposition of strict personal hygiene rules are strongly recommended.