Carlo Sborgia

Accuracy of Orbscan optical pachymetry in corneas with haze.

Purpose: To compare corneal thickness measurements with the Orbscan instrument (Orbtek, Inc.) and an ultrasonic pachymeter (Alcon Surgical) in corneas with haze. Setting: Department of Ophthalmology and Otolaryngology, University of Bari, Bari, Italy. Methods: Six eyes of 6 patients having phototherapeutic keratectomy for treatment of grade 2+ haze were assessed preoperatively and postoperatively by Orbscan optical pachymetry and ultrasonic pachymetry. Contralateral transparent untreated corneas of the same patients were used as controls. Two Orbscan and 5 ultrasound pachymetry measurements were performed at each visit and the mean values recorded. The accuracy and repeatability of the measurements were evaluated. Results: Preoperatively, the median corneal thickness in the 6 eyes with haze was 512.7 &mgr;m by ultrasonic pachymetry and 375.0 &mgr;m by optical pachymetry. The mean difference of 143.1 &mgr;m was statistically significant (Wilcoxon signed rank test, P=.0277). Postoperatively, the median pachymetry was 439.0 &mgr;m and 433.0 &mgr;m, respectively; the mean difference was 10.7 &mgr;m (P= .0277). In the control group, the median ultrasonic pachymetry was 530.9 &mgr;m and the median optical pachymetry, 529.0 &mgr;m; the mean difference was 4.7 &mgr;m (P= .1730). Precision was good in all groups; the standard deviation was less than 6.0 &mgr;m. Conclusions: The Orbscan system showed a decreased accuracy in measuring corneal thickness when clinically significant haze was present. The repeatability of the measures was good, suggesting that the cause of error lies in the optical acquisition process.

Triamcinolone-assisted Pars Plana Vitrectomy for Proliferative Vitreoretinopathy

Purpose To determine whether triamcinolone acetonide (TAAC) staining facilitates posterior hyaloid and epiretinal membrane (ERM) removal in patients undergoing pars plana vitrectomy (PPV) for rhegmatogenous retinal detachment (RRD) with proliferative vitreoretinopathy (PVR). Methods Ten consecutive pseudophakic patients (10 eyes) underwent PPV for RRD with PVR. After a core PPV, a few drops of a commercially available TAAC aqueous suspension (40 mg/mL) with vehicle were injected into the mid vitreous cavity to visualize the posterior hyaloid, thus allowing a complete posterior hyaloidectomy. Next, 0.1 to 0.2 mL of TAAC was applied on the retinal surface to visualize and peel the ERMs. The tamponading agent was silicone oil (1,300 cs) in eight eyes and perfluropropane (C3F8 14%) in two eyes. The minimal follow-up period in all patients was 4 months. Results In all patients, intraoperative staining with TAAC consistently improved direct visualization and delineation of the posterior hyaloid and ERMs and facilitated their removal. No adverse reaction related to the use of TAAC was observed immediately postoperatively or 4 months after surgery. Conclusions Intravitreal TAAC may be an important adjuvant tool in the delineation of posterior hyaloid and ERMs, allowing for a more complete and safer ERM removal in the surgical management of PVR complicating RRD. It is well tolerated with all its vehicle if used at low concentration and rapidly removed during surgery.

Topography-driven photorefractive keratectomy: Results of corneal interactive programmed topographic ablation software

OBJECTIVEnThis study evaluated the efficacy, predictability, stability, and safety of a software program (Corneal Interactive Programmed Topographic Ablation (CIPTA) LIGI, Taranto, Italy) which, by transferring programmed ablation from the corneal topography to a flying-spot excimer laser, provides customized laser ablation.nnnDESIGNnNoncomparative consecutive case series.nnnPARTICIPANTSnForty-two eyes of 34 subjects with a mean age of 33.9 (range, 20-54) had CIPTA at the Cattedra di Ottica Fisiopatologica of Bari (Italy). Twenty-eight eyes were treated for hyperopic astigmatism and 14 for myopic astigmatism. All the subjects had irregular astigmatism. OPERATION: Topography was acquired by a corneal topography mapping system (Orbscan, Orbtek, Inc., Salt Lake City, UT). These data were processed to obtain a customized altimetric ablation profile, which was transferred to a flying-spot laser (Laserscan 2000, Lasersight, Orlando, FL).nnnMAIN OUTCOME MEASURESnData on uncorrected (UCVA) and best-corrected visual acuity (BCVA), predictability, and stability of refraction and any complications were analyzed.nnnRESULTSnMean follow-up was 13.2 months. At the last postoperative examination, 26 eyes (92.8%) in the hyperopic group and 12 eyes (85.7%) in the myopic group had an UCVA superior to 20/40. Twelve hyperopic eyes (42.8%) and five myopic eyes (35.7%) had a UCVA of 20/20. All patients fell between 1 diopter of attempted correction in the spherical equivalent. Only 1 (2.4%) of the 42 eyes, belonging to the hyperopic group, lost 1 Snellen line of BCVA. We did not observe any decentration and/or haze after photorefractive keratectomy treatment or any irregularity in the flap-stroma interface in the three laser in situ keratomileusis operations performed in this study.nnnCONCLUSIONSnThe combination of topographic data with computer-controlled flying-spot excimer laser ablation is a suitable solution for correcting irregular astigmatism due to different causes.

