Maria Gabriella La Tegola

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.

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.

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.

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.

Confocal microscopy analysis of corneal changes after photorefractive keratectomy plus cross-linking for keratoconus: 4-year follow-up.

PURPOSE To analyze corneal confocal microscopy changes after combined photorefractive keratectomy (PRK) plus the cross linking (CXL) procedure. DESIGN Prospective interventional case series. METHODS At the Department of Basic Medical Sciences, Neuroscience, and Sense Organs of the University of Bari, Bari, Italy, 17 eyes of 17 patients with progressive keratoconus underwent confocal microscopy examination before and after 1, 3, 6, 12, 18, and 48 months following PRK plus the CXL procedure. The main outcome measures were mean superficial epithelial cell density; mean basal epithelial cell density; mean anterior, mid and posterior keratocyte density; qualitative analysis of stromal backscatter; sub-basal and stromal nerve density parameters; and mean endothelial cell density. RESULTS During the 4-year follow-up, the mean superficial epithelial cell density, mean basal epithelial cell density and mean endothelial cell density remained unchanged (P > 0.05). The anterior mid-stromal keratocyte density showed a significant decrease (P < 0.05) as compared with preoperative values, and the posterior stromal keratocyte density showed a significant increase at 1 and 3 months of follow-up. Sub-basal and stromal nerve density parameters were significantly decreased until postoperative month 6 (P < 0.05 at 1, 3, and 6 months) and then tended to increase up to preoperative values by the 18th postoperative month. CONCLUSION Corneal changes after the PRK plus CXL procedures seem to be pronounced and long lasting as far as keratocyte density of the anterior and mid stroma is concerned. Sub-basal nerve densities tend to reach preoperative values 6 months after surgery.

Diathermy of leaking sclerotomies after 23-gauge transconjunctival pars plana vitrectomy: a prospective study.

Purpose: To evaluate the efficacy of bipolar diathermy in ensuring closure of leaking sclerotomies after complete 23-gauge transconjunctival sutureless vitrectomy. Methods: In this prospective, interventional case series, in 136 eyes of 136 patients with at least one leaking sclerotomy at the end of a complete 23-gauge transconjunctival sutureless vitrectomy, external bipolar wet-field diathermy was applied to leaking sclerotomies, including the conjunctiva and sclera. Intraoperative wound closure, and postoperatively, at 6 hours, 1 day and 3 days, sclerotomies leakage, intraocular pressure, hypotony, and hypotony-related complications were evaluated. Results: Intraoperative closure was achieved in 231 of 238 leaking sclerotomies (97%) that received diathermy. One of these with postoperative leakage needed suture. Compared with baseline (14.4 ± 2.8 mmHg), mean intraocular pressure was lower at 6 hours (13.2 ± 3.8 mmHg, Tukey–Kramer P < 0.001) and not different at 24 hours or 72 hours. Hypotony (intraocular pressure <5 mmHg) was observed in 6 eyes (4.5%) at 6 hours, in 2 (1.5%) at 24 hours, and in none at 3 days. Logistic regression analysis showed that, 6 hours postoperatively, hypotony was related to younger age (⩽50 years) at surgery (P = 0.031). No hypotony-related complications were recorded. Conclusion: Bipolar wet-field diathermy of sutureless sclerotomies is an effective method for ensuring a leaking sclerotomies closure.

Excimer Laser-Assisted Lamellar Keratoplasty and the Corneal Endothelium

PURPOSE To evaluate endothelial changes after excimer laser-assisted lamellar keratoplasty. DESIGN Retrospective, interventional case series. METHODS Seven eyes of 7 keratoconus patients were evaluated for 1 year after pachymetry-guided lamellar keratoplasty, performed using the iRES Laser (Ligi Tecnologie Medicali S.p.A.), with the Corneal Lamellar Ablation for Transplantation software (Ligi Tecnologie Medicali S.p.A.) procedure. Both anterior segment optical coherence tomography (Visante OCT; Carl Zeiss Meditec, Inc) and in vivo confocal microscopy (Corneal Confocal Microscope CS4; NIDEK Technologies) images were collected. RESULTS Changes in morphologic features were investigated and the endothelium was assessed quantitatively in all 7 patients. In 6 eyes, we measured a mean residual bed thickness of 151.3 +/- 5.46 microm, and a mean endothelial cell density loss of 5.38% at 1 year after surgery, as compared with preoperative values. The mean percentage hexagonality change was 15.67%, and the mean coefficient of variation change was -21.11%. In 1 eye, a residual bed thickness of 72 microm was found and endothelial loss after 1 year was 72.26%; assessment of the coefficient of variation and percentage hexagonality by manual Confoscan4 software (NIDEK Technologies) was not practicable in this case. CONCLUSIONS Our results showed that the Corneal Lamellar Ablation for Transplantation procedure induced mild changes to the endothelium in corneas with a mean residual bed thickness of 151.3 +/- 5.46 microm, but serious damage in one eye with a residual bed thickness of 72 microm.

Capsular block syndrome after implantation of an accommodating intraocular lens

A patient presented with capsular block syndrome (CBS) 1 month after cataract surgery. An unexpected postoperative myopia linked to shallowing of the anterior chamber was evident. The 1540 microm IOL shift was sufficient to give useful spectacle-free near vision. A neodymium:YAG laser peripheral anterior capsulotomy enabled the intracapsular liquid to flow into the anterior chamber, allowing normal placement of a 1CU IOL (HumanOptics AG) but revealing the limited accommodative ability of the IOL to cover the dioptric range from reading distance to infinity. The visual outcome of the patient is in accord with that in other studies of the effective of IOL shifting.