Alfonso Savastano

Morphologic differences, according to etiology, in pigment epithelial detachments by means of en face optical coherence tomography.

Purpose: To assess morphologic differences in pigment epithelial detachment (PED) with en face optical coherence tomography in central serous chorioretinopathy (CSC) and age-related macular degeneration (AMD). Methods: We recruited 30 eyes of 22 patients with PED. Nine eyes had a clinical diagnosis of CSC and 21 had AMD. All patients were assessed with en face optical coherence tomography. Morphologic PED aspects were estimated on C-scans and classified according to shape, inner silhouette, content, wall aspects, wall thickness, and size. Results: Pigment epithelial detachment shape was predominantly circular (88.8%) in CSC and irregular or with multilobular features in AMD (76.2%). The PED inner silhouette had a smooth aspect (88.9%) in CSC and a slightly granular aspect or granular profile in AMD (100%). Clear PED content was the most characteristic feature of CSC (88.9%) but not of AMD. In CSC, PED morphologic wall aspect was uniform or slightly irregular (100%), while in AMD, it was slightly irregular (52.4%) or irregular (47.6%). Pigment epithelial detachment wall thickness and dimensions were larger in AMD than in CSC. Statistically significant differences were observed between CSC and AMD concerning PED inner silhouette, contents, wall aspects, and wall thickness measurements. Conclusion: En face optical coherence tomography scanning is a valuable tool for showing important morphologic differences between CSC and AMD.

En Face Optical Coherence Tomography for Visualization of the Choroid.

BACKGROUND AND OBJECTIVE To assess posterior pole choroid patterns in healthy eyes using en face optical coherence tomography (OCT). PATIENTS AND METHODS This observational study included 154 healthy eyes of 77 patients who underwent en face OCT. The mean age of the patients was 31.2 years (standard deviation: 13 years); 40 patients were women, and 37 patients were men. En face imaging of the choroidal vasculature was assessed using an OCT Optovue RTVue (Optovue, Fremont, CA). To generate an appropriate choroid image, the best detectable vessels in Hallers layer below the retinal pigment epithelium surface parallel plane were selected. RESULTS Images of diverse choroidal vessel patterns at the posterior pole were observed and recorded with en face OCT. Five different patterns of Hallers layer with different occurrences were assessed. Pattern 1 (temporal herringbone) represented 49.2%, pattern 2 (branched from below) and pattern 3 (laterally diagonal) represented 14.2%, pattern 4 (doubled arcuate) was observed in 11.9%, and pattern 5 (reticular feature) was observed in 10.5% of the reference plane. CONCLUSION In vivo assessment of human choroid microvasculature in healthy eyes using en face OCT demonstrated five different patterns. The choroid vasculature pattern may play a role in the origin and development of neuroretinal pathologies, with potential importance in chorioretinal diseases and circulatory abnormalities.

Confocal microscopy after descemet stripping endothelial keratoplasty: a case report.

Purpose: To evaluate the clinical findings, visual outcomes, and confocal microscopic corneal features after Descemet stripping endothelial keratoplasty (DSEK) technique in Fuchs endothelial dystrophy. Methods: A 70-year-old female patient with pseudophakia and Fuchs endothelial dystrophy underwent small-incision DSEK surgery. Best spectacle-corrected visual acuity was 1.30 (20/400) logarithm of the minimum angle of resolution (Snellen) before treatment. Confocal microscopy (ConfoScan 4; Nidek Technologies, Padova, Italy) was performed before surgery, after 7 days, at 1 month, and 6 months after descemet stripping endothelial keratoplasty. Images of corneal structures, including endothelium, donor stroma, and recipient stroma, were obtained. Results: Best spectacle-corrected visual acuity improved to 0.3 (20/40) logarithm of the minimum angle of resolution (Snellen) at 6 months. Endothelial cell density was 850 cells per square millimeter 6 months after surgery. Interface and donor stroma reflectivity were highest, 7 days postoperative showing progressive decrease over time. Conclusions: The DSEK procedure represents a promising alternative to conventional penetrating keratoplasty for patients with Fuchs endothelial dystrophy. Confocal microscopy is able to detect interface morphological characteristics, to improve therapeutic choice, and to understand the pathophysiology of visual recovery.

