Daniele Doro

A Critical Analysis of the Long-Term Results of Trabeculectomy

We analyzed the long-term results of trabeculectomy in a homogeneous group of 90 eyes (75 patients) followed up one to five years after surgery. The effect on intraocular pressure was considered stable after one year; complete success was achieved in 69 (71%) of cases with a further in 8 (9%) partial success in eight (9%). The pressure-lowering effect was closely related to the presence of a filtering bleb. The main complication was the late appearance of lens opacities, although these seemed less frequent than after other antiglaucoma operations. Lens opacities were particularly frequent in hypotonic eyes and may depend upon the process of aqueous humor filtration itself.

Reduced endothelial progenitor cells and brachial artery flow-mediated dilation as evidence of endothelial dysfunction in ocular hypertension and primary open-angle glaucoma.

Purpose:  This study aimed to assess vascular endothelial function in patients with ocular hypertension (OHT) or primary open‐angle glaucoma (POAG) by measuring: (a) endothelium‐dependent flow‐mediated vasodilation (FMD) of the brachial artery, and (b) circulating endothelial progenitor cells, which are believed to support the integrity of the vascular endothelium.

Retained intravitreal lens fragments after phacoemulsification: Complications and visual outcome in vitrectomized and nonvitrectomized eyes

Purpose: To evaluate the ocular complications and visual outcomes in vitrectomized and nonvitrectomized eyes with retained lens fragments after phacoemulsification. Setting: Department of Neurological, Psychiatric, and Ophthalmological Sciences, University of Padua, Padua, Italy. Methods: This prospective nonrandomized study comprised 36 consecutive patients with retained intravitreal lens fragments after phacoemulsification. Eighteen eyes had a pars plana vitrectomy (Group 1), and 18 eyes (Group 2) were treated with medication only. Intraocular pressure (IOP), intraocular inflammation, cystoid macular edema (CME), and best corrected visual acuity (BCVA) were evaluated 1, 3, and 6 months postoperatively. Results: Ophthalmoscopy and B‐scan echography showed that the lens fragments were significantly larger in Group 1 than in Group 2 (P < .03). An uncontrollable IOP rise and inflammation prompted an early vitrectomy in 11 eyes in Group 1. At the 6‐month follow‐up, the IOP with medications was acceptable in 2 and 5 eyes in Group 1 and Group 2, respectively. Intraocular inflammation was no longer detectable 1 month after vitrectomy but persisted during the entire follow‐up in Group 2. At 3 months, 5 eyes in Group 1 and 13 in Group 2 had CME and at 5 months, 3 eyes and 1 eye, respectively, had CME. The difference between groups was significant at both follow‐ups (P < .05). Three retinal detachments, 1 before and 2 after vitrectomy, occurred in Group 1. The mean BCVA in Group 1 was better than in Group 2 during the entire follow‐up; however, the difference was significant at 3 months only (P < .5). At 6 months, 94.4% in Group 1 and 83.2% in Group 2 had a BCVA of 20/50 or better and 66.6% and 55.5%, respectively, attained at least 20/30. Conclusions: Intraocular inflammation, increased IOP, and CME were major complications in nonvitrectomized eyes after phacoemulsification; retinal detachment occurred in 2 vitrectomized eyes. In eyes with intravitreal lens fragments after phacoemulsification, vitrectomy can yield faster visual rehabilitation and better quality of vision. Conservative management is feasible at the price of long‐term intraocular inflammation and slower restoration of comparable visual function.

Extranodal Rosai-Dorfman disease: involvement of eye, nose and trachea

Rosai-Dorfman disease (RDD) is a rare non-neoplastic histiocytic proliferative disorder characterized by painless lymphadenopathy. Extranodal lesions frequently occur in the head and neck regions. We report the clinical and histological features of extranodal RDD in a 43-year-old man with a previously unreported combination of multiple gross anterior epibulbar nodules in the right eye, submucosal masses of nasal septum and trachea, and no lymphadenopathy during the 12-year follow-up. The patient underwent ophthalmological, otolaryngological and systemic evaluation; gallium 67 scintigraphy; bronchoscopy; ophthalmic ultrasound; head and neck CT scan; biopsies of epibulbar, nasal and tracheal tissues; and septoplasty. Histological specimens showed lymphocytophagocytosis and positive immunoperoxidase staining for S100 protein in foamy histiocytes; both features were typical for RDD. No response to topical or systemic steroids or to radiation therapy was recorded. Removal of nasal septum masses resolved nasal obstruction. The diagnosis of RDD requires histological and, in challenging cases, immunohistological specimens and is difficult – especially with pure extranodal localizations as in our case. RDD should be suspected in cases of subconjunctival mass and/or submucosal nasal and tracheal swellings not responding to systemic steroids.

