Anna Maino

A randomized, double-masked, clinical study of the efficacy of four nonsteroidal anti-inflammatory drugs in pain control after excimer laser photorefractive keratectomy.

OBJECTIVE This study assessed the efficacy of 4 nonsteroidal anti-inflammatory drugs (NSAIDs) after excimer laser photorefractive keratectomy (PRK). BACKGROUND Inadequate control of pain after PRK surgery can be a severe source of distress to patients and can interfere with their willingness to undergo a second PRK procedure. METHODS This randomized, double-masked, placebo-controlled clinical study was conducted in 125 patients. Four NSAIDs (diclofenac, flurbiprofen, ketorolac, and indomethacin) were tested against a placebo group (artificial tears). Pain levels after PRK were quantified using Present Pain Intensity (PPI) and Pain Rating Indices based on rank values (PRI[R]) scores, both of which were calculated using patient responses to a modified McGill Pain Questionnaire. The PRI(R) consisted of 4 subscales-sensory (S), affective (A), evaluative (E), and miscellaneous (M)-as well as a total score (T). RESULTS Three hours after PRK, no differences in PPI scores were found between the ketorolac, diclofenac, and indomethacin groups, whereas placebo was significantly less effective than the NSAIDs. Patients who received flurbiprofen reported PPI scores that were significantly lower (P < 0.001) than those of patients who received diclofenac and indomethacin, but PPI scores in the flurbiprofen and the ketorolac groups did not differ significantly. Twenty-four hours after surgery, patients treated with flurbiprofen, ketorolac, and diclofenac reported the lowest PPI scores compared with those treated with indomethacin and placebo (P < 0.001). Moreover, flurbiprofen-treated patients also had the lowest PRI(R)T scores (P < 0.001). When the pain rating index was examined by subclass, a significantly lower PRI(R)S score was detected in the flurbiprofen group at 24 hours (P < 0.001). The PRI(R)A score was significantly higher in the placebo and indomethacin groups compared with the other groups (P < 0.001). At the 48- and 72-hour time points, flurbiprofen-treated patients again reported significantly lower PPI and PRI(R)T scores (P < 0.001 for both) in pair-wise comparisons with the other treatment groups. The number of patients who self-administered additional oral analgesics did not differ significantly between the groups. However, the mean number of analgesic tablets used was significantly higher in the placebo group than in any NSAID group (P < 0.001). The ketorolac group had the largest number of patients complaining of itching (P < 0.043). No other subjective symptoms were significantly different across groups. Finally, all NSAIDs, except flurbiprofen, prolonged the mean reepithelialization period slightly (P < 0.001). CONCLUSIONS Flurbiprofen appeared to be the most effective NSAID for the treatment of pain, even at 24 hours after surgery when pain was at a maximum.

A randomised, double masked, clinical trial of high dose vitamin A and vitamin E supplementation after photorefractive keratectomy

AIM To evaluate the effect of a high dose vitamin A and E supplementation on corneal re-epithelialisation time, visual acuity and haze following photorefractive keratectomy (PRK). METHODS Two groups of 20 patients who underwent myopic PRK were supplemented with either 25 000 IU retinol palmitate and 230 mg α tocopheryl nicotinate or a placebo. Clinical outcomes were evaluated up to 360 days. RESULTS In the vitamin treated group, re-epithelialisation time was significantly faster (p=0.029) and haze incidence was reduced (p=0.035), especially for high myopic corrections (p=0.043). This group also reported a significantly better uncorrected visual acuity (p=0.043). CONCLUSIONS High dose vitamin A and E oral supplementation may accelerate re-epithelialisation time and may reduce corneal haze formation after PRK.

Contrast sensitivity measured by 2 methods after photorefractive keratectomy.

Purpose: To study contrast sensitivity in eyes that had flying‐spot excimer laser photorefractive keratectomy (PRK) and to compare a subjective method (Vision Contrast Test System [VCTS] 6500) and an objective method (visual evoked potential [VEP]) of measuring contrast sensitivity. Setting: Istituto Clinica Oculistica, Università degli Studi, Bari, Italy. Methods: Contrast sensitivity changes over time were evaluated in 26 eyes. The baseline values were compared with measurements 3, 6, and 12 months after PRK using the VCTS 6500 and VEP. Contrast threshold and VEP amplitude were classified by myopic correction. Results: Contrast threshold values changed significantly over time (P < .001). Significant differences were found between mean contrast threshold preoperatively and 12 months postoperatively (P < .001) at all spatial frequencies. A significant relationship was established between baseline and 12 month measurements at 18 cycles per degree. Mean VEP amplitude measurements also changed significantly over time (P < .001) and showed a significant relationship between baseline and 12 month measurements (P < .001). A significant relationship was also established between baseline and 12 month VEP amplitude values at 100% of grating contrast. Patients with high myopia complained significantly more at a lower contrast threshold and at lower VEP amplitude values than patients with low myopia. Conclusions: Three months after PRK, contrast threshold and VEP amplitude values were reduced. Partial recovery was established at 6 months, although patients reported permanent impairment under low‐contrast conditions, especially if the myopia correction was more than 6.0 diopters.