Choroidal effusion and suprachoroidal hemorrhage during phacoemulsification: intraoperative management to prevent expulsive hemorrhage.

Purpose To describe the intraoperative management of choroidal effusion (CE) or suprachoroidal hemorrhage (SCH) during cataract surgery with the phacoemulsification technique. Methods The study is a retrospective interventional study through which we describe the intraoperative management adopted in 6 cases of CE or SCH during cataract surgery. The study involved 6,400 eyes (phacoemulsification) in 6 years observational time (incidence rate 0.094%). The surgical time at which these complications happened differed: nucleolus phacoemulsification in 2 eyes, cortex removal by bimanual irrigation-aspiration in 3 eyes, and intraocular lens implant for 1 eye. Once the complication was recognized, each patient was quickly moved to an extreme reverse Trendelenburg position and pharmacologically treated to manage high blood pressure, pain, and anxiety (150 mL of an 18% mannitol solution delivered in rapid infusion intravenously; 1-3 mg intravenous midazolam; 5 nifedipine sublingual drops). Results In all the cases reported, the surgery was completed after resolution of the acute choroidal exudation or SCH. In the follow-up evaluation, the intraocular pressure was normal at each examination. The visual acuity of the patients was between 6/7.5 and 5/6 Snellen after 4 weeks. We observed a statistically significant reduction in endothelial cells in the 2 eyes in which the CE or SCH happened during the phacoemulsification compared with the other cases; this finding likely results from mechanical damage (p = 0.04 [95% confidence interval]). Conclusions Choroidal effusion or SCH can be intraoperatively managed to avoid expulsive hemorrhage and maintain the possibility of completing the surgery.

CLASSIFICATION OF HALLER VESSEL ARRANGEMENTS IN ACUTE AND CHRONIC CENTRAL SEROUS CHORIORETINOPATHY IMAGED WITH EN FACE OPTICAL COHERENCE TOMOGRAPHY

Purpose: To compare the prevailing patterns of Haller vessel arrangements at the posterior pole between healthy eyes and those with central serous chorioretinopathy (CSC) using en face optical coherence tomography. Methods: Eyes of normal subjects and patients with acute or chronic CSC underwent optical coherence tomography imaging (RTVue 100; Optovue Inc, Fremont, CA). En face sections at the level of the Haller layer were classified by two masked graders into five mutually exclusive morphologic categories (temporal herringbone, branched from below, laterally diagonal, double arcuate, and reticular). The relative prevalence of each Haller vessel arrangement pattern was determined for each phenotype. Results: Numbers of eyes examined were as follows: 154 eyes of 77 normal subjects; 41 eyes of 31 patients with acute CSC; and 39 eyes of 33 patients with chronic CSC. The mean age of participants was 44.4 ± 14.6 years for healthy subjects (M:F = 37:40), 48.5 ± 8.2 years (M:F = 24:7) for acute CSC, and 65.3 ± 13.1 years (M:F = 28:5) for chronic CSC. The relative prevalence of each Haller vessel arrangement pattern differed by phenotype. The temporal herringbone pattern was most prevalent in healthy eyes (49.2%), whereas a reticular pattern was most prevalent in eyes with acute and/or chronic CSC (combined, 48.8%). Conclusion: A significant difference was observed in the prevalence of respective Haller vessel arrangement patterns between eyes of normal subjects and those of patients with either acute or chronic CSC. Although further study is needed to determine the mechanistic factors underlying these differences, and the hemodynamic implications, our data suggest that en face optical coherence tomography may find a formal role in choroidal disease classification.

