Francesco Fasce

Sedative effect of acupuncture during cataract surgery Prospective randomized double-blind study

PURPOSE: To assess the effectiveness of acupuncture in reducing anxiety in patients having cataract surgery under topical anesthesia. SETTING: Vita‐Salute University of Milan and IRCCS H. San Raffaele, Milan, Italy. METHODS: In a prospective randomized double‐blind controlled trial, anxiety levels before and after cataract surgery in 3 groups (A = no acupuncture, B = true acupuncture starting 20 minutes before surgery, C = sham acupuncture starting 20 minutes before surgery) were compared using the Visual Analog Scale (VAS). Twenty‐five patients scheduled for inpatient phacoemulsification were enrolled in each group. All surgeries were performed using topical anesthesia. Exclusion criteria were refusal to provide informed consent, use of drugs with sedative properties, psychiatric disease, pregnancy, knowledge of the principles of acupuncture, anatomic alterations, or cutaneous infections precluding acupuncture at the selected acupoints. RESULTS: Preoperative anxiety levels were significantly lower only in Group B (P = .001). Anxiety in Group B was significantly lower than in Group A (P = .001) and Group C (P = .037). Regarding postoperative anxiety, the mean VAS score was 39 ± 5 in Group A, 19 ± 3 in Group B, and 31 ± 4 in Group C. The difference was significant only between Group A and Group B (P = .003). CONCLUSION: Acupuncture was effective in reducing anxiety related to cataract surgery under topical anesthesia.

Far and near visual acuity with multifocal intraocular lenses in an optomechanical eye model with imaging capability

PURPOSE: To compare the quantitative and qualitative visual performances of different multifocal intraocular lenses (IOLs) in an experimental model of the human eye. SETTING: University Hospital San Raffaele, Milan, Italy. METHODS: Five multifocal IOLs and 1 monofocal IOL were implanted in an optomechanical eye model with imaging capability. The comparative optical characterization of the imaging performance included aberrometry, simulated visual acuity testing at variable contrast for far and near distance, glare tests, and image records of optotype charts. RESULTS: The maximum recorded far visual acuity for the monofocal IOL was between 20/12.5 and 20/16; the multifocal IOLs decreased visual acuity by 1 to 2 lines. The difference tended to increase at reduced contrast. Full‐contrast near visual acuity with multifocal IOLs ranged between 20/63 and 20/25; the near distance performance of the monofocal IOL without an additional correcting lens was worse by 1 to 3 lines of acuity with large pupils but was comparable with small pupils. Multifocal IOLs of different designs showed marked differences as a function of contrast, which tended to balance between far and near behaviors. CONCLUSIONS: Multifocal IOLs of different optical designs were well characterized and distinguished by simulated contrast acuity testing in an experimental eye model, allowing quantitative comparison. Their overall visual performance, averaged over contrast and distance, was not superior to the performance of a monofocal IOL without an additional correcting lens.

Accidental injection of dexamethasone intravitreal implant in the crystalline lens

new onset CMO (10%). The proportion of relapses treated with systemic steroids significantly reduced from 70% prediabetes to 56% postdiabetes diagnosis. Adding local steroid injection while on systemic steroids increased from 4% to 15% (p = 0.003, chi-square test). No significant difference was observed in the uveitis relapse treatment success preversus postdiabetes diagnosis (Table 1). Of the 96 eyes with uveitis and DM, one eye developed a clinically significant macular oedema after 3 years and required grid laser treatment, while seven eyes of six patients (7.3%) developed non-proliferative diabetic retinopathy, which occurred at a median of six (range, 2–11) years. While one previous study explored the visual outcome of 36 patients with diabetes who later developed uveitis (Oswal et al. 2013), our study further explores the synergistic effect of uveitis and diabetes by examining the effect of newly diagnosed diabetes on the eyes with uveitis and the effect of diabetes on uveitis treatment strategies. In conclusion, the concurrent diagnosis of DM in uveitis patients is associated with a significant reduction in visual acuity within the first 2 years. More uveitis relapses were treated with local steroid injection rather than increasing systemic corticosteroid dose, without affecting the ability to control uveitis relapses. It is important to optimize treatment protocols for DM and uveitis when occur concurrently.

