Giovanni Alessio

Accuracy of Orbscan optical pachymetry in corneas with haze.

Purpose: To compare corneal thickness measurements with the Orbscan instrument (Orbtek, Inc.) and an ultrasonic pachymeter (Alcon Surgical) in corneas with haze. Setting: Department of Ophthalmology and Otolaryngology, University of Bari, Bari, Italy. Methods: Six eyes of 6 patients having phototherapeutic keratectomy for treatment of grade 2+ haze were assessed preoperatively and postoperatively by Orbscan optical pachymetry and ultrasonic pachymetry. Contralateral transparent untreated corneas of the same patients were used as controls. Two Orbscan and 5 ultrasound pachymetry measurements were performed at each visit and the mean values recorded. The accuracy and repeatability of the measurements were evaluated. Results: Preoperatively, the median corneal thickness in the 6 eyes with haze was 512.7 &mgr;m by ultrasonic pachymetry and 375.0 &mgr;m by optical pachymetry. The mean difference of 143.1 &mgr;m was statistically significant (Wilcoxon signed rank test, P=.0277). Postoperatively, the median pachymetry was 439.0 &mgr;m and 433.0 &mgr;m, respectively; the mean difference was 10.7 &mgr;m (P= .0277). In the control group, the median ultrasonic pachymetry was 530.9 &mgr;m and the median optical pachymetry, 529.0 &mgr;m; the mean difference was 4.7 &mgr;m (P= .1730). Precision was good in all groups; the standard deviation was less than 6.0 &mgr;m. Conclusions: The Orbscan system showed a decreased accuracy in measuring corneal thickness when clinically significant haze was present. The repeatability of the measures was good, suggesting that the cause of error lies in the optical acquisition process.

Relationship between eye symptoms and blepharospasm: A multicenter case–control study

Although patients with primary blepharospasm (BSP) commonly report experiencing ocular symptoms before the onset of orbicular spasms, the precise frequency and pathogenic role of this subjective ocular discomfort are poorly understood. We conducted a multicenter case–control study to investigate symptoms related to disorders of the anterior segment of the eye, administering a questionnaire to 165 patients with BSP and 180 age‐ and gender‐matched control patients with hemifacial spasm. On a validation sample, our questionnaire yielded high accuracy in detecting eye diseases (predominantly, dry eye syndrome) using detailed ophthalmological examination as the criterion. Logistic regression analysis indicated a significant association between ocular symptoms at disease onset and BSP. Ocular symptoms starting in the year preceding disease onset (short‐latency symptoms) showed a stronger association with BSP than ocular symptoms occurring earlier in time (long‐latency symptoms). The association was stronger when short‐latency symptoms developed from 40 to 59 years of age, whereas this was not observed for long‐latency symptoms. Our findings support the view that eye symptoms associated with BSP result from eye diseases and may be involved in the pathogenesis of BSP. The differential risk of developing BSP, based on age at onset of ocular symptoms, suggests that age and eye diseases may interact in giving rise to BSP.

Topography-driven photorefractive keratectomy: Results of corneal interactive programmed topographic ablation software

OBJECTIVE This study evaluated the efficacy, predictability, stability, and safety of a software program (Corneal Interactive Programmed Topographic Ablation (CIPTA) LIGI, Taranto, Italy) which, by transferring programmed ablation from the corneal topography to a flying-spot excimer laser, provides customized laser ablation. DESIGN Noncomparative consecutive case series. PARTICIPANTS Forty-two eyes of 34 subjects with a mean age of 33.9 (range, 20-54) had CIPTA at the Cattedra di Ottica Fisiopatologica of Bari (Italy). Twenty-eight eyes were treated for hyperopic astigmatism and 14 for myopic astigmatism. All the subjects had irregular astigmatism. OPERATION: Topography was acquired by a corneal topography mapping system (Orbscan, Orbtek, Inc., Salt Lake City, UT). These data were processed to obtain a customized altimetric ablation profile, which was transferred to a flying-spot laser (Laserscan 2000, Lasersight, Orlando, FL). MAIN OUTCOME MEASURES Data on uncorrected (UCVA) and best-corrected visual acuity (BCVA), predictability, and stability of refraction and any complications were analyzed. RESULTS Mean follow-up was 13.2 months. At the last postoperative examination, 26 eyes (92.8%) in the hyperopic group and 12 eyes (85.7%) in the myopic group had an UCVA superior to 20/40. Twelve hyperopic eyes (42.8%) and five myopic eyes (35.7%) had a UCVA of 20/20. All patients fell between 1 diopter of attempted correction in the spherical equivalent. Only 1 (2.4%) of the 42 eyes, belonging to the hyperopic group, lost 1 Snellen line of BCVA. We did not observe any decentration and/or haze after photorefractive keratectomy treatment or any irregularity in the flap-stroma interface in the three laser in situ keratomileusis operations performed in this study. CONCLUSIONS The combination of topographic data with computer-controlled flying-spot excimer laser ablation is a suitable solution for correcting irregular astigmatism due to different causes.