3D SURGICAL VIEWING SYSTEM IN OPHTHALMOLOGY: Perceptions of the Surgical Team

Technology is continuously evolving in the ophthalmology world in many spheres. There is a huge innovation in ways to perform ocular surgery with the introduction of three-dimensional (3D) visualization systems (3D describes an image that provides the perception of depth), technology that makes images and movies appear more lifelike in print, on the computer, in the cinema, or on TV. Known as “stereoscopic imaging” and “3D stereo,” people sense a greater depth than with 2D and feel that they could reach out and touch the objects. However, the effects are not just for entertainment; the more realistic a 3D training session, the greater the test of a person’s reactions. The creation of 3D prints, images, and movies is accomplished by capturing the scene at two different angles corresponding to the distance between a person’s left and right eyes (roughly 64 mm). When the left image is directed to the left eye and the right image to the right eye, the brain perceives the illusion of greater depth. The stereo (left and right) frames are separated by colors, by polarization, or by rapidly alternating the left and right images. A corresponding pair of 3D glasses directs the images to the appropriate eye. In fact, 3D surgical microscopes are the frontiers that many pharmaceutical companies are looking at; in particular, a lot of research has been performed in the endoscopic surgery sphere.1–3 From an ophthalmologic point of view, this way of operating is called “heads-up” surgery, when the surgeon no longer looks through the microscope oculars as in a conventional microsurgical procedure. In fact, although wearing lightweight 3D glasses and watching the surgical field on a large flat screen that displays a high-definition 3D image from a camera mounted on the microscope, the surgeon is capable of performing surgery. Alcon recently launched the NGENUITY system, which consists of a 3D stereoscopic, high-definition digital video camera and workstation, which operates as an adjunct to the surgical microscope during surgery. The system displays images real time or from recordings on a flat-panel, high-definition, digital 3D display. There is no additional light (or energy) delivered by the system for visualization or image capture. In this study, we wanted to investigate surgical team satisfaction when using this system. In a survey conducted at the end of each surgery, the primary surgeon, assistant surgeon, anesthetists, and theater nurse were asked about their own experience and comfort during the 3D surgery.

Shallow Anterior Chamber After Trabeculectomy: Risk Reduction by Use of Removable Compression Sutures

Purpose:To evaluate the risk of shallow anterior chamber after trabeculectomy with removable compression sutures. Methods:A total of 263 eyes affected by primary open-angle glaucoma that was unresponsive to medical treatments were divided into 2 groups: 126 eyes were treated with conventional trabeculectomy (group A) and 137 with a modified surgery technique using 3 removable compression 10-0 nylon sutures (group B). All the participants received intraoperative antimetabolites (mitomycin 0.04%). Increased intraocular pressure (IOP) of >14 mm Hg in the eyes of group B patients was followed by removal of compression sutures. Best corrected visual acuity, slit lamp examination, IOP, and anterior chamber depth were evaluated 1, 7, 30, 60, 90, and 180 days after surgery. Results:On the first postoperative day, 12 eyes from group A (9.5%) exhibited a shallow anterior chamber with marked hypotony and no eyes in group B showed flat anterior chamber at any control evaluation (P<0.001). The day after surgery, group A showed a mean IOP of 5.3 mm Hg (±2.02), whereas group B had a mean of 7.4 mm Hg (±2.10). At 7 days postoperation, the values for IOP were 10.95 (±1.55) and 11.7 mm Hg (±1.66) in groups A and B, respectively. One month later, mean IOP was 11.05 mm Hg (±1.08) for group A and 13.9 mm Hg (±3.26) for group B. The surgeon removed the compression sutures from all eyes with IOP>14 mm Hg (90%). The day after suture removal, mean IOP decreased to 10.45 mm Hg (±1.37). There was no significant statistical difference in visual acuity between the 2 groups at any point during follow-up (P>0.001). At 180 postoperative days the difference in mean IOP between the 2 groups was statistically significant (P<0.001). Conclusions:The application of removable corneoscleral compression sutures during trabeculectomy reduced the risk of postoperative shallow anterior chamber and allowed for safe IOP control after the procedure giving further postoperative chance to reduce the intraocular pressure.

