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Bimanual microphacoemulsification versus coaxial miniphacoemulsification : Prospective study

PURPOSE: To compare the outcomes of bimanual microphacoemulsification and coaxial miniphacoemulsification and assess the potential advantages of the former over the latter. SETTING: Institute of Ophthalmology, University of Modena, Modena, Italy. METHODS: In a controlled prospective clinical trial, 100 eyes of 50 patients with nuclear or corticonuclear cataract of grade 2 to 4 on the Lens Opacities Classification System III had phacoemulsification. Fifty eyes were randomized to have surgery by the bimanual technique and 50, by the coaxial technique. All surgeries were performed by the same surgeon using the same machine (Sovereign WhiteStar, American Medical Optics). In all cases, the incision was made superiorly in clear cornea and a hydrophobic acrylic flexible intraocular lens (Acri.Smart 48 S, Acri.Tec) was implanted. Intraoperative parameters were mean phacoemulsification time, total phacoemulsification percentage, effective phacoemulsification time (EPT), total volume of balanced salt solution (BSS) used, total surgical time, and final size of the corneal incision. Postoperative parameters were visual acuity, astigmatism changes by vector analysis, corneal thickness, endothelial cell count, and presence of flare and cells in the anterior chamber. RESULTS: The only statistically significant difference between the 2 groups was the total volume of the BSS used (P = .004) and total surgical time (P = .045). CONCLUSIONS: Both techniques were safe and effective for cataract surgery. With bimanual microphacoemulsification, significantly less BSS was used and the total surgical time was significantly shorter than with the coaxial method.

Visual recovery after scleral buckling for macula-off retinal detachments: An optical coherence tomography study

Purpose To assess the postoperative macular reattachment through OCT3 in eyes treated with episcleral surgery due to macula-off rhegmatogenous retinal detachment, as well as to verify if there is a statistically relevant relation between the persistence of a subfoveal detachment and poor postoperative functional recovery. Methods Twelve eyes of 12 patients who underwent episcleral surgery due to macula-off rhegmatogenous retinal detachment were enrolled and examined in a prospective study. Exclusion criteria were the following: traumatic retinal detachments, detachment relapses, macular holes, amblyopia, and grade B proliferative vitreoretinopathy or higher. The time period from the onset of subjective symptoms of retinal detachment to retinal surgery ranged from 3 to 7 days. All patients were evaluated in the preoperative and the postoperative period (after 1, 3, and 6 months) through measurement of visual acuity by ETDRS charts, fundus photographs, and macular tomography with OCT3. The postoperative tomography outcomes and the visual acuity were statistically examined using the Mann-Whitney U-test. Results One month after surgery, despite the macular reattachment assessable ophthalmoscopically and through fundus photographs, the OCT examination showed macular subretinal fluid persistence in 66.6% of cases. After 3 and 6 months, the persistence of such foveal detachment was respectively observed in 41.6% and in 33.3% of cases. Moreover, the macular subretinal fluid persistence in the postoperative period showed a statistically significant relation with poor functional recovery. Conclusions Delayed or incomplete visual recovery after episcleral surgery for macula-off retinal detachment may be related to macular subretinal fluid persistence, assessable with tomography and not visible ophthalmoscopically.

Impact of preoperative testing on ophthalmologic and systemic outcomes in cataract surgery

Purpose To evaluate the incidence of ophthalmologic and systemic complications in patients who undergo cataract surgery without preoperative tests compared to subjects undergoing cataract surgery preceded by preoperative tests. Methods The randomized controlled study included 1276 consecutive patients admitted to the Institute of Ophthalmology of the University of Modena and Reggio Emilia for cataract surgery. The patients were randomly divided into two groups: 638 were assigned not to undergo preoperative evaluation based on routine medical tests and electrocardiograms; the other 638 underwent preoperative evaluation based on said tests. Ophthalmologic and systemic complications were assessed intraoperatively and 1 month after surgery. Results Eleven intraoperative complications occurred in the group without preoperative tests and eight in the group with preoperative tests; at 1 month six complications were recorded in the group without tests and five in the group with tests. Systemic adverse events occurred intraoperatively in four patients, whereas no systemic adverse event was recorded at 1 month in either group. No statistically significant differences were observed between the two groups. Conclusions The findings of this study have broad applicability, because the sample is representative of the population existing in numerous social and healthcare settings; they are of value for administrative purposes, because they may be taken as reference in resource allocation plans; and they have medicolegal implications, as the resulting conduct of healthcare providers is supported by a rigorous scientific study.

