Gianluca Martone

An In Vivo Confocal Microscopy Analysis of Effects of Topical Antiglaucoma Therapy With Preservative on Corneal Innervation and Morphology

PURPOSE To evaluate the long-term effects of preservative-free and preservative-containing antiglaucoma eye drops on the tear secretion and ocular surface. DESIGN Comparative retrospective study. METHODS A total of 84 patients with bilateral primary open-angle glaucoma or ocular hypertension divided into 5 groups according to type of topical hypotensive therapy and 20 healthy age-matched volunteers were studied. Clinical tests (corneal sensitivity, Schirmer I test, and lachrymal film break-up time), and in vivo confocal microscopy were performed in all patients. RESULTS A significant reduction of the scores was found between groups on topical hypotensive therapy and the control group in all clinical parameters studied (P < .05). In particular, the clinical scores were significantly lower in the preservative medication groups than in the preservative-free group (P < .05). The density of superficial epithelial cells was reduced in all glaucomatous patients, except for the preservative-free group (P > .05), with respect to control subjects (P < .001). On the contrary, the density of basal epithelial cells of glaucomatous preservative therapy groups was higher than control and preservative-free groups (P < .05). Stromal keratocyte activation and the number of beads were higher in all glaucoma preservative groups (P < .05). The number of sub-basal nerves was lower in all glaucoma groups than in the control group (P < .05) and tortuosity was significantly higher in glaucoma than control groups (P < .05). Reflectivity of fibers did not show any significant difference between the 6 groups (P < .05). CONCLUSIONS Glaucomatous patients with chronic treatment show ocular surface alterations. The development of nontoxic antiglaucoma treatment may reduce damage to the ocular surface and improve the compliance and the adherence in the medical therapy.

Prospective randomized study of clinical performance of 3 aspheric and 2 spherical intraocular lenses in 250 eyes.

PURPOSE To compare the quality of vision with aspheric and spherical intraocular lenses (IOLs) in pseudophakic patients. METHODS This prospective, comparative, randomized study included 250 eyes of 125 patients with bilateral cataracts. Patients were randomly assigned to receive either IOLs with a spherical biconvex optic (Acrysof SN6OAT [Alcon] or Sensar AR40e [Advanced Medical Optics, AMO]) or IOLs with an aspheric optic (Acrysof IQ SN6OWF [Alcon], Tecnis Z9000 [AMO], or Sofport L161AO [Bausch & Lomb]). Ophthalmologic examination including best spectacle-corrected visual acuity, pupil size, ocular dominance investigation, contrast sensitivity under mesopic and photopic conditions, and wavefront analysis was performed 2 months postoperatively. RESULTS Aspheric IOLs showed better contrast sensitivity compared to spherical IOLs at spatial frequencies of 6, 12, and 18 cycles per degree (cpd) under photopic conditions and at all spatial frequencies under mesopic conditions. There was no significant difference among the three aspheric IOLs at all spatial frequencies under either photopic or mesopic conditions. Mean total spherical aberration was statistically lower in dominant eyes with aspheric IOLs (0.05 +/- 0.06, 0.11 +/- 0.1, and 0.19 +/- 0.08 pm for the Tecnis Z9000, Acrysof IQ SN6OWF, and Sofport L161AO, respectively) compared with eyes with spherical IOLs (0.62 +/- 0.24 and 0.46 +/- 0.19 microm for the Acrysof SN6OAT and Sensar AR40e, respectively) for a 5-mm pupil diameter. CONCLUSIONS The aspheric IOLs had less wavefront aberrations and performed better under both photopic and mesopic contrast sensitivity compared to the spherical IOLs. These findings confirm it is possible to improve the optical performance of IOLs by modifying the surfaces.

Longterm follow‐up of diode laser transscleral cyclophotocoagulation in the treatment of refractory glaucoma

Purpose:  This prospective study was conducted to evaluate the efficacy and safety of transscleral diode laser cyclophotocoagulation (TDLCP) in advanced refractory glaucoma.

