Elena Pacella

Preliminary results of an intravitreal dexamethasone implant (Ozurdex ® ) in patients with persistent diabetic macular edema

Background To evaluate the efficacy and safety of an intravitreal dexamethasone implant (Ozurdex®; Allergan Inc, Irvine, CA, USA) in patients with persistent diabetic macular edema (DME) over a 6-month follow-up period. Methods Seventeen patients (20 eyes) affected by DME were selected. The mean age was 67 + 8 years, and the mean duration of DME was 46.3 + 18.6 months. The eligibility criteria were: age ≥ 18, a best-corrected visual acuity between 5 and 40 letters, and macular edema with a thickness of ≥275 μm. Thirteen patients had also previously been treated with anti-vascular endothelial growth factor medication. Results The mean ETDRS (Early Treatment Diabetic Retinopathy Study) value went from 18.80 + 11.06 (T0) to 26.15 + 11.03 (P = 0.04), 28.15 + 10.29 (P = 0.0087), 25.95 + 10.74 (P = 0.045), 21.25 + 11.46 (P = 0.5) in month 1, 3, 4, and 6, respectively. The mean logMAR (logarithm of the minimum angle of resolution) value went from 0.67 + 0.23 (at T0) to 0.525 + 0.190 (P = 0.03), 0.53 + 0.20 (P = 0.034), and 0.56 + 0.22 (P = 0.12) in month 1, 3, and 4, respectively, to finally reach 0.67 + 0.23 in month 6. The mean central macular thickness value improved from 518.80 + 224.75 μm (at T0) to 412.75 + 176.23 μm, 292.0 + 140.8 μm (P < 0.0001), and 346.95 + 135.70 (P = 0.0018) on day 3 and in month 1 and 3, respectively, to then increase to 476.55 + 163.14 μm (P = 0.45) and 494.25 + 182.70 μm (P = 0.67) in month 4 and 6. Conclusion The slow-release intravitreal dexamethasone implant, Ozurdex, produced significant improvements in best-corrected visual acuity and central macular thickness from the third day of implant in DME sufferers, and this improvement was sustained until the third month.

Age‐Related Changes in Rat Optic Nerve: Morphological Studies

Age‐related changes of the optic nerve were studied in 3‐month‐old (young), 12‐month‐old (adult) and 24‐month‐old (aged) male Sprague–Dawley rats. Cross sections of the intracranial portion of the optic nerves of animals of different age groups were stained with haematoxylin–eosin and examined under a light microscope at low and high magnification. Other sections were stained with crystal violet for demonstration of glial cells. A third group of sections were stained immunohistochemically to detect glial fibrillary acidic protein (GFAP) which is a marker for localizing and characterizing astrocytes. All morphological results were subjected to the quantitative analysis of images and to statistical analysis to identify significant morphometrical data. Tissue protein concentrations were determined on homogenized fragments of optic nerve. Our results demonstrate the following age‐related changes : (1) increase of the optic nerve sheaths (meningeal membranes); (2) increased number of astrocytes; (3) increase of areal density of GFAP immunoreactivity; (4) increased diameter and area of the optic nerve; (5) decreased number of nerve fibres; (6) decreased size of nerve fibres and (7) decrease of the nerve fibres/meningeal membrane ratio from 3 : 1 to 1 : 1. Moreover, the protein amount does not change with age. The rat optic nerve, therefore, appears sensitive to ageing processes and can be considered as a useful model for the studies on neuronal ageing.