EVALUATION OF FIXATION ONE YEAR AFTER PERIFOVEAL LASER TREATMENT OF SUBFOVEAL CHOROIDAL NEOVASCULARIZATION

The natural prognosis of subfoveal neovascularization is severe visual acuity loss. Perifoveal laser photocoagulation is meant to spare a small portion of the central retina so as to possibly preserve foveal fixation. The aim of this retrospective study was to detect the persistence of central fixation and to evaluate the visual function of patients who had undergone perifoveal laser photocoagulation one year before, due to the presence of age-related macular degeneration with subfoveal neovascularization. The visual function was assessed by means of visual acuity (VA) measurement, central perimetry, scanning laser ophthalmoscope (SLO) scotometry and capability of using low-vision aids with success. Twelve eyes of 12 patients, 5 males and 7 females, with mean age 72.6 ± 9.62 years, were included in the Study Group. Mean VA was 0.22 ± 0.089 before laser treatment, 0.17 ± 0.054 one week after laser treatment (p=0.0152) and 0.13 ± 0.063 one year after laser treatment (p=0.045), with a statistically significant reduction of VA overtime (initial-final p=0.0015). Mean lesion size was 2.12 ± 0.528 disc diameters on the last follow-up fluorescein angiogram. One year after laser treatment, perimetry showed the persistence of central fixation in 2 eyes, while 10 eyes seemed to have lost it. SLO scotometry revealed central dot stimulus perception in 6 eyes and no central residual in 6 eyes. The SLO fixation plot showed persistence of central fixation also in 1 eye in which static perimetry had not detected it. The preferential retinal locus was located on the upper or upper-right margin of the lesion in 8 of the 9 eyes with paracentral fixation. All patients achieved a useful reading VA using low-vision aids, with 7.16 ± 6.1 mean magnification power.The eyes with central visual residual on SLO scotometry had a final VA slightly higher than those without central residuals (VA 0.158 ± 0.03 and 0.098 ± 0.07, respectively), though the difference was not statistically significant (p=0.0977).

Bilateral choroidal excavation in best vitelliform macular dystrophy.

Focal choroidal excavation (FCE) has recently been described as one or more localized areas of choroidal excavation on spectral-domain optical coherence tomography (SD-OCT). The authors describe a case of bilateral FCE in Best vitelliform macular dystrophy (VMD). SD-OCT revealed FCE in both eyes characterized by interruption of the internal segment-outer segment junction and the presence of subretinal hyporeflective space. This is the first report describing bilateral FCE in a distinct macular disorder and specifically with VMD. Future investigations are warranted to ascertain the involvement of other macular dystrophies with atrophic evolution and the impact of FCE on the clinical course. [Ophthalmic Surg Lasers Imaging Retina. 2014;45:e8-e10.].

Experimental characterization of the imaging properties of multifocal intraocular lenses

Many different types of intraocular lenses (IOL) are currently available for implantation, both as crystalline lens replacements and as phakic refractive elements. Their optical design is increasingly sophisticated, including aspherical surface profiles and multi-zone multifocal structures, however a quantitative and comparative characterization of their imaging properties is lacking. Also a qualitative visualization of their properties would be very useful for patients in the lens choice process. To this end an experimental eye model has been developed to allow for simulated in-vivo testing of IOLs. The model cornea is made of PMMA with a dioptric power of 43 D, and it has an aspherical profile designed to minimize spherical aberration across the visible spectrum. The eye model has a variable iris and a mechanical support to accomodate IOLs, immersed in physiological solution. The eye length is variable and the retina is replaced by a glass plate. The image formed on this retina is optically conjugated to a CCD camera, with a suitable magnification in order to mimic the human fovea resolution, and displayed onto a monitor. With such an opto-mechanical eye model, two types of images have been used to characterize IOLs: letter charts and variable contrast gratings, in order to directly simulate human visual acuity and contrast sensitivity.

Optical coherence tomography in Best vitelliform macular dystrophy

Purpose To analyze spectral-domain optical coherence tomography (SD-OCT)-specific findings in the different stages of vitelliform macular dystrophy (VMD). Methods Thirty-seven patients were prospectively recruited. All the patients underwent a complete ophthalmologic examination, including best-corrected visual acuity (BCVA), biomicroscopy, and SD-OCT. The examined findings were vitelliform material, neurosensory detachment, intraretinal hyperreflective foci, and the status of external limiting membrane, ellipsoid zone, and retinal pigment epithelium. The primary outcome was the stratification of SD-OCT findings in each VMD stage. Secondary outcomes included the description of different characteristics related to intraretinal hyperreflective foci. Results Outer retinal layers were preserved almost exclusively in stage 1 (range 70%-100%), whereas their disruption and absence were typical of stages 2 to 4 (83%-100%) and stage 5 (67%-83%), respectively. Vitelliform material was found always in stages 2 and 3, 89% of stage 4, and rarely in stage 5 (33%). Neurosensory detachment was to some extent representative of stages 3 and 4 (80% and 72%, respectively) when compared with the other stages (p<0.001). Hyperreflective foci (16% of all eyes) demonstrated a progressive increase across stages 2 to 4, with slightly reduced figure in stage 5. These foci were located in the outer nuclear and plexiform layers, showed different sizes, and were not associated with a visual acuity reduction (p = 0.64). Conclusions A progressive deterioration of the outer retinal layers was noticeable in more advanced stages of VMD. The reduction of vitelliform material from stage 3 to 4 was paralleled by an increased evidence of neurosensory detachment. Although showing different size and location, hyperreflective foci did not correlate with worse BCVA.