Diagnosis and management of traumatic cyclodialysis cleft

A 48-year-old man presented with hyphema, iridocyclitis, iridophacodonesis, and maculopathy after a contusive trauma. Ultrasound biomicroscopy identified a 90-degree cyclodialysis cleft with severe damage of the zonular fibers. Echographic B-scan examination revealed intravitreal hemorrhage and a 360-degree choroidal detachment. One month later, phacoemulsification was performed and a single-piece poly(methyl methacrylate) intraocular lens was inserted into the ciliary sulcus, with the haptic rotated toward the cyclodialysis cleft area. Postoperatively, the visual acuity improved and the intraocular pressure returned to normal. Ultrasound biomicroscopy showed closure of the cleft by reattachment of the ciliary body to the scleral spur. Optical coherence tomography revealed complete resolution of the macular and choroidal folds. Ultrasound biomicroscopy is a useful method for appropriate management of traumatic cyclodialysis cleft. In cases of small cyclodialysis clefts, with the surgical method we describe, the lens haptics apply directional force toward the sclera, fostering adherence of the ciliary body fibers.

Pseudoexfoliation syndrome: in vivo confocal microscopy analysis

Pseudoexfoliation (PEX) syndrome is a common ocular disease that also affects the cornea. A case of clinical PEX syndrome, studied by in vivo corneal confocal microscopy is reported. The morphological analysis of the confocal images demonstrated hyper‐reflective deposits and several dendritic cells in the basal epithelial layer. A fibrillar subepithelial structure was also found. The endothelial layer showed cell anomalies (polymegathism and pleomorphism) and hyper‐reflective small endothelial deposits. Confocal microscopy is an in vivo imaging method that may provide new information on corneal alterations in PEX, and detect early corneal features.

Corneal invasion of ocular surface squamous neoplasia after clear corneal phacoemulsification: In vivo confocal microscopy analysis

We describe an unusual case of ocular surface squamous neoplasia (OSSN) that occurred in a male patient after superonasal clear corneal phacoemulsification with extensive papillomatous corneal invasion near a side port. The features of the macroscopic invasion of the corneal superficial layers were analyzed by in vivo confocal analysis using the Heidelberg Retina Tomograph II. After OSSN was diagnosed, topical mitomycin-C 0.02% eyedrops were prescribed 4 times a day in a cyclic manner (3 cycles of 1 week on drops followed by 1 week off). After 1 month (second cycle), the natural visual acuity was 20/20, the corneal epithelium had healed completely, and the limbal lesion had regressed markedly. The patient remained asymptomatic without recurrence during a 6-month follow-up.

In vivo confocal microscopy in a patient with recurrent conjunctival intraepithelial neoplasia

and redness in the right eye (RE) was referred for a clinical evaluation. A 2-year history of corneal ulcer in the RE was elicited. The subject had also undergone pterygium surgery in the same eye at another ophthalmology centre 11 years previously. His left eye (LE) was amblyopic. Best corrected visual acuity (BCVA) was 20 ⁄ 100 LE and 20 ⁄ 200 RE. Slit-lamp examination revealed an area of epithelial defect with a minimally elevated and vascularized patch of leucoplakia that was located inferonasally in the cornea of the RE. The lesion extended to the central portion of the cornea. Lesion borders were indistinct. Bulbar conjunctiva was diffusely congested (Fig. 1A). Corneal scrapings from the ulcer were negative for micro-organisms. No abnormality was present in the LE. Examination by corneal confocal microscopy (CM) was carried out using the HRT II Rostock cornea module (Heidelberg Engineering GmbH, Heidelberg, Germany), in which the x and y positions and section depth are controlled manually. Prior to examination, 0.4% oxibuprocaine chlorhydrate (Novesina ; Novartis Farma, Varese, Italy) and a gel tear substitute (Genteal gel ; Novartis Farma, Varese, Italy) were applied into the inferior conjunctival fornix. Confocal microscopy showed irregular hyperreflective areas with numerous bright elements at the level of the superficial cell layer of the corneal epithelium in the RE. The epithelial cells near the lesion were significantly larger in size and had more irregularities in shape and borders. Furthermore, the nuclei were particularly bright. The distinction between healthy and pathological epithelium appeared very clear (Fig. 1C, D). Eight months later, an excisional biopsy with cryotherapy to the bare sclera was performed. The histo-pathological examination revealed diffuse epithelial atypia, consistent with corneal and conjunctival intraepithelial neoplasia (CIN). After surgery, complete resolution of the limbal and corneal lesions with mild paracentral corneal scarring was noted (Fig. 1B). Best corrected VA was 20 ⁄ 60 in the RE. Six months later, the patient underwent a penetrating keratoplasty (PK) in the RE. Pathological examination of the corneal button revealed normal corneal epithelium and an intact basement membrane. The patient was observed for 9 months after PK without recurrence (Fig. 2A). Nine months later, when the patient returned for a longterm follow-up visit, slit-lamp examination of the RE showed corneal recurrence of CIN as multiple, faintly demarcated, small islands of peripheral corneal epithelial opacities and persistent epitheliopathy on the nasal and inferior graft (Fig. 2B, C). Confocal microscopy confirmed lesions characteristic of CIN, with larger, irregular, bright cells with hyperreflective larger nuclei in the superficial epithelium. Some cells presented two bright intracellular bodies. In this case, the distinction between abnormal and normal epithelial cells was not very clear (Fig. 2D–F). Confocal microscopy is an imaging method that allows real-time, noninvasive optical microscopic sectioning of the ocular surface (Chiou et al. 2006). Duchateau et al. (2005) explored CIN using CM for the first time. The main pathological lesions detected by histopathology were confirmed by CM. Although CIN is a slowly progressive condition with a small risk of malignant potential, recurrence rates are high if traditional therapies are used (Basti & Macsai 2003). Because of the subsequent risk of recurrence with standard treatments, and because repeated surgery can cause Diagnosis ⁄Therapy in Ophthalmology

