Carlos Laria

Combined Non-Steroidal Therapy in Experimental Corneal Injury

PURPOSE The effects of anti-inflammatory non-steroidal therapy combined with free-radical scavengers were studied and compared to corticosteroid use in the treatment of experimental corneal injury. METHOD Eighty New Zealand albino rabbits were used in this study. A corneal alkali burn was induced by applying 1-N NaOH filter paper on the central axis of the right cornea for 30 s. Animals were distributed into five treatment groups: group 1 (control group) was only given gentamicin; group 2 was treated with 0.5% dimethylthiourea (DMU); group 3 received 1% dexamethasone; group 4 was given combined 0.5% DMU and 1% indomethacin; group 5 was treated with 0.5% DMU and 0.1% diclofenac sodium. One 50-microliter drop of gentamicin was instilled every 12 h, whereas the other drugs were instilled every 6 h (50 microliters). All groups received the same antibiotic treatment as the control group. The animals were killed on the 5th day. Inflammatory index, area and perimeter of the wounded corneal zone, and corneal transparency were evaluated. RESULTS No significant differences in the inflammatory index were found between the treatment groups and the control group after 72 h. Significant differences (p < 0.001) were observed at 24 h in groups 3-5 when compared with the control group. Planimetry showed significant differences in group 4 when compared with the other groups (p < 0.05). Corneal transparency study showed statistically significantly better values in groups 4 and 5, when compared with the other groups, including group 3 (p < 0.05). CONCLUSIONS The use of 0.5% DMU combined with 1% indomethacin can be considered an alternative to corticosteroid treatment in our experimental chemical corneal injury.

Phakic Intraocular Lens Implantation for Treatment of Anisometropia and Amblyopia in Children: 5-year Follow-up

PURPOSE To evaluate the safety and efficacy during 5-year follow-up of phakic intraocular lens (PIOL) implantation to correct high anisometropia in amblyopic children who were non-compliant with traditional medical treatment including spectacles or contact lenses. METHODS Retrospective study of 10 eyes of 10 children with high anisometropia who underwent PIOL implantation (9 with an iris-supported IOL and 1 with a posterior chamber IOL). Patient age at the time of implantation ranged from 2 to 15 years. Mean preoperative spherical equivalent refraction was -10.14 ± 6.96 diopters (D) (range: +8.00 to -18.00 D). Mean logMAR corrected distance visual acuity (CDVA) was 0.84 ± 0.52. Postoperative data at 6, 24, and 60 months were evaluated. RESULTS Corrected distance visual acuity improved in all children. At 24 months, logMAR CDVA was 0.39 ± 0.35 and at 5 years was 0.36 ± 0.38 (range for both: 0.1 to 1.0) (P=.01). Improvement of more than three logMAR lines of CDVA was achieved in all children except for one (one line improvement) who was implanted with a posterior chamber PIOL. No loss of CDVA was detected in any patient. Five years after surgery, endothelial cell count was >2000 cells/mm(2) in eight (80%) patients; for the remaining two patients, one reported frequent eye rubbing and the other suffered ocular trauma. CONCLUSIONS Phakic IOL implantation in children with anisometropic amblyopia showed a positive long-term impact on visual acuity.

Pediatric refractive surgery and its role in the treatment of amblyopia: meta-analysis of the peer-reviewed literature.