Age-related changes in the human optic nerve

BACKGROUND Recent morphologic research has demonstrated the presence of nerve fibres of different diameters in the human optic nerve. The purpose of this study was to investigate age-related changes in fibres of the human optic nerve. METHODS We studied the left optic nerve of 50 male cadaveric donors, 16 aged 18 to 22 years (mean 20 [standard deviation 1.2] years) and 34 aged 68 to 76 years (mean 72 [standard deviation 1.6] years). The samples were carefully harvested during autopsy from the intracranial portion of the optic nerve. Each nerve was cut into four 4-mm segments. After morphologic, histochemical and immunohistochemical staining, the optic nerve fibres were counted and measured. Each segment was evaluated under light microscopy for microanatomic details, glial cells and glial fibrillary acidic protein (GFAP) staining. The protein content was determined under biochemical analysis. We performed morphometric analysis by examining the optic nerve images quantitatively. RESULTS Compared with the younger group, in the older group there was an increase in mean diameter of the optic nerve (p < 0.001), due to an increase in the optic nerve:meningeal membrane ratio. There was also an increase in mean optic nerve area (p < 0.001) and in mean number of astrocytes and the related GFAP-immunoreactive area (p < 0.001). The mean number of nerve fibres of large diameter (greater than 4 pm) was decreased (p < 0.001). There was no difference in mean protein content of the fibres between the two groups. INTERPRETATION The human optic nerve is sensitive to the aging process and may be considered as a model for studies on neuronal aging.

Fox's modified technique using the Mersilene mesh sling in the management of blepharoptosis.

BACKGROUND AND OBJECTIVE Frontalis suspension is the best surgical procedure for severe ptosis with poor or absent levator muscle function. In addition to autologous fascia lata, a variety of materials are available for suspension. The authors describe the use of Mersilene mesh slings developed to overcome the problems of failure, slippage, and extrusion commonly associated with various suspensory materials. PATIENTS AND METHODS Brow suspension was performed in 20 ptotic eyelids of 14 patients. All patients had severe ptosis with levator function of 4 mm or less. The surgical technique used was a modified version of the method originally described by Fox using the Mersilene mesh sling. RESULTS The improvement in lid height was evaluated by preoperative and postoperative vertical aperture measurements and ranged from 2 to 5 mm (average 3.5 mm). The results were maintained in all cases during a follow-up period of 18 months. CONCLUSION The good functional and cosmetic results suggest that Foxs modified technique using the Mersilene mesh sling has a definite place in ptosis management.

Occiput posterior position diagnosis: vaginal examination or intrapartum sonography? A clinical review.

Abstract The occiput posterior (OP) position is one of the most frequent malposition during labor. During the first stage of labor, the fetal head may stay in the OP position in 30% of the cases, but of these only 5–7% remains as such at time of delivery. The diagnosis of OP position in the second stage of labor is made difficult by the presence of the caput succedaneum or scalp hair, both of which may give some problem in the identification of fetal head sutures and fontanels and their location in relationship to maternal pelvic landmarks. The capability of diagnosing a fetus in OP position by digital examination has been extremely inaccurate, whereas an ultrasound approach, transabdominal, transperineal and transvaginal, has clearly shown its superior diagnostic accuracy. This is true not only for diagnosis of malpositions, detected in both first and second stage of labor, but also in cases of marked asynclitism.

Excimer Laser Photorefractive Keratectomy for Hyperopia

BACKGROUND AND OBJECTIVE Photorefractive keratectomy (PRK) has been extensively evaluated for the correction of myopia. This study was undertaken to assess the safety, efficacy, and reliability of PRK in the correction of hyperopia. PATIENTS AND METHODS There were 28 eyes with refractions of +1 to +7.75 D treated for hyperopia with the Chiron Technolas 217-C excimer laser. Thorough visual assessments were made before treatment and at regular follow-up to 18 months. Complications and patient satisfaction were noted. RESULTS At 18 months the mean subjective refraction was +0.46+/-1.00 D with 26 eyes (92.8%) within 1 D of emmetropia. Thirteen eyes (46.4%) achieved uncorrected visual acuity (UCVA) of 20/20 or better and all patients had an UCVA of > or = 20/32 or better. Best corrected visual acuity (BCVA) remained unchanged in 26 eyes (92.8%) and improved in 2 eyes (7.2%). On the seventh day from treatment, 17 eyes (25%) had a loss of 2 or more lines of BCVA. At 15 days this was reduced to 8 eyes (14.3%) and at one month to 3 eyes (3.6%). There were no cases of loss of 2 or more lines of BCVA at 18 months of follow-up. All patients expressed a high degree of satisfaction. CONCLUSIONS Photorefractive keratectomy safely and effectively reduced hyperopia in the patients studied. The technique was reliable and still offered good results at 18 months of follow-up.