Choroidal vascular changes after transpupillary thermotherapy for choroidal melanoma

OBJECTIVE To evaluate choroidal vascular alterations after transpupillary thermotherapy used as the sole treatment for choroidal melanoma. DESIGN Prospective noncomparative interventional case series. PARTICIPANTS Forty-five eyes of 45 patients affected by malignant choroidal melanoma treated with transpupillary thermotherapy alone with more than 1 year of follow-up. INTERVENTION Transpupillary thermotherapy was performed through a panfunduscopic contact lens using an 810-nm diode laser. MAIN OUTCOME MEASURES Dynamic/static fluorescein and indocyanine green angiography were performed at scheduled intervals (24 hours, at 3-month intervals during the first year, and every 6 months thereafter) after transpupillary thermotherapy. Visual acuity, clinical evaluation, fundus photographs, and ultrasonographic examination were also performed. RESULTS The mean follow-up was 30.5 months (range, 12-54 months). Changes in the choroidal circulation were always confined within the treatment margins (except in one case) and characterized by occlusion of choriocapillaris (100%), patent medium and/or large choroidal vessels (76%), retinochoroidal anastomosis (11%), and progressive choroidal vascular remodeling (42%). Forty-one cases (91%) showed persistent clinical regression, and four cases (9%) recurred; recurrent cases showed retinochoroidal anastomosis. CONCLUSIONS Transpupillary thermotherapy is suggested as a new single therapeutic modality in the treatment of selected choroidal melanomas, but more precise eligibility criteria and longer follow-up are mandatory. Patent choroidal circulation, choroidal vascular remodeling, and anastomosis after transpupillary thermotherapy might be helpful to detect recurrent tumors.

Long-term follow-up with optical coherence tomography and microperimetry in eyes with metamorphopsia after macula-off retinal detachment repair

PurposeTo report the long-term sequential morphological and functional results in eyes with metamorphopsia after retinal detachment (RD) repair.Patients and methodsIn six eyes of six patients aged 58.7±11.0 years with metamorphopsia after successful buckling surgery for macula-off RD, best-corrected visual acuity (BCVA), fundus biomicroscopy, Amsler grid test, time-domain optical coherence tomography (TD-OCT) and central 12° microperimetry (MP-1) were performed at months 1, 3, 6, 12, and 18. At 5 to 6 years after surgery all patients underwent also spectral domain (SD)-OCT.ResultsThree eyes slowly recovered pre-RD BCVA. In the remaining three eyes—with good final BCVA—the interrupted junction line between photoreceptor cell inner and outer segments (IS/OS) was progressively less evident after RD surgery; and the external limiting membrane was preserved on SD-OCT examination. In all eyes post-operative metamorphopsia faded with time, but fully disappeared in 6 years only in two eyes without photoreceptor abnormalities. One of the two eyes with subretinal fluid up to 6 months and IS/OS disruption had central dense scotoma with relatively unstable fixation on MP-1 and persistent metamorphopsia. Macular sensitivity (MS) increased from 9.7±7.1 at month 1 to 13.5±5.6 dB at the final check, and was weakly (r=0.33) correlated with post-operative BCVA and OCT abnormalities.ConclusionLong-standing metamorphopsia can occur after successful macula-off RD repair even without detectable photoreceptor disruption on OCT. Post-operative BCVA recovery weakly correlates with increasing MS, and late restoration of the photoreceptor layer may be observed

Skin and Eye: Uncommon Sites of Distant Metastasis from Tongue Base Squamous Cell Carcinoma

