Carlo Alberto Cutolo

Comparison of Central Corneal Thickness Measurements Using Ultrasonic Pachymetry, Anterior Segment OCT and Noncontact Specular Microscopy

Purpose: To evaluate and compare central corneal thickness (CCT) values measured with anterior segment optical coherence tomography (AS-OCT), noncontact specular microscopy (NCSM), and ultrasound pachymetry (USP). Materials and Methods: CCT was measured in 182 healthy eyes without ocular abnormalities other than refractive errors. Three consecutive measurements of CCT by the same examiner were obtained during the same session. The testing sequence of AS-OCT and NCSM was randomly selected. The USP always was performed after the noncontact examinations. Results: The average CCT measured by AS-OCT, NCSM, and USP were 535.8±35.5, 547.7±38.2, and 537.4±37.5 &mgr;m, respectively. The mean differences between modalities were 11.8±14.7 &mgr;m (P<0.01) between NCSM and AS-OCT, 10.3±17.7 &mgr;m (P<0.01) between NCSM and USP and 1.6±8.6 &mgr;m (P=0.02) between USP and AS-OCT. Conclusions: AS-OCT, NCSM, and USP showed an overall strong agreement in measuring CCT. However, CCT measurements with AS-OCT showed a good correlation to those obtained by USP, NCSM tended to give statistically significant higher CCT readings than either alternative and showed the worse repeatability indices. On the basis of our results, CCT measurement obtained with different instruments cannot be considered directly interchangeable.

The Use of Topical Corticosteroids for Treatment of Dry Eye Syndrome

ABSTRACT Dry eye disease (DED) is a multifactorial disease that results in symptoms of discomfort, visual disturbance, and damage to the ocular surface. Because chronic inflammation plays an important role in DED, treatment with topical corticosteroids has been demonstrated to ameliorate the signs and symptoms of the disease. Although these agents have proven short-term efficacy, their long-term use may cause intraocular pressure elevation and cataract progression. A carefully review of the different studies shows that differences between corticosteroids may exist regarding the incidence of side effects and evidence of efficacy in DED patients.

Color Doppler Imaging and Glaucoma: Comparison of Doppler Waveform of Retrobulbar Vessels between a Glaucomatous Patient and a Healthy Subject

Ocular blood flow abnormalities are believed to play an important role in the pathogenesis of primary open angle glaucoma (POAG). For this reason the Color Doppler Imaging (CDI) evaluation of the retro bulbar vessels is used for research purposes to investigate the degree of these abnormalities and their role in the pathogenesis of PAOG. The most widely measured variables are peak systolic velocity (PSV), end-diastolic velocity (EDV) and resistivity index (RI) of the ophthalmic artery, central retinal artery, and short posterior ciliary arteries. According to a recent study that has found statistically significant differences in two variables measured in the ophthalmic artery, the early systolic acceleration (ESA) and the ratio between the mean velocities of the systolic and diastolic components (Sm/Dm), we present the CDI evaluation of a case of normal tension glaucoma (NTG) compared to a healthy subject. The values obtained are in agreement with the literature and all the measured velocities, except for the PSV and the RIs in the ophthalmic artery that were respectively reduced and increased as compared to the healthy volunteer. Moreover, ESA is reduced and Sm/Dm increased. Further studies are needed to evaluate the degree of the pathological alterations and their role in the progression of the optic nerve injury.

Cataracts and Dupuytren disease: a case report and review of the literature

Purpose. Dupuytren disease is an inherited proliferative and progressive connective disease. Ectopic disease may, however, be located distant from the palmar fascia. Methods. Case report and review of the literature. Results. We describe a case of symmetric bilateral posterior subcapsular cataracts associated with symmetric bilateral Dupuytren disease and symmetric bilateral Ledderhose disease in a 56-year-old Caucasian man. His medical history was negative for glucocorticoids intake, diabetes, and exposure to radiation. Serum transforming growth factor β (TGF-β)1 concentration has been evaluated and was found to be almost double compared to the controls. Conclusions. We speculate that the TGF-β plays an important role for ocular and connective tissue disorders.

