Fernanda 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.

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.

Glycosaminoglycans in the Human Cornea: Age-Related Changes

Aim To investigate possible age-related changes in glycosaminoglycans (GAGs) in the human cornea. The substances today called GAGs were previously referred to as mucopolysaccharides. Methods Samples of human cornea were taken from 12 younger (age 21 ± 1.2) and 12 older (age 72 ± 1.6) male subjects. Samples were weighed, homogenized, and used for biochemical and molecular analyses. All the quantitative results were statistically analyzed. Results The human cornea appears to undergo age-related changes, as evidenced by our biochemical and molecular results. The total GAG and hyaluronic acid counts were significantly higher in the younger subjects than in the older subjects. The sulfated heavy GAGs, such as chondroitin, dermatan, keratan, and heparan sulfate, were lower in the younger subjects than in the older subjects. Discussion GAGs of the human cornea undergo numerous age-related changes. Their quantity is significantly altered in the elderly in comparison with younger subjects. GAGs play an important role in age-related diseases of the human cornea.

Intravitreal Injection of Ozurdex® Implant in Patients with Persistent Diabetic Macular Edema, with Six-Month Follow-Up

Aim To evaluate the efficacy of intravitreal dexamethasone injections in diabetic macular edema (DME). Methods A 700 μg slow-release intravitreal dexamethasone implant (Ozurdex®) was placed in the vitreal cavity of 17 patients (19 eyes) affected with persistent DME. Best corrected visual acuity (BCVA) was assessed through Early Treatment Diabetic Retinopathy Study (ETDRS). Central macular thickness (CMT) was measured by spectral-domain optical coherence tomography. BCVA and CMT examinations were carried out at baseline (TO) and repeated after three days, one month (T1), three months (T3), four months (T4), and six months (T6) post injection. Results Dexamethasone implant induced an improvement in ETDRS at T1, T3, T4, and T6 post injection. CMT was reduced at T1, T3, and T4, while at T6, CMT values were not statistically different from baseline. No complications were observed during the follow-up. Conclusion Our data suggest that dexamethasone implant is effective in reducing DME symptoms within a six-month frame.

Dorzolamide Chlorhydrate Versus Acetazolamide in the Management of Chronic Macular Edema in Patients with Retinitis Pigmentosa: Description of Three Case Reports

Aims To assess the efficacy of topical dorzolamide for treating cystoid macular edema in patients with retinitis pigmentosa and minimize the secondary effects of maintenance therapy in patients with retinitis pigmentosa (RP) who present with chronic microcystic macular edema. Methods To replace acetazolamide systemic treatment, with a topical treatment using 2% dorzolamide in three patients. The methods performed were OCT scan with a Spectralis HRA-OCT, for the measurement of macular thickness and morphology; best corrected visual acuity was assessed using Early Treatment Diabetic Retinopathy Study (ETDRS), was assessed slit-lamp biomicroscopy, ocular tonometry, fundus biomiocrosopy, and color fundus photography. This therapeutic protocol has been applied and described in three patients. Results In all three tested patients, following the administration of dorzolamide in eye drop, we observed a remarkable decrease in macular edema, almost comparable to that obtained with acetazolamide per os. Conclusion The study confirms the anti-edematogenic effect of topical dorzolamide in RP with recurring macular cysts, as this can have a favorable response with topical dorzolamide. In all the three examined patients, the instillation of topical dorzolamide caused a remarkable reduction in their macular edema, as highlighted on OCT.

Management of anterior chamber dislocation of a dexamethasone intravitreal implant: a case report

BackgroundOzurdex is a 700 mcg dexamethasone intravitreal implant, approved for the management of macular edema secondary to retinal vein occlusion, and other related pathoglogiesAnterior chamber dislocation of Ozurdex represents an uncommon complication of the intravitreal injection, which can be managed by repositioning the implant into the vitreous cavity. We describe the case of a successful repositioning of an Ozurdex implant by mobilization and subsequent balanced saline solution injection in the anterior chamber.Case presentationAn 83-year-old white woman presented to our Emergency Unit complaining of pain and vision loss in herright eye lasting a week. Her anamnesis revealed a history of persistent cystoid macular edema after phacoemulsification with scleral-fixated posterior chamber intraocular lens implantation, recently treated with an intravitreal Ozurdex implant. She also took a long-distance flight 2 days after the injection.An anterior segment examination showed corneal edema and the rod implant adherent to corneal endothelium. To avoid corneal decompensation, we opted for a implant repositioning. Under topical anesthesia, a 30-gauge needle was introduced through a limbar incisionto mobilize the dislocated rod. Balanced saline solution was injected, with a successful repositioning of the implant into the vitreous cavity. Topical 5 % hypertonic saline solution and 0.2 % betamethasone associated with 0.5 % chloramphenicol drops were administered four times a day. To prevent redislocation of the Ozurdex implant, she was instructed to avoid prone position, any kind of physical effort, and not to undertake long-distance flights during the first postoperative week. One week after surgery, an anterior segment examination showed an improvement of corneal edema. Funduscopy showed that the Ozurdex implant was settled into the vitreous cavity.ConclusionsAnterior chamber dislocation of Ozurdex from the vitreous cavity is rare. In our patient, in addition to the posterior capsule tearing, the long-distance flight could have contributed to implant dislocation. Repositioning of the implant is necessary to avoid endothelial decompensation. It can be carried out by using saline balanced solution with the same efficacy as other surgical procedures reported in the literature. A possible disadvantage of this procedure could be implant migration.