Bottle-cork injury to the eye: a review of 13 cases

Purpose To analyze the anatomic and functional consequences of wine-cork injury to the eye in relation to the patients age and the type of cork and wine. Methods We retrospectively studied 13 patients, six women and seven men, presenting to our department with bottle-cork injury to the eye between January 1999 and June 2001. Results All patients presented with closed-globe injury according to Kuhn et als classification. All the cases were injured by bottle corks from sparkling wine: white in ten cases and red in three. Mean visual acuity at admission was 20/100 (range, hand motion to 20/20). The most frequent early injury was anterior chamber hyphema (84.6%), followed by corneal injury (62.2%), ocular hypertension (46.1%), lens subluxation (30.8%), traumatic cataract (23.1%), and post-traumatic retinal edema (23.1%). Mean final visual acuity was 20/25; the follow-up ranged from 3 to 29 months, averaging 16.1 months. Late complications were as follows: pupil motility anomalies (38.5%), traumatic cataract (30.8%), iridodialysis (15.4%), traumatic optic neuropathy (7.7%), post-traumatic glaucoma (7.7%), and traumatic maculopathy (15.4%). Surgical treatment was necessary in two cases (15.4%). Conclusions Bottle-cork eye injuries account for 10.8% of post-traumatic hospital admissions to our department. Most of them are due to sparkling white wine served at room temperature. There is no correlation between ocular injury and the eye-bottle distance or the type of cork.

Lidocaine versus ropivacaine for topical anesthesia in cataract surgery

Purpose: To assess the anesthetic efficacy and safety of topical ropivacaine versus topical lidocaine in cataract surgery. Setting: Institute of Ophthalmology, University of Modena and Reggio Emilia, Modena, Italy. Methods: This prospective controlled randomized double‐blind study comprised 64 patients scheduled for planned routine cataract extraction. Patients were randomized into 2 groups; 1 received topical ropivacaine 1% and the other, topical lidocaine 4%. The duration of surgery, intraoperative and early postoperative complications, and the need for supplemental intracameral anesthesia were recorded. Intraoperative and postoperative subjective pain was quantified by patients using a scale from 1 to 10. An endothelial cell count was performed preoperatively and 2 months after surgery. Results: The mean endothelial cell density decreased from 2334 cells/mm2 ± 496 (SD) to 2016 ± 674 cells/mm2 in the ropivacaine group and from 2519 ± 404 cells/mm2 to 1847 ± 607 cells/mm2 in the lidocaine group. The difference in cell density between groups was not significant before (P = .154) or after surgery (P = .329); however, the difference in mean cell loss between groups was statistically significant (P = .031). The duration of surgery and intraoperative complications were the same in both groups. Four patients in the ropivacaine group and 5 in the lidocaine group required supplemental anesthesia (P > .05). The mean subjective analog pain score was slightly higher in the lidocaine group (P > .05). The day after surgery, 12 eyes in the ropivacaine group and 6 in the lidocaine group had transient corneal edema (P = .150). Conclusions: Topical ropivacaine performed at least as well as topical lidocaine in efficacy and safety in cataract surgery. It provided sufficient and long‐lasting analgesia without the need for supplemental intracameral anesthesia in most cases.

Orbital Actinomycosis Associated with Painful Ophthalmoplegia

Purpose: To evaluate a case of orbital actinomycosis presenting as Tolosa-Hunt syndrome in a patient with a history of carcinomas of the kidney and breast. Methods: A woman with ingravescent painful ophthalmoplegia was brought to our observation. Brain and orbital and total body CT scans showed the presence of two orbital neoformations and a miliary pattern of dissemination in the lung. The initial diagnosis, which pointed to secondary localisations of the previous kidney and breast tumours, was changed to orbital and pulmonary actinomycosis following microbiological analysis of lung biopsy samples. Results: Prolonged antibiotic therapy with synthetic penicillin completely resolved the case. Conclusions: Actinomycosis is a very rare infection that may also affect the orbit and its association with a pulmonary dissemination is highly unusual. It is important to consider this type of infection among the causes of painful ophthalmoplegia.

Capsulorhexis phimosis after bimanual microphacoemulsification and in-the-bag implantation of the Akreos MI60 intraocular lens

An 80-year-old woman with corticonuclear cataract had cataract extraction by bimanual microphacoemulsification and in-the-bag implantation of the Akreos MI60 (Bausch & Lomb) intraocular lens (IOL). After 6 months, a complete capsulorhexis phimosis developed and surgery was performed to open and reduce the phimosis, with complete functional recovery. In the fellow pseudophakic eye, an acrylic hydrophobic Acri. Smart 48S (Acri.Tec) IOL had been implanted without complications. We conclude that a capsulorhexis phimosis may occur a few months after uneventful cataract surgery and in-the-bag implantation of the Akreos MI60 IOL.