Perioperative management of anticoagulated patients having cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists

&NA; An 11‐item questionnaire was mailed to 891 consultant members of the Royal College of Ophthalmologists (RCOphth) to audit compliance with RCOphth guidelines for perioperative management of anticoagulated patients having cataract surgery. Four hundred ninety‐nine questionnaires were analyzed. The results showed that 29.5% of respondents adhered to all aspects of RCOphth guidelines; that is, they checked the international normalized ratio (INR) preoperatively, continued warfarin, operated within the desired therapeutic INR range for the condition that warfarin was being used to treat (as set by the treating physician), and considered sub‐Tenon or topical anesthesia in anticoagulated patients.

Acute and Chronic Effects of Brimonidine 0.2% on Intraocular Pressure and Pulsatile Ocular Blood Flow in Patients with Primary Open-Angle Glaucoma: An Open-Label, Uncontrolled, Prospective Study

BACKGROUND Brimonidine has been reported to decrease aqueous production and increase uveoscleral outflow; however, the hemodynamic effects of brimonidine are still under investigation. OBJECTIVE The purpose of this study was to report the acute and chronic effects of brimonidine 0.2% on intraocular pressure (IOP) and pulsatile ocular blood flow (pOBF) in patients with primary open-angle glaucoma (POAG). METHODS Nonsmoking patients aged 45 to 67 years with POAG and normal blood pressure, heart rate, body mass index, and hemorheologic parameters were enrolled in the study. Brimonidine 0.2% was self-administered twice daily for 180 days. IOP and pOBF were determined using Goldmann applanation tonometry and the Langham system. All measurements were taken at baseline and 4, 8, and 12 hours after treatment and were repeated on days 7, 15, 30, 60, 90, 120, 150, and 180 of treatment. RESULTS Of the 18 eligible patients, 10 (6 men and 4 women) were enrolled (mean age, 51.5 +/- 4.39; range, 47-64 years). When measured 12 hours after instillation, mean IOP was significantly reduced by 21.5% (P < 0.001) compared with the baseline value. The greatest decrease in IOP (-23.5%) was observed at 8 hours. After 12 hours, a significant increase (P < 0.001) in pOBF was measured. A stable IOP reduction (P < 0.001 vs baseline), as well as an increase in pOBF (P = 0.015), was recorded at the subsequent time points. The pOBF increases ranged from 22.5% at day 30 to 9.2% at day 180 of treatment. No evidence of adverse events was found at any time point. CONCLUSIONS In this sample of patients with open-angle glaucoma, brimonidine induced a rapid reduction in IOP that was significant even after 6 months. Moreover, an increase in pOBF was observed from the first day of treatment, and remained consistent throughout the study.

A randomized, comparative study of fluorometholone 0.2% and fluorometholone 0.1% acetate after photorefractive keratectomy.

Purpose To compare the efficacy and tolerance of fluorometholone 0.1% acetate and fluorometholone 0.2% eyedrops in the postoperative management of photorefractive keratectomy (PRK). Methods A randomised single-blind comparative study was performed on two groups of 30 patients who underwent myopic PRK. The first group was given fluorometholone 0.1% acetate and the second fluorometholone 0.2%. Uncorrected and best corrected visual acuity, haze, IOP and local tolerance were evaluated. Statistical analysis was done using parametric and non-parametric tests. Results Visual acuity did not differ in the two groups; both were homogeneous as far as refractive error and haze were concerned. Three patients (10%) treated with fluorometholone 0.2% and two patients (6.6%) with fluorometholone 0.1% acetate developed ocular hypertension, but this was not statistically significant. Conclusions Fluorometholone 0.1% acetate was effective on inflammation after PRK, with the same efficacy as fluorometholone 0.2%.

Corneal temperature changes during photorefractive keratectomy using the Laserscan 2000 flying spot laser.