Glutathione S-Transferase Genotype polymorphism and Primary Open-Angle Glaucoma in an Italian population

Purpose Oxidative damage to the trabecular meshwork (TM) represents one of the pathogenic mechanisms leading to primary open angle glaucoma (POAG). Glutathione S-transferase mu 1 (GSTM1) may neutralizes reactive oxygen species protecting the TM. The present paper investigates the prevalence of GSTM1 null genotype in an Italian population, and its association with POAG treated either medically or surgically. Methods In a case-control study, the GSTM1 genotype was identified in POAGs and controls. The POAGs patients were divided in two groups: medical POAGs and surgical POAGS. Medical POAGs consisted of patients with a well-controlled intraocular pressure (IOP) by IOP-lowering medications and a stable visual field (VF). Patients with an uncontrolled IOP and a progressing VF that were submitted to incisional surgery formed the surgical POAGs’ group. Results We enrolled 104 medical POAGs, 158 surgical POAGs and 263 Controls. No significative differences between the groups existed regarding age and gender (p=0.275 and p=0.950, respectively). All the enrolled subjects were Caucasian of Italian descents. The GSTM1 null genotype was identified in 57 (45.2%) medical POAGs, 91 (57.6%) surgical POAGs and, 119 (45.3%) controls (p=0.033). The association between medical POAG and GSTM1 null status was non-significant (OR= 1.44, 95% IC = 0.86 to 2.39) whereas the association was significant for surgical POAGs (OR= 2.01, 95% IC= 1.26 to 3.21) Conclusions Our results showed an association between the GSTM1 null genotype and glaucoma that require surgery in an Italian population. GSTM1 null genotype detection may help to identify high-risk glaucoma patients that require a closer follow-up and a more aggressive treatments.

The Eye, Oxidative Damage and Polyunsaturated Fatty Acids

Polyunsaturated fatty acids (PUFA) are known to have numerous beneficial effects, owing to their anti-inflammatory and antioxidant properties. From a metabolic standpoint, the mitochondria play a fundamental role in cellular homeostasis, and oxidative stress can affect their functioning. Indeed, the mitochondria are the main source of ROS, and an imbalance between ROS and antioxidant defenses leads to oxidative stress. In addition, aging, the decline of cellular functions, and continual exposure to light underlie many diseases, particularly those of the eye. Long-term exposure to insults, such as UV light, visible light, ionizing radiation, chemotherapeutics, and environmental toxins, contribute to oxidative damage in ocular tissues and expose the aging eye to considerable risk of pathological consequences of oxidative stress. Ample antioxidant defenses responsible for scavenging free radicals are essential for redox homeostasis in the eye, indeed, eye tissues, starting from the tear film, which normally are exposed to high oxygen levels, have strong antioxidant defenses that are efficient for protecting against ROS-related injuries. On the contrary, instead, the trabecular meshwork is not directly exposed to light and its endothelial cells are poorly equipped with antioxidant defenses. All this makes the eye a target organ of oxidative damage. This review focuses on the role of the polyunsaturated fatty acids in the human eye, particularly in such pathologies as dry eye, glaucoma, and macular degeneration, in which dietary PUFA supplementation can be a valid therapeutic aid.

Comparison of local recurrence among early breast cancer patients treated with electron intraoperative radiotherapy vs hypofractionated photon radiotherapy An observational study

Purpose To evaluate local recurrence (LR) in women with early breast cancer (BC) who underwent intraoperative radiation therapy with electrons particles (IORT-E) or adjuvant hypofractionated external radiotherapy (HYPOFX). Materials and methods We retrospectively analyzed 470 patients with early BC treated at our center from September 2009 to December 2012. 235 women were treated with breast-conserving surgery and immediate IORT-E (21 Gy/1 fraction) while 235 patients underwent wide excision followed by hypofractionated whole-breast irradiation. Radiotherapy modality was chosen according to an individualized decision based on tumor features, stage, technical feasibility, age, and acceptance to be enrolled in the IORT-E group. Results After a median follow-up of 6 years, we observed 8 (3.4%) and 1 (0.42%) LR in the IORT-E and in the HYPOFX group (p = 0.02), respectively. The two groups differed in the prevalence of clinical characteristics (p < 0.05): age, tumor size, surgical margins, receptors, ki67, and histology. 4 and 1 woman in the IORT-E and HYPOFX group died of BC, respectively (p = 0.167). OS and DFS hazard ratio [HR] were 2.14 (95% IC, 1.10–4.15) and 2.09 (95% IC, 1.17–3.73), respectively. Conclusion Our comparison showed that IORT-E and HYPOFX are two effective radiotherapy modalities after conservative surgery in early BC. However, at 6 years a significant higher rate of LR occurred in patients submitted to IORT-E with respect to HYPOFX. This finding may be correlated to some subsets of patients who, depending on the biological characteristics of the BC, may be less suitable to IORT-E.