Suspensory Materials for Surgery of Blepharoptosis: A Systematic Review of Observational Studies.

Background Frontalis suspension surgery is considered the procedure of choice in cases of blepharoptosis. Among all the materials used in this type of surgery, ophthalmic and plastic surgeons prefer to use autologous Fascia Lata. However, during years, other autogenous and exogenous materials have been introduced. Objectives The aim of this study was therefore that of systematically reviewing the functional results and the rate of complications of different synthetic materials, as compared to autogenous Fascia Lata. The primary objective was to determine the rates of Successful Surgeries (SSs) of these materials. The secondary objective was to assess the onset of complications. The following materials were investigated: Fascia Lata, Mersilene, polytetrafluoroethylene (PTFE) and Silicon. Data Source and Methods Following the Prisma procedure, on January 30th, 2016 we used the following electronic databases to select the studies: MEDLINE and Scopus. Results The search strategy retrieved 48 publications that met the eligibility criteria of the systematic review. All studies were non-comparative. PTFE (n = 5) showed the best rate of SSs among the materials compared (statistically significant). Surgeries performed with autogenous Fascia Lata (n = 19) had a 87% rate of success those performed with Mersilene (n = 12)had 92% and those performed with Silicon (n = 17)88%. PTFE had the best outcome, with 99% success rate. As for complications, surgeries performed with PTFE had a higher rate of suture infections (1.9%) as compared to Fascia Lata, but lower incidence for all other complications. Conclusions Although most studies were good quality cohort studies, the overall quality of this evidence should be regarded as low due to their non-comparative design. Our data suggest that PTFE seems to be the most valid alternative material for frontalis suspension surgery, with low recurrence rates and good cosmetic and functional results.

Efficacy and safety of 0.5% levobupivacaine versus 0.5% bupivacaine for peribulbar anesthesia.

Background This randomized double-blind study examined the use of a new anesthetic agent, levobupivacaine 0.5%, which is the S(−)-enantiomer of a racemic mixture of bupivacaine, for peribulbar anesthesia and compared it with racemic bupivacaine 0.5% alone or in combination with hyaluronidase 10 IU/mL. Methods A total of 160 patients undergoing ophthalmic surgery were randomized into four groups (n = 40 each) to receive inferotemporal peribulbar injection of levobupivacaine 0.5% (group L), racemic bupivacaine 0.5% (group B), levobupivacaine + hyaluronidase 10 IU/mL (group LH), or racemic bupivacaine + hyaluronidase 10 IU/mL (group BH) by two anesthetists and two ophthalmologists in a ratio of 25% each. Ocular akinesia and orbicularis oculi function were evaluated using a three-point scale; a value < 5 points was considered as requiring surgery, and movements were re-evaluated the day following surgery to confirm regression of the block. Results The time to onset (12 ± 2.6 minutes versus 13 ± 2.8 minutes) and duration of anesthesia (185 ± 33.2 minutes versus 188 ± 35.7 minutes) were similar between groups L and B. Complete akinesia (score 0) was obtained more frequently when hyaluronidase was used in addition to the anesthetic, with occurrences of 72.5% versus 57.5% in group LH versus L, respectively, and 67.5% versus 45% in group BH versus B. Moderate hypotension (<30% of baseline) was observed in four patients (10%) in group L, two (5.0%) in group B, one (2.5%) in group LH, and three (7.5%) in group BH. The time to onset was significantly different between groups L and BH, B and BH, and LH and BH, and the duration of anesthesia differed significantly between groups B and LH, B and BH, and L and LH. The akinesia score differed significantly between groups L and LH and between groups B and LH (P = 0.043 and P = 0.018, respectively), and the number of patients with a score of 0 differed significantly between groups B and LH and between groups B and BH (P = 0.004 and P = 0.017, respectively). Conclusion Levobupivacaine is a long-lasting local anesthetic with limited cardiotoxicity and neurotoxicity, and may be considered the landmark for vitreoretinal surgery in elderly patients.

An immunocompetent migrant presenting with neurosyphilis with an unusual unilateral papillitis: a case report

Unilateral papillitis caused by Treponema pallidum was found in an immunocompetent homosexual patient with severe vision loss who had received previous antibiotics treatment. Syphilis-related ocular manifestation is more common in the early stages of the disease and it can be associated with a central nervous system localization. In this patient, neurosyphilis was diagnosed on the basis of clinical and laboratory findings. Optical examination revealed unilateral papillitis in the left eye and no relative afferent pupillary defects. The patient underwent visual field examinations with conventional perimetry using the 30-2 program of the Humphrey Visual Field Analyzer, which indicated a blind spot enlargement in the left eye. Optical coherence tomography, visual evoked potentials (VEP), and fluorescein angiograms revealed inflammation of the optic nerve head with edematous and blurred margins. A reactive T. pallidum hemagglutination assay with low rapid plasma reagin (RPR) serum titer was performed; an HIV antibody test and MRI of the orbits and head with contrast gave negative results. Resolution of the ocular inflammation after intravenous penicillin treatment was obtained. The reported case illustrates the importance of early recognition of this treatable disease. The rise of syphilis, especially in urban areas, necessitates a high level of suspicion when dealing with patients with intraocular inflammation of unknown origin. Lues serology should be incorporated into routine laboratory diagnostics to aid in the detection of such cases. Considering the re-emergence of syphilis, screening of migrants from countries with high syphilis seroprevalences should be recommended.