Ioannis Tsinopoulos

Primary vitrectomy with perfluoro-n-octane use in the treatment of pseudophakic retinal detachment with undetected retinal breaks.

PURPOSE This report describes the results of a prospective trial to evaluate the efficacy of pars plana vitrectomy (PPV) in conjunction with perfluoro-n-octane (PFO) as initial treatment of pseudophakic retinal detachment (RD) with no breaks diagnosed preoperatively. METHODS Fourteen consecutive eyes presenting with pseudophakic RD in which retinal breaks could not be identified preoperatively underwent primary PPV, internal microsurgical identification of the retinal breaks with endoillumination and noncontact wide angle viewing system, PFO retinal reattachment, transscleral cryopexy or endolaser treatment of breaks, PFO-air exchange, and final injection of 20% sulfur hexafluoride. In five eyes, a scleral buckle was also used. Mean follow-up period was 18 months. RESULTS In 13 of the 14 eyes in which no breaks had been identified preoperatively, breaks were diagnosed during surgery. Perfluoro-n-octane retinal attachment facilitated accurate microscopic treatment of retinal breaks. The retina was reattached with a single operation in all eyes. Eleven eyes had final visual acuity of 20/60 or better. Complications were minimal. CONCLUSIONS Pars plana vitrectomy in conjunction with PFO expression of subretinal fluid is effective in the initial treatment of pseudophakic RD with no preoperative diagnosis of retinal breaks.

Ultrasonographic classification and phacoemulsification of white senile cataracts

OBJECTIVE To classify the white senile cataracts and report the results of phacoemulsification of white cataracts. DESIGN Prospective, noncomparative case series. PARTICIPANTS One hundred eyes were included. INTERVENTION White cataracts were examined biomicroscopically before surgery, and their acoustic structure was analyzed with standardized A-scan echography. White cataract surgery was performed with phacoemulsification via a superior temporal near-limbus corneal approach using a bimanual divide-and-conquer or stop-and-chop technique. Patients were followed after surgery for a period of 9 months. MAIN OUTCOMES MEASURES The A-scan acoustic structure of white cataracts; successful accomplishment of capsulorrhexis; mean phacoemulsification time, power, and energy; intraoperative and postoperative complications of phacoemulsification; and visual acuity at 9 months after surgery. RESULTS White senile cataracts were categorized into three different types. Type I included intumescent, white cataracts with cortex liquefaction and high internal acoustic reflections (44 eyes), type II included white cataracts with voluminous nuclei, little amount of whitish solid cortex, and low internal acoustic reflections (49 eyes), and type III included white cataracts with fibrosed anterior capsule and low internal echospikes (7 eyes). Circular capsulorrhexis was completed in 79 eyes and was significantly less successful in eyes with type I intumescent, white cataracts compared with type II white cataracts (P = 0.0034). Mean phacoemulsification time and energy were higher in type II and type III white cataracts. Posterior capsule rupture occurred in ten eyes, and three of these eyes were complicated by vitreous loss. In 95 eyes, the posterior chamber lens was implanted in the capsular bag and in five eyes in the sulcus. After surgery, a transient corneal edema developed in 31 eyes. At the final 6-month examination, the mean postoperative visual acuity was 20/30. CONCLUSION Current phacoemulsification techniques can safely manage eyes with senile white cataracts. The increased risk of difficulty with continuous capsulorrhexis in type-I and type-III white cataracts and the substantial nuclear hardness in type-II and mainly type-III white cataracts would suggest that current phacoemulsification techniques might not be as successful in these patients as they are in ordinary earlier cataracts.

Acrylic toric intraocular lens implantation: a single center experience concerning clinical outcomes and postoperative rotation

Purpose: To present clinical results of toric intraocular lens (IOL) implantation for preexisting astigmatism correction and determine the time of any postoperative rotation. Patients and methods: Twenty-nine eyes of 19 patients underwent uncomplicated phacoemulsification and were implanted with an Acrysof

The effect of subconjunctival ranibizumab on primary pterygium: a pilot study.