Photorefractive keratectomy followed by cross-linking versus cross-linking alone for management of progressive keratoconus: two-year follow-up.

PURPOSEnTo compare visual, refractive, topographic, and corneal higher-order aberration outcome at the 2-year follow-up after customized photorefractive keratectomy (PRK) followed by cross-linking (CXL) as a single procedure versus CXL alone in eyes with progressive keratoconus.nnnDESIGNnProspective, interventional, nonrandomized clinical trial.nnnMETHODSnSeventeen patients (34 eyes) with progressive keratoconus were assigned to 2 groups: the worse eye (17 eyes) was assigned to the PRK plus CXL group and the better eye (17 fellow eyes) was assigned to the CXL group.nnnRESULTSnIn the PRK plus CXL group, uncorrected distance acuity improved significantly, from a mean ± standard deviation of 0.63 ± 0.36 logarithm of the minimal angle of resolution (logMAR) units to 0.19 ± 0.17 logMAR units (P < .05) and best distance acuity from 0.06 ± 0.08 logMAR to 0.03 ± 0.06 logMAR (Pxa0<xa0.05). Manifest refraction spherical equivalent and spherical and cylindrical power improved significantly (P < .05). Simulated keratometry, flattest, steepest, average, cylindrical, apex keratometry, and inferior-superior value decreased significantly (P < .05). Total and coma-like aberrations significantly decreased for all pupil diameters (P < .05). In the CXL group, uncorrected distance acuity improved, but not significantly, from 0.59 ± 0.29 logMAR units to 0.52 ± 0.29 logMAR units, and best distance acuity improved from 0.06 ± 0.11 logMAR units to 0.04 ± 0.07 logMAR units (P > .05). Manifest refraction spherical equivalent and cylindrical power improvement was not significant (P > .05), unlike spherical power (P < .05). Steepest simulated keratometry, average simulated keratometry, and inferior-superior value significantly decreased (P < .05), unlike flattest simulated keratometry, cylindrical simulated keratometry, and apex keratometry (P > .05). Total and coma-like aberrations were not decreased significantly for all pupil diameters (P > .05). No significant endothelial changes were observed in either group.nnnCONCLUSIONSnThe PRK plus CXL procedure may bexa0a good option to reduce corneal aberrations and stabilize corneas with progressive keratoconus.

Intravitreal triamcinolone acetonide in refractory pseudophakic cystoid macular edema: functional and anatomic results.

Purpose To evaluate safety and efficacy of intravitreal triamcinolone acetonide (TAAC) injections in the treatment of refractory pseudophakic cystoid macular edema (CME). Methods Seven eyes of six patients (age range: 50–74) with pseudophakic CME resistant to standard treatment received intravitreal injections of 4 mg of TAAC with all vehicle. Mean preinjection duration of CME was 18.3 months. A mean of 2.1±1.2 (range 1 to 4) treatments were performed in four eyes (57.1%) when visual acuity deteriorated towards baseline levels. Visual acuity assessment, optical coherence tomography (OCT), and fluorescein angiography (FFA) were performed pre- and postoperatively to evaluate results of TAAC injections. Intraocular pressure (IOP) and complications related to treatment were assessed. Results After 11.1±3.9 months, mean best-corrected visual acuity (BCVA) increased (p=0.019) from 20/132 to a best value of 20/38. Mean macular thickness decreased from 517.29±146.98 mm to a best value of 263.71±83.13 mm (p=0.0018). Area of fluorescein leakage decreased (p<0.0001) from 11.84±0.93 mm2 at baseline to a minimal value of 3.86±0.98 mm2. The anatomic and functional improvement appeared after 1 month from the intravitreal injection and persisted through at least 3 months of follow-up. At the end of follow-up BCVA, macular thickness, and area of fluorescein leakage did not differ from baseline. Four eyes (57.1%) developed IOP values higher than 21 mmHg, controlled by topical treatment. Two patients developed an endophthalmitis-like reaction. Conclusions Intravitr eal TAAC was relatively safe and effective in resistant cases of pseudophakic CME with a temporary beneficial effect on visual acuity and macular edema.