Imaging of Ocular Perforation After Retrobulbar Block.

A man in his 40s underwent surgery to place a scleral buckle for retinal detachment in his left eye. Surgery was performed under retrobulbar anesthesia. During surgery, the patient complained of pain, so another retrobulbar injection was performed. As this was done, the needle was noted to have perforated the eye.1-3 Indirect ophthalmoscopy revealed a vitreous hemorrhage and the intraocular pressure was low (Figure). Sterile air was injected into the vitreous and the scleral buckle procedure was completed. Laser retinopexy was performed 1 week later to treat the retinal holes.4 One month later, the best-corrected visual acuity was 20/25 OS.

Re: Fast circulation of cerebrospinal fluid: an alternative perspective on the protective role of high intracranial pressure in ocular hypertension: Letter to the Editor

EDITOR: We read with interest the paper by Wostyn and colleagues on ‘Fast circulation of cerebrospinal fluid: an alternative perspective on the protective role of high intracranial pressure in ocular hypertension’ recently published in Clinical and Experimental Optometry. The potential role of trans-lamina cribrosa pressure difference (ΔP = intraocular pressure – intracranial pressure) in the pathogenesis of glaucoma is discussed. The authors argued against the exclusive role of abnormally high ΔP in baro-traumatically induced optic nerve damage. They postulated that the protective effect of higher intracranial pressure could be due to a pressure-independent mechanism, namely faster cerebrospinal fluid production and clearance of potentially toxic molecules. We feel that this pathogenic mechanism deserves further discussion. Recently, Chen and colleagues reported on a case of a patient with normal tension glaucoma, who underwent ventriculo-peritoneal shunt to treat concurrent normal pressure hydrocephalus. Interesting correlations between worsening of glaucoma damage and intracranial pressure changes were reported. At the decrease of intracranial pressure obtained by regulation of valve opening pressure, optic disc haemorrhages were observed. Bleedings promptly disappeared when intracranial pressure was raised, thus indicating a baro-traumatic cause of the lesions. The findings provided by this experimentum naturae support the ΔP theory and encourage exploration of ‘ΔP threshold value by time exposure’ possibly resulting in optic nerve damage. In fact, in physiological and pathological conditions both intracranial and intraocular pressures can change in a non-proportional or independent way. On the other hand, the results by Chen and colleagues do not seem to support the speculation by Wostyn and colleagues. In fact, cerebrospinal fluid diversion decreased intracranial pressure but increased clearance. This latter associates with cerebrospinal fluid production and turnover and results in the enhancement of cerebrospinal fluid sink action. Moreover, even though evidence suggests wide overlapping between pathogenic pathways acting in glaucoma and Alzheimer’s disease, it would have been plausible to expect an association between these diseases, whereas this is epidemiologically questionable; however, the role of cerebrospinal fluid clearance in glaucoma, which moves in the emerging field of brain waste molecules removal, remains very attractive. In this context, it could be interesting to study the association between glaucoma and the expanding world of cerebrospinal fluid clearance failure conditions.

Ointment in the Anterior Chamber

Author Contributions:Dr Guedj had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Guedj, Queant, Lellouch, Gantzer, Brezin. Acquisition, analysis, or interpretation of data: Guedj, Queant, Funck-Brentano, Kramkimel, Monnet, Longvert, Brezin. Drafting of the manuscript: Guedj, Queant, Lellouch, Gantzer, Brezin. Critical revision of the manuscript for important intellectual content:Queant, Funck-Brentano, Kramkimel, Monnet, Longvert, Brezin. Statistical analysis: Guedj. Administrative, technical, or material support: Guedj, Funck-Brentano. Study supervision: Guedj, Queant, Funck-Brentano, Monnet, Gantzer, Brezin.