Purpose: A prospective interventional pilot study was performed to estimate the effect of ranibizumab injection on the clinical and histological picture of primary pterygium. Methods: Five patients with primary pterygia received a single subconjunctival injection of ranibizumab (0.3 mg), whereas 5 nontreated pterygia served as controls. The treated pterygia were surgically removed 3 days, 1 week, 2 weeks, 1 month, and 2 months after the injection, respectively. Digital photographs of the pterygia were taken immediately before injection, 1 week after, and on the day of operation. Results: Ranibizumab was well tolerated by all patients, and no side effects were reported. However, it had no effect on the extent of vascularization of pterygium, regardless of the interval between injection and operation. No regression of pterygium vessels was noted in any of the patients. Immunohistochemical analysis also showed no particular differences in the number of vessels stained positive for vascular endothelial growth factor A, in the intensity of vessel staining among the treated pterygia, and between the treated and the nontreated pterygia. Conclusions: Subconjunctival ranibizumab at a single dose of 0.3 mg was not associated with any side effects but had no effect on the extent of vascularization of primary pterygium in our study.

Sulcus implantation of a 3-piece, 6.0 mm optic, hydrophobic foldable acrylic intraocular lens in phacoemulsification complicated by posterior capsule rupture.

Purpose: To evaluate the safety of implanting a 3‐piece, 6.0 mm optic, foldable acrylic intraocular lens (IOL) in cases of posterior capsule rupture during phacoemulsification. Setting: Department of Ophthalmology, Ahepa Hospital, Aristotle University Medical School, and Interbalkan Medical Center, Thessaloniki, Greece. Methods: This prospective noncomparative case series included 28 eyes (28 patients) having phacoemulsification complicated by extensive posterior capsule rupture with or without vitreous loss. In all eyes, a 3‐piece, 6.0 mm optic, foldable acrylic IOL (AcrySof® MA60BM, Alcon) was implanted in the sulcus. Postoperative examination included best corrected visual acuity (BCVA), anterior segment biomicroscopy, IOL centration and position, intraocular pressure (IOP), and fundus biomicroscopy. The follow‐up was 6 months. Results: The most common postoperative complications were transient corneal edema in 12 eyes and increased IOP in 11 eyes. Slight asymptomatic decentration from the center of the pupil (1.0 to 2.0 mm) and pseudophacodonesis were observed in 5 eyes each. Friction of the IOL with the iris occurred in 1 eye. Clinically significant cystoid macular edema occurred in 3 eyes. The final BCVA was between 20/15 and 20/25 in 18 patients, 20/30 in 2, between 20/40 and 20/50 in 4, and between 20/60 and 20/200 in 4. Conclusions: AcrySof IOL implantation in the sulcus during phacoemulsification complicated by posterior capsule rupture preserved the advantages of small‐incision surgery. The postoperative behavior and centration of the IOLs resembled those of poly(methyl methacrylate) lenses.

Matrix metalloproteinase (MMP-2, -9) and tissue inhibitor (TIMP-1, -2) activity in tear samples of pediatric type 1 diabetic patients

BackgroundThe presence of matrix metalloproteinase (MMP-2, -9) and tissue inhibitor (TIMP-1, -2) activity in tear samples of pediatric type 1 diabetes mellitus (DM) patients and potential correlations with clinical parameters (Schirmer testing, glycosylated hemoglobin-HBA1C) were investigated.MethodsTear samples from the right eyes of 27 type 1 DM patients and 17 healthy control subjects were included in this study. The MMP gelatinolytic activity was determined by gelatin zymography analysis using sodium dodecyl sulphate–polyacrylamide gel electrophoresis (SDS-PAGE), while MMP and TIMP concentrations (in ng/ml) were quantified in tears of type 1 diabetic patients and healthy controls, with the use of enzyme-linked immunosorbent assay (ELISA).ResultsMMP-9, TIMP-1, -2 levels, MMP-9/TIMP-1, and MMP-9/TIMP-2 ratios in the patient group were significantly elevated. There was a significant correlation between TIMP-2 and HBA1C values, as well as between MMP-2 and MMP-9.ConclusionsSignificant correlations between TIMP-2 and HBA1C and between Schirmer test results and HBA1C were revealed. Significant increase in tear MMP and TIMP levels in pediatric type 1 diabetic patients may be suggestive of disease progression and localized pathologic remodelling. Further studies are required in order to ascertain whether MMPs and TIMPs could be employed as indicators of early disease progression.