PURPOSE To provide an overview of the visual outcomes after pediatric refractive surgery in anisometropic amblyopia and to analyze the relationship of these outcomes with age and type of refractive surgery. METHODS Systematic searches in PubMed, Embase, and Web of Science databases without data restrictions and a search by surveillance of the literature regarding pediatric refractive surgery were performed. Only studies reporting individual data of pediatric cases (age 1 to 17 years) undergoing photorefractive keratectomy (PRK), laser epithelial keratomileusis (LASEK), and LASIK were included. A total of 15 articles including data from a total of 213 amblyopic eyes were considered: LASIK in 95 eyes and surface ablation in 118 eyes. Changes in uncorrected (UDVA) and corrected distance visual acuity (CDVA) were investigated as well as their relation with age and ablation type. RESULTS A significant increase in logMAR UDVA and CDVA was found in the overall sample of amblyopic eyes after surgery (P<.001). A significant correlation was found between age and preoperative CDVA (r=0.34, P<.001) as well as between age and the change in CDVA after surgery (r=-0.38, P<.001). The change in UDVA was significantly superior for eyes undergoing surface ablation compared to those undergoing LASIK (P=.04). Corneal haze was the predominant complication, which was reported in 5.3% of LASIK cases and 8.5% of surface ablation cases. CONCLUSIONS Laser refractive surgery is an effective option for improving the visual acuity in children with an amblyopic eye in association with anisometropia.

Corneal higher-order aberrations in amblyopia

Purpose To investigate the amount, type, and role of corneal higher order aberrations in both isotropic and anisometropic amblyopic adult patients. Methods A total of 125 eyes of 78 patients with age ranging from 18 to 67 years (30 patients with unilateral amblyopia, 17 with bilateral amblyopia, and 31 normal eyes considered as the control group) were included. All eyes received a comprehensive ophthalmologic examination that included corneal topographic and aberrometric analysis with the CSO system. The aberrometric study was performed for a 6-mm pupil using different root mean square (RMS) parameters. Additionally, the ocular residual astigmatism (ORA) was also calculated and analyzed. A comparative analysis of the refractive and aberrometric data between groups was performed. Results In the unilateral amblyopia group, statistically significant differences between the amblyopic and non-amblyopic eye were found in cylinder (p=0.003), best-corrected visual acuity (BCVA) (p<0.001), total RMS (p=0.015), and astigmatic RMS (p=0.019). Statistically significant differences between the bilateral amblyopia and control groups were observed in sphere (p=0.025), cylinder (p=0.005), and BCVA (p <0.001). When comparing isometropic and anisometropic bilateral amblyopic eyes, significant differences in total (p=0.025) and astigmatic RMS (p=0.013) were detected. Higher but nonsignificant amounts of primary coma were found in isometropic eyes (0.25 μm anisometropic vs 0.43 μm isometropic, p=0.09). Regarding the ORA, no significant differences between groups were found (p≥0.224). Conclusions In unilateral and bilateral amblyopia, lower order aberrations are the main refractive factors leading to amblyopia. Higher order aberrations could have a bilateral amblyogenic effect in those cases where isometropia is present.

Conversion visual loss: a differential diagnosis in infant amblyopia.

Purpose To report the first case of amblyopia due to a conversion disorder in a child. Methods A 9-year-old girl without allergies or family or personal antecedents of interest presented to our clinic. She manifested a progressive visual loss after an episode of lumbar pain. This progressive loss led the patient in a 6-month period to legal bilateral blindness: visual acuity inferior to 2/20 in both eyes and severe constriction of both visual fields. Results Several pathologic processes were discarded by means of multiple explorations and a general multidisciplinary analysis: physical pathology, simulating patient, schizophrenia, and the Briquet syndrome. Finally, she was diagnosed with a conversion somatoform disorder leading to a bilateral blindness. For 6 months, the patient was successfully treated with psychotherapy and a pharmacologic protocol. Total recovery was achieved with final visual acuity of 20/20 in both eyes and normal visual fields. Conclusions Conversion disorders should be considered as an additional etiology of visual loss in children. In these cases, the analysis and multidisciplinary treatment is crucial for a successful outcome.

Botulinum Toxin as an Alternative to Treat the Spasm of the Near Reflex.

