Alessandro Galan

Spontaneous extrusion of a stainless steel glaucoma drainage implant (Ex-PRESS)

Purpose To report a case of spontaneous extrusion of a stainless steel glaucoma drainage implant (Ex-PRESS). Methods An Ex-PRESS was implanted under the conjunctiva in a 76-year-old man with primary open-angle glaucoma. Results Two years after implantation, the Ex-PRESS extruded spontaneously. Despite this adverse event, there was no increase in intraocular pressure. Conclusions This is the first report of spontaneous extrusion of an Ex-PRESS device. Implanting the device under a scleral flap should be considered to avoid adverse events such as extrusion or conjunctival erosion.

Efficacy and safety of ab interno excimer laser trabeculotomy in primary open-angle glaucoma : Two years of follow-up

Ab interno trabeculotomy was performed using the recently developed XeCl excimer laser in 21 eyes of 21 patients with primary open-angle glaucoma refractory to medical therapy. The patients were followed at the Eye Department of S. Antonio Hospital in Padova, for an average of 25.3 ± 1.3 months. Intraocular pressure (IOP), visual acuity and ocular complications were evaluated. The laser procedure was quick and relatively easy, with minimal manipulation of tissues; complications were clinically insignificant. At the last follow-up, a marked IOP-lowering effect compared to baseline was observed (from 24.8 ± 2.0 to 16.9 ± 2.1 mm Hg; –31.8%, p < 0.0001). Nineteen patients (90.5%) had an IOP lowering of 20% or more; however, 8 of these eyes (38.1%) required additional IOP-lowering medical therapy. The procedure failed in 2 cases (9.5%) despite additional therapy. In conclusion ab interno excimer laser trabeculotomy seems effective to decrease IOP, serves to reduce the number of antiglaucoma medications and is relatively safe, proving to be a promising therapeutic option in glaucoma surgery.

Single-session photodynamic therapy combined with intravitreal bevacizumab for retinal angiomatous proliferation.

Purpose: To evaluate the efficacy of single-session photodynamic therapy (PDT) combined with intravitreal bevacizumab (IVB) in the treatment of retinal angiomatous proliferation (RAP) in age-related macular degeneration. Methods: In this pilot study, eight patients with RAP underwent indocyanine green angiography (ICGA)-guided single-session verteporfin PDT followed by intravitreal bevacizumab (1.25 mg) within a 0-day ± 1-day interval. All patients were naïve to treatment. Best-corrected visual acuity (BCVA), fluorescein angiography, ICGA, and optical coherence tomography (OCT) were performed at baseline and at each follow-up visit. All patients received three consecutive monthly IVB injections; thereafter, retreatment with bevacizumab was performed in the case of worsening BCVA or a deterioration of angiographic or OCT findings. Results: All patients had 9 months of follow-up. Complete resolution of angiographic leakage was achieved in all eyes at 9 months. A significant improvement in the mean BCVA was observed at 1 month, 3 months, 6 months, and 9 months after combined treatment (P = 0.004). Visual acuity improved in 62.5% and was stable in 37.5% of cases. No patients had a decrease in BCVA of three or more lines during follow-up. Mean central macular thickness was significantly reduced in all patients (P < 0.0001) as controlled at 1-month, 3-month, 6-month, and 9-month intervals from initial treatment. The mean number of injections for the 9 months were 3.2 ± 0.4. No ocular complications or systemic events developed. Conclusion: Sequenced combined treatment with single-session PDT and IVB injections may be useful in treating RAP, reducing or eliminating retinal edema, and improving or stabilizing visual acuity. Further investigations are warranted to outline the appropriate treatment paradigm for combination therapy.