Surgical outcomes in phacoemulsification after application of a risk stratification system

Background The purpose of this study was to determine whether application of a risk stratification system during preoperative assessment of cataract patients and subsequent allocation of patients to surgeons with matching experience may reduce intraoperative complications. Methods Nine hundred and fifty-three consecutive patients (1109 eyes) undergoing phacoemulsification cataract surgery were assigned to two groups, ie, group A (n = 498 patients, 578 eyes) and group B (n = 455 patients, 531 eyes). Patients from group A were allocated to surgeons with varying experience with only a rough estimate of the complexity of their surgery. Patients from group B were assigned to three risk groups (no added risk, low risk, and moderate-high risk) according to risk factors established during their preoperative assessment and were respectively allocated to resident surgeons, low-volume surgeons, or high-volume surgeons. Data were collected and entered into a computerized database. The intraoperative complication rate was calculated for each group. Results The intraoperative complication rate was significantly lower in group B than in group A (group A, 5.88%; group B, 3.2%; P < 0.05). Patients from group B with no added risk and allocated to resident surgeons had a significantly lower rate of intraoperative complications than those from group A allocated to resident surgeons (group A, 7.2%; group B, 3.08%; P < 0.05). Conclusion Our study demonstrates that allocation of cataract patients to surgeons matched for experience according to a uniform and reliable preoperative assessment of their risk of complications allows for better surgical outcomes, especially for resident surgeons.

Binocularity enhances visual acuity of eyes implanted with multifocal intraocular lenses.

PURPOSE To investigate the effect of binocularity on long-term visual acuity in patients who have undergone bilateral implantation of a presbyopia-correcting diffractive multifocal intraocular lens (IOL). METHODS Twenty patients (9 men and 11 women) with an average age of 70 ± 7 years (range: 56 to 78 years) underwent bilateral implantation of a diffractive multifocal IOL (AcrySof IQ ReSTOR IOL, SN60D3; Alcon Laboratories, Inc., Fort Worth, TX). Uncorrected visual acuity was measured monocularly and binocularly on average 26 ± 6 months following implantation in the second eye (range: 17 to 40 months) using the University of Crete European-wide modified Early Treatment Diabetic Retinopathy Study charts at the following distances: (1) 4 m, uncorrected distance visual acuity (UDVA), (2) 66 cm, uncorrected intermediate visual acuity (UIVA), and (3) 33 cm, uncorrected near visual (UNVA). RESULTS Mean ± standard deviation UDVA was 0.07 ± 0.10 and 0.21 ± 0.12 logMAR (20/23 and 20/32 Snellen) in the better and worse eye, respectively, improving to 0.00 ± 0.09 logMAR (20/20 Snellen) binocularly. Mean ± standard deviation UIVA was 0.18 ± 0.14 and 0.32 ± 0.15 logMAR (20/30 and 20/42 Snellen) in the better and worse eye, respectively, improving to 0.08 ± 0.15 logMAR (20/24 Snellen) binocularly. Mean ± standard deviation UNVA was 0.20 ± 0.09 and 0.32 ± 0.12 logMAR (20/32 and 20/42 Snellen) in the better and worse eye, respectively, improving to 0.11 ± 0.10 logMAR (20/26 Snellen) binocularly. Binocular summation, defined as the difference between the binocular and better eye visual acuity, was found to be statistically significant at all distances: 0.07 ± 0.05 logMAR at 4 m, 0.10 ± 0.11 logMAR at 66 cm, and 0.09 ± 0.08 logMAR at 33 cm. CONCLUSIONS The results confirm that there is substantial benefit of binocular vision in individuals with bilateral multifocal IOL implantation in terms of increased visual acuity. This effect is evident at all distances.