Surgically induced astigmatism after manual extracapsular cataract extraction or after phacoemulsification procedure

Astigmatic changes in three series of cataract surgical procedures were compared. The first two series comprised eyes having a manual extracapsular cataract extraction (ECCE) through a 12.0 mm or 8.0 mm incision and implant of a PMMA posterior chamber lens. The third series comprised eyes having phacoemulsification through a scleral pocket and implant of a PMMA posterior chamber lens. Preoperative keratometry measurements and corneal topography maps were compared with those obtained two days, one week, one, three and six months postoperatively. The keratometry measurements, obtained with computerized videokeratography, revealed: on day 2, 4.89 D (1st series), 3.95 D (2nd series), 2.66 D (3rd series); one week, respectively 4.46 D, 3.51 D and 2.14 D; one month, 0.65 D, 0.53 D and 0.05; three months, 1.44 D, 0.35 D and 0.36 D; six months, 1.36 D, 0.42 D and 0.48 D. The surgically-induced cylinder at three months was four times greater in the manual ECCE 12.0 mm incision series than in the phacoemulsification series. However, by six months all differences were markedly reduced. The results add to the growing evidence that the phacoemulsification procedure produces less astigmatism and more rapid visual rehabilitation than the manual ECCE procedure. Topographic analysis showed much less corneal steepening after phacoemulsification than after manual ECCE. However, all three surgical procedures offered satisfactory clinical results.

Clear corneal incisions in bimanual microincision cataract surgery: Long-term wound-healing architecture

PURPOSE: To evaluate bimanual microincision cataract surgery (MICS) clear corneal incision (CCI) architectural features over the long‐term using anterior segment optical coherence tomography (AS‐OCT). DESIGN: Case series. SETTING: Institute of Ophthalmology, University of Modena, Modena, Italy. METHODS: Patients who had uneventful bimanual MICS in the previous 2 to 16 months were examined using AS‐OCT. Images were used to measure corneal thickness, incision length, incision angle, incidence of epithelial or endothelial gaping, misalignment, Descemet membrane detachment, and posterior wound retraction. RESULTS: Fifty‐two eyes (33 patients) were enrolled. Mean incision length and incision angle were, respectively, 1427.91 μm and 31.19 degrees for the right hand, 1440.63 μm and 31.54 degrees for the left hand, 1474.13 μm and 31.27 degrees for temporal incisions, and 1394.41 μm and 31.46 degrees for nasal CCIs. Posterior wound retraction was the only architectural feature found. Its prevalence was 7.10% at 2 to 3 months, 31.8% at 4 to 11 months, and 33.3% at 12 months. Fifty‐three percent of posterior wound retractions were in 1.8 mm CCIs and 47% in 1.4 mm CCIs. CONCLUSIONS: Bimanual MICS was not related to particular morphologic features of CCIs. The enlargement of 1 incision or construction of the incision with the dominant or the nondominant hand did not affect long‐term wound architecture. Posterior wound retraction was the only architectural feature; however, its prevalence seems substantially lower than with other surgical techniques. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Comparison of the clinical performance of Healon 5 and Healon in phacoemulsification.

Purpose Healon 5 is a high-molecular-mass fraction of sodium hyaluronate. Its density endows it with a number of viscoelastic characteristics. In this prospective, randomised clinical study we compared the performance of Healon 5 and Healon in phacoemulsification. SETTING. Institute of Ophthalmology, University of Modena and Reggio Emilia, Italy. Methods Two groups of patients underwent phacoemulsification and intraocular lens (IOL) implantation. In the first 27 patients Healon 5 was used as viscoelastic substance during surgery, and in the second 27 Healon was used. The surgeons subjective comments on the performance of these viscoelastic agents were recorded at the different steps of surgery: injection, capsulorhexis, phacoemulsification, IOL implantation, removal of viscoelastic agent and trasparency throughout the operation. The surgeons overall impression of the viscoelastics during the whole operation was noted. Tonometry and endothelial cell count were performed in all patients before and after operation. Results There was no statistical difference between the two groups as regards visual acuity, ocular pressure and endothelial damage. Healon 5 showed excellent ability to maintain the anterior chamber during capsulorhexis, phacoemulsification and IOL implantation. Removal time with Healon 5 was not appreciably longer than Healon. Conclusions Healon 5 emerges as a very interesting viscoelastic substance. Visibility is better if the anterior chamber is filled completely. Removal is easier if it is aspirated while moving the irrigation aspiration tip with circular movements over the top and around the border of the IOL.