Corneal Interactive Programmed Topographic Ablation customized photorefractive keratectomy for correction of postkeratoplasty astigmatism

OBJECTIVE This study evaluated the efficacy, predictability, stability, and safety of a software program (Corneal Interactive Programmed Topographic Ablation [CIPTA], LIGI, Taranto, Italy), which, by transferring programmed ablation from the corneal topograph to a flying-spot excimer laser, provides customized laser ablation for correction of postkeratoplasty astigmatism. DESIGN Noncomparative consecutive interventional case series. PARTICIPANTS Ten eyes of 10 patients with a mean age of 41.4 years (range, 26-64) had CIPTA-guided photoastigmatic refractive keratectomy (PARK) at the Clinica Oculistica of Bari (Italy). Two patients were treated for hyperopic astigmatism and eight for myopic astigmatism. All the patients had irregular astigmatism after penetrating keratoplasty. OPERATION: Topography was acquired by a corneal topograph (Orbscan II, Orbtek, Inc., Salt Lake City, UT). This, together with refractive data, was processed to obtain a customized altimetric ablation profile that was transferred to a flying-spot laser (Laserscan 2000, Lasersight, Orlando, FL). MAIN OUTCOME MEASURES Data on uncorrected (UCVA) and best-corrected (BCVA) visual acuity, predictability, stability of refraction, and any complications were analyzed. RESULTS Mean follow-up was 8.4 months (range, 6-12; SD 2.4). At the last postoperative examination, seven eyes (70%) had a UCVA superior to 20/40. Three eyes (30%) had a UCVA of 20/20. Five eyes (50%) were within 0.50 diopters (D) of attempted correction in the spherical equivalent, and eight eyes (80%) within 1 D. Index of success of astigmatic correction was 0.19. All the eyes (100%) gained Snellen lines of BCVA. We did not observe any decentration and/or haze after PARK treatment performed in this study. CONCLUSIONS The combination of topographic data with computer-controlled flying-spot excimer laser ablation is a suitable solution for correcting irregular astigmatism after penetrating keratoplasty.

Topography-driven excimer laser for the retreatment of decentralized myopic photorefractive keratectomy

OBJECTIVE This study evaluated the efficacy, predictability, stability, and safety of a software program (Corneal Interactive Programmed Topographic Ablation, CIPTA, LIGI, Taranto, Italy), which, by transferring programmed ablation from the corneal topograph to a flying-spot excimer laser, provides customized laser ablation for correction of postmyopic photorefractive keratectomy (PRK) decentrations. DESIGN Noncomparative consecutive case series. PARTICIPANTS Thirty-two eyes of 32 subjects with a mean age of 35 years (range, 19-49; standard deviation [SD], 7.9) had CIPTA-guided PRK at the Clinica Oculistica of Bari University (Italy). All the subjects had irregular astigmatism after postmyopic PRK because of clinically significant, decentered treatments of more than 1 mm. OPERATION: Individual topographies were acquired by a corneal topograph (Orbscan II, Orbtek, Inc., Salt Lake City, UT). These, together with refractive data, were processed to obtain a customized altimetric ablation profile that was transferred to a flying-spot laser (Laserscan 2000, Lasersight, Orlando, FL). MAIN OUTCOME MEASURES The topographic study of centration and data on uncorrected (UCVA) and best-corrected (BCVA) visual acuity, predictability, and stability of refraction, and any complications, were analyzed. RESULTS Mean follow-up was 10.3 months (range, 4-18 months; SD, 5.8). At the last postoperative examination, 29 eyes (90.6%) had a UCVA superior to 20/40. Nineteen eyes (59.4%) had a UCVA of 20/20. Twenty-two eyes (68.75%) were within 0.50 diopters (D) of attempted correction in the spherical equivalent and 28 eyes (87.5%) were within 1 D. The index of success of astigmatic correction was 0.15. No eye lost Snellen lines of BCVA, whereas 18 eyes (56.25%) gained Snellen lines. Postoperative topographies revealed well-centered treatments. CONCLUSIONS The combination of topographic data with computer controlled flying-spot excimer laser ablation is a suitable solution for correcting irregular astigmatism after postmyopic PRK decentrations.