Interleukin-6 and matrix metalloproteinase expression in the subretinal fluid during proliferative vitreoretinopathy: Correlation with extent, duration of RRD and PVR grade

PURPOSE To investigate interleukin (IL)-6 protein levels in the subretinal fluid (SRF) of patients with rhegmatogenous retinal detachment (RRD) complicated by proliferative vitreoretinopathy (PVR); to correlate the IL-6 levels with matrix metalloproteinases (MMP)-1, -2, -3, -8, -9 and tissue inhibitor of metalloproteinases (TIMP)-1 with respect to RRD extent, duration and PVR grade. METHODS Thirty-one SRF samples from 31 eyes of 31 patients with RRD complicated with PVR and five SRF samples from five eyes of five patients suffering from RRD not complicated with PVR were collected during treatment by scleral buckling. Enzyme-Linked Immunosorbent Assay was employed for the measurement of IL-6, MMP-1, -3, -8 and TIMP-1 levels while the enzymatic activity of MMP-2 and MMP-9 was assessed by gelatin zymography. RESULTS Protein levels of IL-6 (p=0.050), MMP-1 (p=0.001), MMP-3 (p=0.005), MMP-8 (p=0.003), TIMP-1 (p=0.001) as well as enzymatic activity of proMMP-2 (p=0.001), MMP-2 (p=0.023) and MMP-9 (p=0.015), were significantly higher in the SRF of PVR patients compared to controls. IL-6 levels correlated significantly with TIMP-1 (r=0.528, p=0.035). Regarding clinical parameters of the detachment, IL-6 levels correlated with RRD extent (r=0.592, p=0.016), but not with RRD duration (p=0.857) and PVR grade (p=0.594). Regression analysis revealed positive correlations between IL-6 and MMP-2. CONCLUSIONS There was a significant correlation between IL-6 and TIMP-1 levels in the SRF of PVR patients. The findings of this study are in agreement with relevant studies concerning IL-6 involvement in the modulation of MMP expression and are indicative of IL-6 and MMP activity during PVR, mainly that of MMP-2 and TIMP-1.

Self-retaining bicanaliculus stents as an adjunct to 3-snip punctoplasty in management of upper lacrimal duct stenosis: a comparison to standard 3-snip procedure.

Purpose: To evaluate the efficacy of self-retaining bicanaliculus stents when used as an adjunct to 3-snip punctoplasty in comparison with standard 3-snip procedure between fellow eyes. Methods: Prospective, randomized, comparative study. Thirty-two eyes of 16 consecutive patients with acquired, nontraumatic stenosis of the proximal lacrimal duct were randomly distributed into 2 equal study groups. Lower punctal stenosis was a standard prerequisite. Group A (16 eyes) received a simple 3-snip punctoplasty, while group B (16 fellow eyes) underwent a modified 3-snip punctoplasty combined with insertion of self-retaining bicanaliculus stents. Duration of follow ups: 6 months. Anatomical, functional, and subjective parameters were evaluated. Results: A statistically significant difference in anatomical success rates was observed in favor of group B (p = 0.011) 6 months postoperatively. Complete relief from epiphora was noted in 8 eyes of group B compared with 2 eyes of group A (p = 0.057). In regard to mixed (absolute and partial) functional success rates, group B exceeded with statistically significant difference (15 eyes group B vs. 6 eyes group A; p = 0.002). A nasolacrimal duct obstruction was subsequently diagnosed in 3 of the nonpatient eyes. Reintroduction of silicone tubes was required in 4 eyes of group B. Conclusions: The use of self-retaining bicanaliculus stents seems to improve anatomical, functional, and subjective scores when combined with standard 3-snip punctoplasty in patients with acquired upper lacrimal duct stenosis.