PURPOSE To evaluate the thermal variations during photorefractive keratectomy (PRK) induced by a Laserscan 2000 flying spot excimer laser. METHODS Thermal changes during PRK were recorded using a non-contact infrared thermometer on 58 eyes with an attempted correction ranging from -1.25 to -9.00 D. The eyes were randomly divided into two groups to test the thermal effects of two different ablation scan techniques: sequential and randomized modes. Thermal measurements were also performed during myopic ablations on polymethylmethacrylate (PMMA) test plates. RESULTS On PMMA plates, a significant relationship between the amount of attempted myopic correction and thermal changes was established (P=.017 in sequential mode and P=.007 in randomized mode); this was not established for human eyes. With the sequential mode, an unexpected cooling effect after PRK was reported for each myopia subgroup (P=.003 in the low and high myopia subgroups, P<.001 in the medium myopia subgroup). With the randomized mode, the cooling effect was detected only for low amounts of myopia. CONCLUSION Despite a high repetition rate, the Laserscan 2000 flying spot laser minimized thermal shock. In comparison with randomized (nonsequential) pulse application, sequential pulsing showed no increase in the thermal loading of corneas. In fact, a cooling effect during PRK was produced.

Retinal nerve fiber layer measurements using scanning laser polarimetry after photorefractive keratectomy

Purpose To assess the effects of corneal depth changes on retinal nerve fiber layer (RNFL) postoperative measurements in myopic patients who had undergone photorefractive keratectomy (PRK). Methods A total of 120 myopic patients underwent PRK for myopia (range −2 to −10 diopters) and were divided into three groups according to their myopic correction: lower than 3 diopters (low myopia group), between 3 and 6 diopters (medium myopia group), over 6 diopters (high myopia group). RNFL parameters were evaluated preoperatively and 5 days, 3 months and 6 months after surgery, using a GDx NFA II scanning laser ophthalmoscope. Results Significant changes were seen in the symmetry, superior maximum, and average thickness, comparing baseline with six-month measurements (p=0.008, 0.027, 0.015 respectively). Dividing the sample according to attempted myopic correction, it was found that mean postoperative RNFL thickness was significantly lower after PRK only in the high myopia group. Mean RNFL thickness did not change with time (p = 0.884). Ablation depth was correlated with a change in RNFL thickness by the sixth postoperative month for each group. These variables were significantly related only in the high myopia group (p=0.003). Conclusions As polarised light penetrates the ablation area, morphological and functional changes might affect Gdx NFA II measurements. It must always be borne in mind that RNFL thickness can decrease either in cases of glaucoma or after PRK for high myopia, so close attention must be paid to interpreting these measurements in patients who have undergone PRK.

Prospective randomized comparison of simultaneous and sequential bilateral photorefractive keratectomy for the correction of myopia

BACKGROUND AND OBJECTIVE To evaluate the efficacy and safety of simultaneous bilateral photorefractive keratectomy (PRK). PATIENTS AND METHODS There were 52 patients (104 eyes) with myopia less than -6 diopters entered in this prospective trial and randomized to simultaneous or sequential bilateral PRK. Main outcome measures were uncorrected visual acuity (UCVA), percentage of eyes within +/-0.5 D of attempted outcome, present pain intensity (PPI) and total pain rating index (PRI(R)T) scores resulting from McGill the Pain Questionnaire, subjective symptoms, haze, and patient satisfaction. Follow-up extended to 14 months. RESULTS There was no significant difference in UCVA (P=0.996) and percentage of eyes within +/-0.5 D of attempted correction (P=0.932). Present pain intensity and PRI(R)T scores were significantly higher in the sequential group (P=0.037; P=0.034). The percentage of satisfied patients after bilateral PRK was significantly higher in the simultaneous group (P=0.036). CONCLUSIONS Simultaneous bilateral PRK was safe and effective, without any significant difference from sequential treatment.

Frequency-doubling perimetry after photorefractive keratectomy

Purpose: To evaluate the effect of photorefractive keratectomy (PRK) on frequency‐doubling perimetry (FDP) patterns in myopic patients without glaucoma. Setting: Department of Ophthalmology, University of Bari, Bari, Italy. Methods: Sixteen myopic patients (16 eyes) with a spherical equivalent worse than −7.0 diopters were enrolled. The fellow eyes were used as controls. All patients had PRK for myopia. Using FDP, the mean defect (MD) and pattern standard deviation (PSD) were evaluated preoperatively and 2 weeks and 3 and 6 months after PRK. At the same examinations, the effect of the reprofiled cornea on the visual field was studied; the cornea was divided into 4 concentric zones (central, paracentral, lateral, and peripheral) and each median zone contrast sensitivity (MZCS) evaluated. Results: There was no difference in PSD and MZCS between treated eyes and controls in any zone at any time (P > .05). Longitudinally, there was no variation in any perimetry zone (P > .05). In treated eyes, there was a significant relationship among ablation depth, MD, and MZCS in all zones until 2 weeks after laser surgery (P < .02). Conclusions: Frequency‐doubling perimetry did not appear to be affected by corneal changes induced by PRK and can therefore be safely used in the early diagnosis of glaucoma.