A Case of Neurotrophic Keratopathy Concomitant to Brain Metastasis

We report a case of a 63-year-old Caucasian female referred to the cornea service of Clinica Oculistica with a neurotrophic corneal ulcer, decreased corneal sensitivity, absent corneal reflex, and decreased lacrimation. The medical record review was relevant for mastectomy and adjuvant therapy for breast cancer complicated by pontocerebellar angle metastasis. Eye patching and application of antibiotic and vitamin ointments were prescribed at first, without a significant improvement. Thus, treatment with autologous serum was started. In about two weeks, the cornea recovered and visual acuity improved with a residual corneal scarring. Finally, we should mention that, in our case, the main cause of the neurotrophic corneal ulcer could be identified in the previous trigeminal damage at the pontocerebellar angle and trigeminal ganglion. Sensory nerves play an important regulatory role via neuro-mediators on corneal wound healing, as denervation may interfere with cellular metabolism and inhibit mitosis, leading to an epithelial defect even with no direct damage.

Phacoemulsification and Glaucoma

Cataract and glaucoma are main causes of blindness and visual impairment in Europe and worldwide. Both conditions are associated with the aging process, and their prevalence is expected to further inc

Computer-aided ophthalmic artery waveform analysis in healthy individuals and glaucoma patients

We thank Michael Brodsky for his interest in our study and for drawing our attention to a paper by Brodsky and Klaehn that examined optokinetic responses in humans with infantile esotropia using what the authors labeled an ‘‘optokinetic uncover test.’’ We commend Brodsky and Klaehn on the observations and conclusions that they draw from their study. However, we would like to point out some key differences between their study and our study. A major difference is in the construction and delivery of the stimulus. Brodsky and Klaehn presented the patients with an optokinetic stimulus, first monocularly to the fixating eye and then binocularly. Further, the stimulus itself was full field, that is, not localized to any part of the visual field of the deviated eye. In our study, we utilized a dichoptic presentation in which the optokinetic stimulus is presented only to the deviated eye (never binocularly) and the fixating eye sees only a stationary target. Moreover, the optokinetic stimulation is restricted to a 108 patch, and we observed optokinetic nystagmus (OKN) only when the patch occupied the central 108 of the deviated eye that included the fovea. We also made quantitative evaluations of the strength of the OKN response and its gradation with spatial location and contrast of the OKN stimulus, whereas the Brodsky and Klaehn study was essentially a qualitative evaluation of the OKN response. Therefore, in our view, the two studies are not directly comparable. However, our results do agree with one of the conclusions that they reached, which was that information is being processed via both eyes. In his letter, Brodsky does not question our results but perhaps suggests two additional discussion points with regard to our study: (1) The OKN responses that we observed are driven by a subcortical optokinetic circuit, that is, no cortical involvement, and (2) cortical suppression of the fovea of the deviating eye might still have been present because the OKN leaked through via the subcortical pathway. In response to his two points, we make the following arguments. (1) In strabismus, nasotemporal asymmetry is observed in motion detection, visually evoked potential (VEP) response, smooth pursuit, and OKN. Neurophysiological investigation in strabismic monkeys has shown loss of binocularity in cortical areas V1, MT, MST, and also in brainstem area nucleus of the optic tract (NOT). Therefore, as proposed by models in the literature, the loss of binocular connections in the pathway from V1 MT MST NOT could lead to asymmetric visual or oculomotor response to monocular motion stimuli. Subcortical projections (direct retina–NOT projections) may also play a role, but it is not clear that they play an exclusive or primary role in generating nasalward OKN in strabismus. (2) Our study was focused on identifying areas of retinal suppression in strabismus, and OKN was simply used as a readout to identify suppressed versus unsuppressed retina. Our data and conclusions fit in nicely with the previous work in the literature. For instance, Economides, Adams, and Horton used a visual psychophysical paradigm, and showed that the fovea of the deviated eye was not suppressed. In addition, other work from our lab in which we used a saccade paradigm to examine spatial patterns of fixation switch behavior (presumably driven by suppression) also revealed similar results. Taken together with these other studies, our current study does indeed support the idea of lack of suppression of the fovea of the deviated eye in exotropia. Finally, we would like to point out that the discussion points above are fundamentally speculative because neither Brodsky’s previous work nor our current study directly examined neural responses, and therefore cannot ascribe the optokinetic responses to cortical/subcortical pathways. As always in science, the best way to settle the issue would be to design and perform an appropriate experiment and quantitatively evaluate the data.