Acute visual loss and chorioretinal infarction after photodynamic therapy combined with intravitreal triamcinolone

Purpose To report acute visual loss associated with dynamic vascular changes after photodynamic therapy (PDT) combined with intravitreal triamcinolone (IVTA) for the treatment of occult choroidal neovascularization (CNV). Methods An 86-year-old woman complained of visual loss in her left eye. Angiographic examination showed a serous pigment epithelium detachment complicated by CNV. She underwent combined treatment with IVTA (4 mg) followed by standard verteporfin PDT administered after a 5-day interval. Results The patient developed vision loss 1 day after PDT. Ophthalmoscopic examination disclosed an acute serous neurosensory retinal detachment. Fluorescein angiography showed a large area of early hypofluorescence in correspondence to and extending beyond the photodynamic spot. Neurosensory retinal vessels involvement with dilation of the retinal arterioles and capillary nonperfuion were also revealed. Indocyanine green angiography showed choroidal infarction within the collateral choroid included in the area of light exposure, with associated nonperfusion of medium and large choroidal vessels being revealed. Five days after PDT, spontaneous severe bleeding with breakthrough into the vitreous occurred, in addition to an RPE tear. Conclusions Acute loss of vision associated with vascular changes in retinal and choroidal circulation represents an uncommon but serious complication following combined PDT and IVTA. These risks should be carefully considered in combination therapies.

Effect of 60 kHz and 150 kHz Femtosecond Lasers on Corneal Stromal Bed Surfaces: A Comparative Study

Purpose. To compare the effect of 60 kHz and 150 kHz femtosecond (FS) laser on the corneal stromal bed surfaces (SBS). Methods. Sixteen human donor corneal tissues unsuitable for transplantation were used. Anterior and posterior lamella was obtained using 60 kHz and 150 kHz FS laser. A standard depth of 400 μm was set for anterior lamellar keratoplasty (ALK) and endothelial lamellar keratoplasty (ELK). The quality and smoothness of the SBS post-FS laser dissection were graded for statistics. Results. No intraoperative complications were found. The side cuts were straight, and the SBS appeared smoother in cuts obtained using 150 kHz. The average values of the SBS quality of the anterior lamellar cut were found to be 2.25 (±0.28) for 60 kHz and 3.125 (±0.25) for 150 kHz (P = 0.0039). Whereas, 2 (±0.4) for 60 kHz and 2.75 (±0.28) for 150 kHz (P = 0.0273) was the quality observed in endothelial cuts. No significant difference was found between anterior and posterior cuts performed using the same FS laser (60 kHz or 150 kHz) (P > 0.05). Conclusions. The 60 kHz and 150 kHz FS lasers are equally effective in performing lamellar dissection for ALK and ELK. 150 kHz FS laser allows a tighter spot and layer separation which creates a slightly smoother SBS.

Fungal keratitis following deep lamellar keratoplasty.

A young man affected from keratoconus was submitted to deep lamellar keratoplasty (DLK). The day after, the presence of pseudochamber between the donor and the recipient cornea was observed by the slit-lamp and the patient was submitted to the injection of an air bubble into the anterior chamber. Approximately six days later, multiple, whitish patches mostly located in the centre of the lamellar interface were noticed. Medical treatment was started immediately but no improvement was observed and penetrating keratoplasty was performed. Although this organism has been described as a microbial pathogen in blepharitis, conjunctivitis, keratitis, canaliculitis, dacryocystitis, and endophthalmitis, to the best of our knowledge, this is the first case report of keratitis after DLK caused by Actinomyces species.

Large-spot subthreshold transpupillary thermotherapy for chronic serous macular detachment

Purpose: To report the effect of subthreshold transpupillary thermotherapy (TTT) in treating serous detachment of the neurosensory retina secondary to chronic central serous chorioretinopathy (CCSC). Methods: Seven eyes from five patients with CCSC, persistent serous detachment of the neurosensory retina and a clinical course of between 12 and 60 months were treated. All eyes received large-spot TTT guided by indocyanine green angiography (ICGA). Subthreshold TTT was performed using an 810 nm diode laser with a spot size of 3.0 mm (power was set at 350 mW). Treatment was applied for 60 seconds to the areas of choroidal hyperfluorescence on ICGA. Results: The mean number of TTT sessions was 1.4 ± 0.5. All eyes were followed up for at least 6 months (mean 9.6 ± 3.2 standard deviation; range 6–12 months). The mean logarithm of the minimum angle of resolution best-corrected visual acuity was significantly better compared with baseline. All TTT-treated eyes had stable or improved vision (P < 0.001). Mean optical coherence tomography (OCT) central foveal thickness was significantly lower in all patients (P < 0.001) compared with pretreatment OCT, with a reduction in subretinal fluid and resolution of serous detachment associated with anatomical fovea restoration. No patient had any treatment-related side effects. Conclusion: Modified subthreshold TTT appears to have a beneficial effect in treating patients with CCSC and persistent neurosensory detachment. The encouraging results and lack of visually significant complications suggest that further investigation is warranted.