Abstract We describe the case of an eight-year-old girl with complaints of headaches and blurred vision (uncorrected visual acuity: 0.1 decimal) that showed on examination miotic pupils, pseudomyopia, no ocular motility restrictions, and no associated neurological disease. After initial treatment with cyclopentolate for two months, pseudomyopia persisted with an intermittent and variable esotropia. Spectacles of +1 both eyes and atropine 1% one drop daily were then prescribed. The situation improved and remained stable for several weeks, with pseudomyopia and esotropia reappearing later. Finally, botulinum toxin (2.5 iu Botox®) was injected in the medial rectus muscle on two occasions and a visual therapy program based on the stimulation of fusional divergence, diplopia, and stereopsis consciousness was recommended. This prescription was combined with the use of atropine during the first few weeks. Orthotropia and corrected distance visual acuity of 1.0 were found three months after treatment. The evolution and clinical results of this case report suggest that botulinum toxin in combination with other therapeutic alternatives may be useful in the treatment of spasm of the near reflex.

Adjustable muscle plication: a new surgical technique for strabismic patients with high risk for anterior segment ischemia

Anterior ciliary arteries provide 70% of the vascular supply of the anterior segment. A significant interruption of the vascular flow of these arteries increases the risk for anterior ischemia. Although the frequency of this special condition is low after strabismus surgery (1:13 000)[1], its effects may involve substantial visual problems[2]. We report the successful outcome of a new surgical approach for strabismus management in a case of high risk for anterior ischemia. Specifically, we show the correction of the horizontal ocular deviation by means of an adjustable muscle plication technique based on the Wright method in a patient with a history of III cranial nerve palsy combined with a thyroid myopathy and multiple previous strabismus surgical procedures.

Relevance of ocular motility on refractive surgery: how to avoid unexpected complications

Refractive surgery can be considered as one of the most successful subspecialities of ophthalmology, as it started and developed fully in the second half of the 20th Century. The correction of refractive errors, most of them in normal eyes, has given a completely new perspective to ophthalmic practice and has had tremendous consequences on the quality for life by improving the quality of vision in many patients. As usual in biology, the visual function needs to be considered as a whole, in an integrated perspective. Different areas of ophthalmology, apparently unrelated to refractive surgery, have finally found their way to influence refractive surgery outcomes. This is the case for strabology and, more precisely, ocular motility conditions in the refractive surgery patient. As an example, all refractive surgeons know the relevance of adequate cycloplegic refraction in hyperopic patients in order to ascertain the manifest refraction or the total refraction to be corrected. The relevance of refractive examination in the hyperop is well known if an ocular motor imbalance happens to occur. The knowledge of the refraction is as relevant for the treatment of strabismus for the refractive surgeon as the knowledge of ocular motility in the hyperopic patient. The development of ocular motility complications and imbalances following refractive surgery is an issue that will be difficult to accept for the patient and, indeed, will complicate the outcome and patient satisfaction if postoperative diplopia, such as strabismus, develops following a refractive surgery procedure. Another relevant aspect is the correction of astigmatism, especially with lasers with poor tracking or torsional movements that are inadequate to follow. Astigmatism is affected by torsional movements and they even happen to change from standing to supine positions [1,2]. Any disassociation of the excimer laser ablation or its optic alignment with the visual axis or the astigmatic meridian will also affect this outcome [3]. The refractive surgeon should acknow ledge torsional movements and their relation to latent strabismus, which are present more frequently than usually reported, and their impact on the patient’s quality of life through astenopia and inadequate visual and refractive outcomes. Refractive surprises may occur in these conditions and, in these cases, they will be very difficult to treat [4,5]. The latest generation of excimer lasers are equipped with iris registration and active, sophisticated, 5D eye-tracking techniques, tracking not only the horizontal and vertical movements but also torsional and rolling, thereby avoiding these refractive surprises in patients with ocular motor imbalance or movements during surgery. Unexpected decentered ablations have been positively avoided with the use of this improved technology. The study of the ocular motility has experienced great advances in the last few decades [6–9], thanks to the development of eye-tracking techniques, that were first developed for refractive surgery and then used for the tracking of ocular motility and strabismus. Recently developed video oculographic systems, which allow the examination of ocular motility under Jorge L Alió, MD, PhD