In vivo confocal microscopy in recurrent granular dystrophy in corneal graft after penetrating keratoplasty

Two case reports of recurrent granular dystrophy in corneal grafts after penetrating keratoplasty are presented. Slit‐lamp examination and confocal microscopy (HRT II) were performed in two patients with recurrent granular dystrophy. All confocal microscopic findings of granular dystrophy were evaluated in the graft. Dystrophic lesions of the donor cornea presented the same confocal microscopic aspects in both eyes, and were similar to granular dystrophy lesions. Confocal microscopy is an imaging method that may provide new information on corneal microanatomy in dystrophies. It may be particularly useful in improving the early diagnosis of dystrophic lesions in corneal grafts.

Contrast sensitivity evaluation of aspheric and spherical intraocular lenses 2 years after implantation.

PURPOSE To compare the quality of vision with aspheric and spherical intraocular lenses (IOLs) in pseudophakic patients after long-term follow-up. METHODS Two hundred eyes of 100 patients with bilateral cataracts were randomly assigned to receive spherical (Acrysof SN60AT [Alcon Laboratories Inc] or Sensar AR40e [Advanced Medical Optics Inc]) or aspheric IOLs (Acrysof SN60WF [Alcon] or Tecnis Z9000 [Advanced Medical Optics]). Ophthalmologic examination, including best spectacle-corrected visual acuity (BSCVA), pupil size, ocular dominance, contrast sensitivity under mesopic and photopic conditions, and wavefront analysis, was performed 2 months and 1 and 2 years after surgery. RESULTS No statistically significant differences among the four groups in terms of age, pupil diameter, postoperative BSCVA, comeal spherical aberration, and posterior capsular opacification were noted. At all followup examinations, contrast sensitivity results showed no significant differences between the two aspheric IOLs at all spatial frequencies. Under photopic conditions, significant differences (P<.05) between spherical and aspheric IOLs were detected for spatial frequencies of 12 and 18 cycles per degree (cpd) at 2 months and 2 years and 12 cpd at 1 year. Under mesopic conditions, significant differences (P<.05) were detected between spherical and aspheric IOLs for all spatial frequencies at 2 months; all spatial frequencies except 18 cpd at 1 year; and spatial frequencies of 3, 12, and 18 cpd at 2 years. In addition, aspheric IOLs had statistical reductions in total spherical aberration at all follow-up examinations (P<.01). CONCLUSIONS This study confirms that implantation of a modified aspheric IOL improves functional visual performance at 2 years postoperative.

In vivo confocal microscopy in a patient with conjunctival lymphoma

A case of primary conjunctival mucosa‐associated lymphoid tissue lymphoma studied by in vivo corneal confocal microscopy (IVCM) is described for the first time. Examination of the lower mediobulbar and forniceal conjunctiva of the left eye of a 37‐year‐old female patient showed a typical salmon‐pink patch. IVCM examination of the conjunctival lesion showed irregular, polygonal, conjunctival bulbar epithelial cells with blurred edges and without visible nucleus. Many small, roundish, hyper‐reflective cells were also seen. These cells were arranged diffusely or in nests in cyst‐like hypo‐reflective spaces. A few highly reflective cells were also visible among deep stromal collagen fibres. The IVCM picture recalled the histological profile of low‐grade mucosa‐associated lymphoid tissue lymphoma, characterized by sheets of neoplastic cells around reactive follicles. IVCM enabled non‐invasive evaluation of the eye surface at high magnification and with good contrast, and could be useful for early differential diagnosis of conjunctival lesions.