Fundus autofluorescence and multiple evanescent white dot syndrome.

Objective: To describe fundus autofluorescence (FAF) in a series of patients with multiple evanescent white dot syndrome. Methods: Three eyes of three patients with multiple evanescent white dot syndrome were evaluated with indocyanine green angiography and FAF imaging to evaluate the correspondence between FAF and ICG patterns and the nature of the focal hypocyanescent spots evident with ICG. Results: In the acute phase, all three eyes showed increased autofluorescence area corresponding precisely to the site of the focal hypocyanescent spots seen on ICG but less numerous. After 2 months, mean best-corrected visual acuity improved from 20/38 to 20/20 and FAF and indocyanine green angiography returned to normal pattern. Discussion: FAF is an useful noninvasive diagnostic adjunct to identify multiple evanescent white dot syndrome, suggesting the inflammatory nature of the disease, probably due to perturbation of the photoreceptor-retinal pigment epithelium complex affecting the function of these cells.

Combined Topical anesthesia and sedation for open-globe injuries in selected patients

PURPOSE To evaluate the efficacy and safety of topical anesthesia (TA) and IV sedation in surgery for less severe open-globe injury (OGI). DESIGN Noncomparative consecutive interventional case series. PARTICIPANTS Of 67 OGI cases reviewed at the Department of Ophthalmology and Otolaryngology, University of Bari, Bari, Italy, in the period from 1999 to 2000, 10 eyes (14.9%) of 10 consecutive patients (age range, 6-58 years) were repaired using TA and IV sedation. All patients belonged to the American Society of Anesthesiologists risk class I or II. Nine eyes had corneoscleral wounds, four had vitreous loss, two had traumatic cataract, and three had an intraocular foreign body (IOFB); one patient had interruption of a continuous penetrating keratoplasty suture. Preoperatively, best-corrected visual acuity (BCVA) ranged from hand movement to 20/20. INTERVENTION Corneoscleral suture was performed in nine patients, vitreous excision in four, uveal excision or reposition in four, IOFB removal in three, and cataract extraction in two; corneal button resuture was carried out in one patient. All patients received topical oxybuprocaine hydrochloride 0.4%, and IV propofol, midazolam, and fentanyl for anesthesia. MAIN OUTCOME MEASURES The change in BCVA was evaluated. Within 24 hours after surgery, each patient was asked to grade subjective pain and discomfort on a 4-point scale. The surgeon was asked to report difficulties attributable to the operating conditions. Complications related to anesthesia and to surgery were assessed. RESULTS Best-corrected visual acuity stabilized or improved in all patients. All patients had grade 1 pain and discomfort during most of the procedure. All patients had grade 2 (mild) pain and discomfort during external bipolar cautery and conjunctival closure. No patient required additional anesthesia. The operating conditions as reported by the surgeons were graded slightly difficult in all cases but one, which was graded moderately difficult. No patient had surgical or anesthesia-related adverse events or life-threatening complications. CONCLUSIONS Topical anesthesia and IV sedation are safe and effective and could be a reasonable alternative for less severe OGI. The degree of patient discomfort is only marginal during surgery and postoperatively. However, surgical training and patient preparation are the keys to the safe use of this anesthetic modality.

Ocular Toxicity in Metastatic Melanoma Patients Treated With Mitogen-Activated Protein Kinase Kinase Inhibitors: A Case Series

PURPOSE To report the clinical features and management of mitogen-activated protein kinase kinase inhibitor-associated ocular side effects in 4 patients with advanced melanoma and a review of literature. DESIGN Interventional case series. METHODS Four patients with advanced cutaneous melanoma were treated with a mitogen-activated protein kinase kinase (MEK) inhibitor as single therapy or together with a v-raf murine sarcoma viral oncogene homolog B1 (BRAF) inhibitor. All patients underwent ophthalmologic examinations at regular intervals or as needed, including visual acuity, intraocular pressure, external eye examination, and funduscopy. When pathologic findings were found, patients underwent visual field examination, optical coherence tomography (OCT), and/or fluorescein angiography. Ocular toxicity was assessed and handled according to the Common Terminology Criteria for Adverse Events. RESULTS Ocular adverse events appeared early in the treatment. In 3 patients OCT revealed subfoveal neuroretinal elevation, often asymptomatic, also after discontinuation and re-starting of MEK inhibitor. Vascular injury appeared in 2 patients, in 1 case associated with a visual field defect reduced after discontinuation of the drug and use of systemic therapy. In 1 case an inflammatory reaction was observed in the anterior chamber. Visual symptoms were usually mild and short-lived. CONCLUSIONS MEK inhibitor as a single agent or in combination with BRAF inhibitor induces transient retinopathy with time-dependent recurrence and usually mild visual symptoms. Vascular injuries can be observed and their management is essential in clinical practice. It is important to investigate all previous ocular disorders, systemic conditions, and pharmacologic interactions of MEK inhibitor that could facilitate the onset of associated ocular effects.