Photodynamic therapy with verteporfin for retinal angiomatous proliferation

PurposeThe aim of this study was to evaluate the results of photodynamic therapy (PDT), using verteporfin, for subfoveal neovascular age-related macular degeneration (ARMD) with retinal angiomatous proliferation (RAP) with pigment epithelial detachment (PED) and/or choroidal neovascularization (CNV).MethodsIn this non-comparative, consecutive, interventional, case series, the data on 21 eyes (19 with stagexa02 and two with stagexa03 RAP) of 20 patients were reviewed. Serous PED occupied more than 50% of the lesion in 19 eyes. PDT was performed as per TAP protocol. Biomicroscopy and fluorescein and indocyanine-green angiography were performed to evaluate anatomical results and need for retreatment. Changes from baseline in best-corrected visual acuity (BCVA), and complications, were assessed.ResultsA mean of 3.5±0.9 treatments was performed. After 13.7±2.2 months, mean BCVA decreased from 20/80 to 20/174 (P=0.0063). In six eyes (28.6%) BCVA remained stable, whereas in 15 eyes (71.5%) it decreased. Occlusion of RAP and flattening of PED was observed in three (14.2%) eyes, conversion to disciform lesion in one (4.7%), and persistence of PED in 11 eyes (52.3%). One eye (4.7%) evolved to haemorrhagic PED, and one (4.7%) toward stagexa03 RAP. A tear in the retinal pigment epithelium (RPE) was observed in four eyes (19%). Eleven (52.3%) showed progression of leakage, six moderate leakage (28.6%), and three (14.2%) absence of leakage.ConclusionsTimely PDT with verteporfin in the early stages in eyes with smaller lesions has the potential for a beneficial effect on vision, whereas it might worsen the natural course of larger lesions, with most eyes undergoing enlargement, disciform transformation or RPE tear.

Corneal Interactive Programmed Topographic Ablation customized photorefractive keratectomy for correction of postkeratoplasty astigmatism

OBJECTIVEnThis study evaluated the efficacy, predictability, stability, and safety of a software program (Corneal Interactive Programmed Topographic Ablation [CIPTA], LIGI, Taranto, Italy), which, by transferring programmed ablation from the corneal topograph to a flying-spot excimer laser, provides customized laser ablation for correction of postkeratoplasty astigmatism.nnnDESIGNnNoncomparative consecutive interventional case series.nnnPARTICIPANTSnTen eyes of 10 patients with a mean age of 41.4 years (range, 26-64) had CIPTA-guided photoastigmatic refractive keratectomy (PARK) at the Clinica Oculistica of Bari (Italy). Two patients were treated for hyperopic astigmatism and eight for myopic astigmatism. All the patients had irregular astigmatism after penetrating keratoplasty. OPERATION: Topography was acquired by a corneal topograph (Orbscan II, Orbtek, Inc., Salt Lake City, UT). This, together with refractive data, was processed to obtain a customized altimetric ablation profile that was transferred to a flying-spot laser (Laserscan 2000, Lasersight, Orlando, FL).nnnMAIN OUTCOME MEASURESnData on uncorrected (UCVA) and best-corrected (BCVA) visual acuity, predictability, stability of refraction, and any complications were analyzed.nnnRESULTSnMean follow-up was 8.4 months (range, 6-12; SD 2.4). At the last postoperative examination, seven eyes (70%) had a UCVA superior to 20/40. Three eyes (30%) had a UCVA of 20/20. Five eyes (50%) were within 0.50 diopters (D) of attempted correction in the spherical equivalent, and eight eyes (80%) within 1 D. Index of success of astigmatic correction was 0.19. All the eyes (100%) gained Snellen lines of BCVA. We did not observe any decentration and/or haze after PARK treatment performed in this study.nnnCONCLUSIONSnThe combination of topographic data with computer-controlled flying-spot excimer laser ablation is a suitable solution for correcting irregular astigmatism after penetrating keratoplasty.

Topography-driven excimer laser for the retreatment of decentralized myopic photorefractive keratectomy