Outcomes of 195 consecutive patients undergoing 2-port pars plana vitrectomy with slit-lamp illumination system for posterior segment disease: a retrospective study.

Purpose: The purpose of this study was to evaluate the safety and efficacy of 2-port 20-gauge pars plana vitrectomy with a slit-lamp illumination system in different vitreoretinal pathologies. Design: Retrospective, consecutive, interventional case series. Methods: One hundred and ninety-five consecutive eyes of 195 patients underwent 20-gauge 2-port pars plana vitrectomy with a combination of slit-lamp illumination and a plano-concave contact lens, at the San Paolo Ophthalmology Center, from September 2005 through November 2007. Postoperative visual acuity at baseline and at 1, 3, and 6 months; intraoperative and postoperative complication rate; and surgical time were evaluated. Results: All patients completed 6 months of follow-up. The mean overall visual acuity was 0.74 ± 0.03 (mean ± SD) at baseline, improving to 0.56 ± 0.03 (P < 0.0001), 0.48 ± 0.03 (P < 0.0001), and 0.43 ± 0.03 (P < 0.0001) at 1, 3, and 6 months, respectively. No intraoperative complications occurred. Postoperative complications included retinal detachment in three patients, epiretinal membrane recurrence in three eyes, persistent macular hole in four eyes, and phthisis in one eye. Cataract formation was observed in 25 eyes. The total mean surgical time was 28.3 ± 10.1 minutes. No one had hypotony after the surgical procedure, and no cases of endophthalmitis were observed. Conversion to standard three-port vitrectomy was not necessary in any of the cases. Conclusion: Two-port 20-gauge pars plana vitrectomy with slit-lamp illumination is a safe and effective procedure for posterior segment surgeries.

Grading the Surgical Difficulty of Cataract Phacoemulsification

BACKGROUND AND OBJECTIVE To propose a new grading system to preoperatively evaluate the difficulty of phacoemulsification surgery according to the anatomic condition of a patients eye. PATIENTS AND METHODS In this prospective case series, a grading system covering the entire cataract spectrum was developed and field-tested in 400 consecutive patients undergoing phacoemulsification. For each eye, nine anatomic parameters were evaluated and a level of severity was assigned. The system identifies five levels of surgical difficulty based on the combined degree of severity of each parameter considered. RESULTS Preoperative score and intraoperative difficulty closely corresponded in the first 400 test cases. Analysis using the Fleiss-Cohen kappa coefficient showed substantial agreement between preoperative and intraoperative scores (k value = 0.76; 95% confidence interval = 0.71 to 0.81). CONCLUSION A grading system of the preoperative difficulties of each phacoemulsification procedure is provided. This system is easy to complete and interpret and can be transmitted to the surgeon, patient, and anyone who may subsequently examine the case.

Rapid response to dexamethasone intravitreal implant in diabetic macular edema

Purpose: To evaluate the early effects of dexamethasone (DEX) intravitreal implants in patients with diabetic macular edema (DME). Methods: This was a prospective, single-arm, interventional clinical series. Eighteen patients (18 eyes) with chronic/recalcitrant or naive DME were included. Patients underwent single DEX intravitreal implant. Clinical assessments, including ophthalmologic examination, central retinal thickness (CRT) measurement by spectral-domain optical coherence tomography (SD-OCT) scan, best-corrected visual acuity (BCVA), and intraocular pressure (IOP) were carried out at baseline, 1-3 hours, and then 3, 7, and 30 days after treatment. The main outcome was change in CRT on SD-OCT, while secondary outcome measures included visual acuity (VA) and changes in IOP following implant. Results: Mean CRT significantly decreased from 565 ± 171 µm at baseline to 310 ± 89 µm at end of follow-up (p<0.001), with reduction becoming evident 1-3 hours after injection. Mean BCVA also significantly improved 7 days and 30 days after treatment up to 0.14 logMAR (p<0.05). All patients had a controlled IOP after the injection with only 1/18 eyes having a transient increase in IOP during follow-up. Conclusions: This is the first study showing very early effects of DEX implants on CRT reduction and VA improvement in DME.