The frequency of non-lymphatic distant metastases from primary head and neck squamous cell carcinoma (SCC) appears to be higher than previously presumed. The general conditions of the affected patients, who usually also present with locoregional recurrences, are so impaired as to limit the use of available methods for diagnosing the distant spread of head and neck SCC. The incidence reported in autopsy studies is approximately three to four times higher than that in clinical studies. Lung metastases from head and neck SCC are most common, followed by metastases to bone and liver. Metastases to the skin are unusual. Secondary ocular localizations of head and neck SCC are exceedingly rare. We report the first case of synchronous intraocular (involving the choroid and vitreous body) and cutaneous metastases from a recurrent tongue base SCC in a 64-year-old woman who had undergone radiotherapy, bilateral neck dissection and chemotherapy. Cytological evaluation of vitreous aspirate and histological diagnosis of the skin lesion were performed < 1 month before the patients death. Skin metastases occur in 1–4% of patients with diagnosed head and neck SCC and are usually associated with advanced or recurrent disease. To the best of our knowledge, fewer than 10 cases of ocular metastases from head and neck SCC have been reported. The average survival time after diagnosis of ocular or skin metastases from head and neck SCC is ≈ 7 months. Treatment for eye and skin metastases is palliative and rarely alters patient outcome.

Intracorneal blood removal six weeks after canaloplasty

In a 71-year-old patient with bilateral open-angle glaucoma, intracorneal blood was found after a canaloplasty procedure in the right eye. Six weeks after surgery on ultrasound biomicroscopy examination, liquified blood and blood clots could be observed nasally in the deep corneal stroma close to the Descemets membrane. The intracorneal blood was washed out with balanced saline solution following deep corneal incision and lamellar dissection. Descemets membrane was reattached with air injection into the anterior chamber. Two months later, visual acuity improved to 20/50, intraocular pressure was 16 mm Hg without medication and confocal microscopy showed deep stromal folds and limited endothelial cell loss. Viscoelastic entering the cornea at Schwalbes line and reflux of blood from the collector channels to Schlemms canal can account for corneal hematoma. Even six weeks after canaloplasty, successful blood removal could be fulfilled without rupturing the Descemets membrane.

Long-term Echographic Surveillance of Elevated Choroidal Nevi

PURPOSE To report the outcomes of choroidal nevi monitoring and to compare the detection of ultrasonographic hollowness, a risk factor of malignant transformation, from a B-scan with results from an A-scan examination. DESIGN Retrospective cohort study. METHODS Standardized A- and B-scan echography and ophthalmoscopy in 358 consecutive patients with median age 69 years and baseline choroidal nevus higher or lower than 1.5 mm in 51 (14%) and 307 (86%) eyes, respectively. RESULTS No growth or change in echographic or ophthalmoscopic features were found in 307 nevi with a median elevation of 0.9 mm (range, 0.7 to 1.5 mm) and a median follow-up of 6 years (range, 4 to 9 years). After 2 to 6 years, decreased internal reflectivity on standardized A-scan and ultrasonographic hollowness on B-scan were detected in 7 (18%) of 38 initially highly reflective choroidal nevi (thickness, 1.98 ± 0.37 mm); 2 (5%) nevi grew into melanoma 15 years after the first observation. Of 13 choroidal nevi (thickness, 2.75 ± 0.66 mm), with initial atypical medium to high reflectivity on standardized A-scan (100%) and hollowness on B-scan (85%), 6 (46%) were plaqued 6 to 15 months later because of the presence of multiple risk factors. CONCLUSIONS No changes in thickness or echographic features of choroidal nevi elevated up to 1.5 mm were recorded during the follow-up period. In initially typical choroidal nevi higher than 1.5 mm, strong agreement was detected between decreased reflectivity on standardized A-scan and ultrasonographic hollowness on B-scan found after up to 15 years of stability. The vast majority of choroidal nevi with initial atypical standardized A-scan features showed ultrasonographic hollowness.

First report of centroblastic lymphoma in a human immunodeficiency virus-positive patient with a rare congenital coagulation disorder (factor X Friuli).

The association of lymphoma and human immunodeficiency virus (HIV) seropositivity in a patient with a rare congenital clotting disorder (Factor X Friuli) is reported. The propositus was a previously asymptomatic HIV-positive 46-year-old man who suddenly presented a rapidly evolving right exophthalmos due to a centroblastic lymphoma, as the presenting symptom of full-blown AIDS. The clinical picture was characterized by unusual site of presentation, advanced stage and fatal course over a short period of time, despite therapy. Bone marrow, but not lymph node or parenchymal involvement, was present. Central nervous system involvement, with an unusual diffuse and massive pattern, and the B-cell origin of the lesion were demonstrated at autopsy. Few reports exist so far about the association of malignancy and HIV in patients with congenital coagulation disorders and this is the first report about a defect other than classic hemophilia.