Dome-shaped macula associated with Best vitelliform macular dystrophy.

Purpose Dome-shaped macula (DSM) has been described recently as an inward convexity of the macula typical of myopic eyes detectable on spectral-domain optical coherence tomography (SD-OCT). The authors describe a case of monolateral DSM associated with Best vitelliform macular dystrophy (VMD). Methods Case report. Results A 60-year-old man already diagnosed with VMD in vitelliruptive stage underwent SD-OCT that revealed the typical vitelliform material accumulation associated in the left eye with a convex elevation of the macula. No change was registered over a 1-year follow-up. Conclusions This is the first report describing a monolateral DSM associated with VMD. Dome-shaped macula could be considered as a nonspecific scleral alteration, probably due to increased scleral thickness, which can accompany many retinal disorders.

Pupil dilation dynamics with an intracameral fixed combination of mydriatics and anesthetic during cataract surgery

PURPOSEnTo compare the pupil dynamics of an intracameral combination of 2 mydriatics and 1 anesthetic (Mydrane) to a standard topical regimen for cataract surgery.nnnSETTINGnSixty-two centers in Europe and 6 centers in Algeria.nnnDESIGNnProspective case series.nnnMETHODSnPupil size measurements were performed in 2 randomized studies (phase 2 and phase 3) under masked conditions (recorded videography, masked reading center). The outcomes in the phase 2 study supported evaluation of the timeframe to obtain pupil dilation and the phase 3 study provided results on mydriasis stability.nnnRESULTSnPhase 2 and phase 3 comprised 139 patients and 591 patients, respectively. After intracameral combination administration, 95% of the pupil dilation was achieved within a mean of 28.6xa0secondsxa0±xa04.6 (SD). At the beginning of capsulorhexis creation, the mean pupil diameter was larger than 7.0xa0mm in both groups. The intraoperative pupil diameter remained stable in the intracameral combination group and decreased in the topical group. The mean change in pupil size just before capsulorhexis to the end of surgery (just before cefuroxime injection) was -0.22xa0±xa00.72xa0mm and -1.67xa0±xa00.98xa0mm, respectively. No clinically significant change in pupil diameter (change <1.0xa0mm) occurred in the majority of the intracameral combination group (89.3%) compared with the topical group (26.8%).nnnCONCLUSIONSnIntracameral combination of 2 mydriatics and 1 anesthetic is an alternative to topical mydriatics for cataract surgery. The prompt onset of pupil dilation and the stable mydriasis induced by this drug combination improved the intraoperative conditions during crucial steps, such as intraocular lens implantation.

Rotational stability of a single‐piece hydrophobic acrylic intra‐ocular lens in myopic and emmetropic eyes

Alfawaz A (2013): Cytomegalovirus-related corneal endotheliitis: a review article. Saudi J Ophthalmol 27: 47–49. Jhanji V,KwokR&YoungAL (2013): Eighteen months of anterior chamber inflammation. BMJ Case Reports 2013: pii: bcr2013200739. Khodadoust AA & Attarzadeh A (1982): Presumed autoimmune corneal endotheliopathy. Am J Ophthalmol 93: 718–722. Koizumi N, Yamasaki K, Kawasaki S, Sotozono C, Inatomi T, Mochida C & Kinoshita S (2006): Cytomegalovirus in aqueous humor from an eye with corneal endotheliitis. Am J Ophthalmol 141: 564–565. Koizumi N, Inatomi T, Suzuki T et al. (2015): Clinical features and management of cytomegalovirus corneal endotheliitis: analysis of 106 cases from the Japan corneal endotheliitis study. Br J Ophthalmol 99: 54–58. Pavan-Langston D, Welch CL & Zegans ME (2012): Ganciclovir gel for cytomegalovirus keratouveitis. Ophthalmology 119: 2411.