Potential regulatory molecules in the human trabecular meshwork of patients with glaucoma: Immunohistochemical profile of a number of inflammatory cytokines

Glaucoma occurs when there are imbalances between the production and the drainage of the eye liquid. The vast majority of the aqueous humor leaves the eye through the trabecular meshwork (TM). The cause of hypertonicity may be due to an alteration in the thickness of the TM. In the majority of cases the molecular changes that determine primary open‑angle glaucoma (POAG) are unclear. However, it has been hypothesized that the significant increase in the extracellular matrix (ECM) of the fibrillary bands in the TM is associated with possible inflammatory conditions. In this study the tissue distribution of interleukin (IL)‑6, IL‑1β, transforming growth factor-β1 (TGF‑β1), vascular endothelial growth factor (VEGF) and tumor necrosis factor α (TNF‑α) was analyzed in TM samples from patients with POAG by immunohistochemistry. Seven specimens from patients with POAG and three control tissues were analyzed by immunohistochemistry using specific antibodies against these cytokines. Morphological changes in the TM, such as increased cell content, macrophages, fibrosis and accumulation of neutrophils, were observed by transmission electron microscopy. In human TM tissues, an evident immunoreactivity for IL‑6, IL‑1β and TNF‑α was observed in patients with POAG when compared with the control subjects, indicating that these cytokines may be correlated with disease activity. TM endothelial cells secrete a number of factors and cytokines that modulate the functions of the cells and the ECM of the conventional outflow pathway. In the TM in glaucoma, macrophages produce cytokines, including IL‑6, IL‑1β and TNF‑α, leading to an acute inflammatory response and recruitment of other immune cells, including T lymphocytes. In addition, TGF‑β1 regulates and induces the expression of IL‑6 in TM that indirectly induces angiogenesis by stimulating VEGF expression. The present results support previous evidence that suggests that growth factors and cytokines can induce ECM remodelling and alter cytoskeletal interactions in the TM.

A Morphometric Study of Age Changes in the Rat Optic Nerve

Age-related changes of the optic nerve fibres were studied in 3-month-old (young), 12-month-old (adult) and 24-month-old (aged) male Sprague-Dawley rats. The optic nerve was harvested with particular care from the intracranial portion. Cross sections from the optic nerve of animals of different age groups were stained with toluidine blue and examined under a light microscope at low and high magnification. Other sections were stained for the demonstration of glial cells using the method described by Holzer. A third group of sections were stained by the immunohistochemical method to detect glial fibrillary acidic protein, which is a marker for localising and characterising astrocytes. All these morphological results were subjected to the quantitative analysis of images and to statistical analysis of the values to identify significant morphometric data. Biochemical dosages of proteins were also performed on homogenised fragments of the optic nerve. Our results demonstrate that the following age-related changes can be observed: (1) an increase in meningeal membranes, (2) an increased number of astrocytes, (3) an increase in areal density of glial fibrillary acidic protein immunoreactivities, (4) an increased thickness of the entire optic nerve and an increased area of the nerve, (5) a decreased number of nerve fibres and (6) a decrease in the nerve fibre/meningeal membrane ratio from 3:1 to 1:1. Moreover, the amount of protein does not change with age. The rat optic nerve, therefore, appears sensitive to aging processes.

The synergistic effect of exposure to alcohol, tobacco smoke and other risk factors for age-related macular degeneration.