OBJECTIVEnThis study evaluated the efficacy, predictability, stability, and safety of a software program (Corneal Interactive Programmed Topographic Ablation, CIPTA, LIGI, Taranto, Italy), which, by transferring programmed ablation from the corneal topograph to a flying-spot excimer laser, provides customized laser ablation for correction of postmyopic photorefractive keratectomy (PRK) decentrations.nnnDESIGNnNoncomparative consecutive case series.nnnPARTICIPANTSnThirty-two eyes of 32 subjects with a mean age of 35 years (range, 19-49; standard deviation [SD], 7.9) had CIPTA-guided PRK at the Clinica Oculistica of Bari University (Italy). All the subjects had irregular astigmatism after postmyopic PRK because of clinically significant, decentered treatments of more than 1 mm. OPERATION: Individual topographies were acquired by a corneal topograph (Orbscan II, Orbtek, Inc., Salt Lake City, UT). These, together with refractive data, were processed to obtain a customized altimetric ablation profile that was transferred to a flying-spot laser (Laserscan 2000, Lasersight, Orlando, FL).nnnMAIN OUTCOME MEASURESnThe topographic study of centration and data on uncorrected (UCVA) and best-corrected (BCVA) visual acuity, predictability, and stability of refraction, and any complications, were analyzed.nnnRESULTSnMean follow-up was 10.3 months (range, 4-18 months; SD, 5.8). At the last postoperative examination, 29 eyes (90.6%) had a UCVA superior to 20/40. Nineteen eyes (59.4%) had a UCVA of 20/20. Twenty-two eyes (68.75%) were within 0.50 diopters (D) of attempted correction in the spherical equivalent and 28 eyes (87.5%) were within 1 D. The index of success of astigmatic correction was 0.15. No eye lost Snellen lines of BCVA, whereas 18 eyes (56.25%) gained Snellen lines. Postoperative topographies revealed well-centered treatments.nnnCONCLUSIONSnThe combination of topographic data with computer controlled flying-spot excimer laser ablation is a suitable solution for correcting irregular astigmatism after postmyopic PRK decentrations.

Fundus autofluorescence and multiple evanescent white dot syndrome.

Objective: To describe fundus autofluorescence (FAF) in a series of patients with multiple evanescent white dot syndrome. Methods: Three eyes of three patients with multiple evanescent white dot syndrome were evaluated with indocyanine green angiography and FAF imaging to evaluate the correspondence between FAF and ICG patterns and the nature of the focal hypocyanescent spots evident with ICG. Results: In the acute phase, all three eyes showed increased autofluorescence area corresponding precisely to the site of the focal hypocyanescent spots seen on ICG but less numerous. After 2 months, mean best-corrected visual acuity improved from 20/38 to 20/20 and FAF and indocyanine green angiography returned to normal pattern. Discussion: FAF is an useful noninvasive diagnostic adjunct to identify multiple evanescent white dot syndrome, suggesting the inflammatory nature of the disease, probably due to perturbation of the photoreceptor-retinal pigment epithelium complex affecting the function of these cells.

Combined Topical anesthesia and sedation for open-globe injuries in selected patients

PURPOSEnTo evaluate the efficacy and safety of topical anesthesia (TA) and IV sedation in surgery for less severe open-globe injury (OGI).nnnDESIGNnNoncomparative consecutive interventional case series.nnnPARTICIPANTSnOf 67 OGI cases reviewed at the Department of Ophthalmology and Otolaryngology, University of Bari, Bari, Italy, in the period from 1999 to 2000, 10 eyes (14.9%) of 10 consecutive patients (age range, 6-58 years) were repaired using TA and IV sedation. All patients belonged to the American Society of Anesthesiologists risk class I or II. Nine eyes had corneoscleral wounds, four had vitreous loss, two had traumatic cataract, and three had an intraocular foreign body (IOFB); one patient had interruption of a continuous penetrating keratoplasty suture. Preoperatively, best-corrected visual acuity (BCVA) ranged from hand movement to 20/20.nnnINTERVENTIONnCorneoscleral suture was performed in nine patients, vitreous excision in four, uveal excision or reposition in four, IOFB removal in three, and cataract extraction in two; corneal button resuture was carried out in one patient. All patients received topical oxybuprocaine hydrochloride 0.4%, and IV propofol, midazolam, and fentanyl for anesthesia.nnnMAIN OUTCOME MEASURESnThe change in BCVA was evaluated. Within 24 hours after surgery, each patient was asked to grade subjective pain and discomfort on a 4-point scale. The surgeon was asked to report difficulties attributable to the operating conditions. Complications related to anesthesia and to surgery were assessed.nnnRESULTSnBest-corrected visual acuity stabilized or improved in all patients. All patients had grade 1 pain and discomfort during most of the procedure. All patients had grade 2 (mild) pain and discomfort during external bipolar cautery and conjunctival closure. No patient required additional anesthesia. The operating conditions as reported by the surgeons were graded slightly difficult in all cases but one, which was graded moderately difficult. No patient had surgical or anesthesia-related adverse events or life-threatening complications.nnnCONCLUSIONSnTopical anesthesia and IV sedation are safe and effective and could be a reasonable alternative for less severe OGI. The degree of patient discomfort is only marginal during surgery and postoperatively. However, surgical training and patient preparation are the keys to the safe use of this anesthetic modality.