Combined cataract extraction and intravitreal bevacizumab in eyes with choroidal neovascularization resulting from age-related macular degeneration

PURPOSE: To evaluate the safety and efficacy of phacoemulsification, intraocular lens (IOL) implantation, and a single intravitreal injection of bevacizumab in patients with coexisting visually significant cataract and subfoveal neovascularization due to age‐related macular degeneration. SETTING: Department of Ophthalmology, University of Bari, Bari, Italy. METHODS: Eyes with predominantly classic subfoveal neovascularization and cataract had phacoemulsification, IOL implantation, and a 1.25 mg intravitreal injection of bevacizumab. One month after combined surgery, corrected distance visual acuity (CDVA), anterior chamber reaction, and intraocular pressure were evaluated and central foveal thickness was measured by optical coherence tomography. RESULTS: Twenty eyes of 20 patients were evaluated. One month postoperatively, the mean CDVA improved significantly, from 20/100 (range 20/160 to 20/80) at baseline to 20/63 (range 20/125 to 20/50) (P<.0001). The mean central foveal thickness decreased significantly, from 353.75 μm ± 12.50 (SD) (range 334 to 375 μm) at baseline to 275.7 ± 17.3 μm (range 255 to 323 μm) at 1 month (P<.0001). Intraocular pressure did not change significantly, and anterior chamber reaction was absent. No ocular or systemic adverse events were observed. CONCLUSION: Combined phacoemulsification, IOL implantation, and intravitreal bevacizumab was a safe and efficacious treatment in patients with visually significant cataract and active subfoveal neovascularization.

Topographic customized photorefractive keratectomy for regular and irregular astigmatism after penetrating keratoplasty using the LIGI CIPTA/LaserSight platform.

PURPOSE To evaluate the use of a software ablation program (Corneal Interactive Programmed Topographic Ablation [CIPTA]) that provides customized photorefractive keratectomy (PRK) to correct astigmatism after keratoplasty. METHODS In this prospective, noncomparative, consecutive case series, 44 eyes underwent CIPTA for correction of astigmatism after penetrating keratoplasty. Eighteen eyes were treated for regular astigmatism and 26 eyes were treated for irregular astigmatism after penetrating keratoplasty. Orbscan II topography (Bausch & Lomb) and a flying-spot laser (LaserScan 2000; LaserSight) were used. Epithelial debridement with alcohol was performed before PRK in 16 eyes and transepithelial PRK was performed in 28 eyes. Mean target-induced astigmatism was 8.19 +/- 2.68 diopters (D) and 7.68 +/- 4.50 D in the regular and irregular astigmatism groups, respectively. RESULTS Mean follow-up was 25.4 +/- 13 months. At last postoperative follow-up, 13 (72.2%) and 18 (69.2%) eyes in the regular and irregular astigmatism groups, respectively, had uncorrected visual acuity (UCVA) better than 20/40. Four (22.2%) and 8 (30.7%) eyes in the regular and irregular astigmatism groups, respectively, had UCVA of 20/20. Fourteen (77.7%) and 18 (69.2%) eyes in the regular and irregular astigmatism groups, respectively, were within 1.00 D of attempted correction in spherical equivalent manifest refraction. No eye lost Snellen lines of best spectacle-corrected visual acuity. Mean surgically induced astigmatism was 7.66 +/- 2.70 D and 6.99 +/- 3.80 D for the regular and irregular astigmatism groups, respectively. Index of success of astigmatic correction was 0.138 and 0.137 for the regular and irregular astigmatism groups, respectively. Haze developed in three eyes. CONCLUSIONS Topography-driven PRK using CIPTA software is a suitable solution for correcting regular and irregular astigmatism after penetrating keratoplasty.