Age-related macular degeneration (AMD) is the leadingcause of severe visual loss among people aged 50 yearsand older in the developed world [1]. Cigarette smoking,hypertension, inflammation and alcohol consumption, havebeen shown to be associated with AMD in some, but not allstudies [2–4]. In our study we have evaluated the syner-gistic effect of alcohol and tobacco smoking with other riskfactors in the risk of developing AMD.The investigation adhered to the Declaration of Helsinkiand was approved by the Ethics Committee. We recruitedpatients, providing written informed consent, with AMD(the phenotype was early AMD, both the drusen and thepigmentary changes) during the period between August andNovember 2011 from the Center Maculopathy of theDepartment Sense Organs Sapienza University of Rome,Teaching Hospital Umberto I.The controls, matched to cases by age and sex, consist oftwo distinct groups:a) patients with eye diseases (unrelated with AMD);b) individuals belonging to the Clinic Orthopedic of theTeaching Hospital Umberto I, Rome.A questionnaire was administered to cases and controlsfor collecting data including thirty-five questions dividedinto five sections. The first section asked for demographicdata regarding age, gender, occupation, education level,weight, height, eyes colour. The second section asked forAMD family history (any relative), cardiovascular disease,hypertension, hypercholesterolemia, diabetes, cataractsurgery. The third section ascertained whether the patientsare ever smokers. The fourth section asked if the patientsdrink wine, beer or hard liquor. The last section tested howmany times a week, patients eat the following foods: bread,pasta, legumes, fruit, vegetables, red meat, white meat,cheese, fish, sweets.The possible interaction between sociodemographicvariables was tested using the synergism index, calculatedas follows: S = [OR11 - 1]/([OR01 ? OR10] -2), whereOR11 is equal to OR of the joint effect of two risk factorsand OR10 and OR01 are equal to OR of each risk factor inthe absence of the other. A value of S equal to unity wasinterpreted as indicative of additivity, whereas a valuegreater than unity was indicative of superadditivity andsynergism [5].A total of 122 cases and 124 controls were enrolled.The median age in the case group was 75, whilst in thecontrol group was 74. Alcohol intake is the same in bothgroups (2.4 grams per day); as regards smoking condi-tion, we found that 61.5 % (75 persons) in the case groupare ever smokers, in the control group they are 41.9 %(52 persons).Table 1 shows OR for each variables AMD-related.There was an indication for the additivity and synergismbetween many risk factors (Table 2): family history AMDand ever smokers (S = 1.51; 95 %CI 0.11–20.69), hyper-cholesterolemia and ever smokers (S = 1.77; 95 %CI0.44–7.10), finally from hypercholesterolemia and alcoholintake (S = 1.64; 95 %CI 0 -[999). Moreover, we foundout a synergistic interaction for Obesity with Ever smokers(1.54; 95 %CI 0.24–9.63) and Alcohol intake (4.2; 95 %CI0 -[999).Our findings suggest that many risk factors are associ-ated to the development of AMD, some of them have a

Photorefractive keratectomy in the management of refractive accommodative esotropia in young adult patients.

PURPOSE: To evaluate the visual, motor, and sensory outcomes of photorefractive keratectomy (PRK) in the treatment of purely refractive accommodative esotropia in young adult patients. SETTING: Policlinico Umberto I, Department of Ophthalmology, Rome, Italy. METHODS: This prospective study comprised patients with hyperopia and purely accommodative hyperopic esotropia. A complete ophthalmologic examination was performed preoperatively and 1, 3, and 12 months postoperatively. The examination included uncorrected (UDVA) and corrected (CDVA) distance visual acuities and orthoptic and sensory tests. All patients also had keratometry, pachymetry, and corneal topography assessment before and after treatment. Treatment was performed using a Technolas 217 excimer laser. RESULTS: Thirty eyes of 15 patients (mean age 30.8 years) were treated. Preoperatively, the CDVA was 20/30 or better in all eyes and the mean cycloplegic spherical equivalent (SE) was +3.50 diopters (D). One year postoperatively, the UDVA was 20/30 or better in all eyes and the mean SE was −0.01 D. The mean esotropic deviation for distance vision without correction preoperatively was 8.7 prism diopters. At 1 year of follow‐up, 12 patients achieved orthophoria and 3 patients had a reduction in the angle of deviation. There were no intraoperative or postoperative complications. Stereopsis was unaffected by treatment in all patients. CONCLUSIONS: Photorefractive keratectomy was effective in the treatment of purely accommodative esotropia in young adult patients at a follow‐up of 1 year. There were no cases of visual acuity loss or complications from the laser treatment.