Massimiliano Serafino

Photorefractive keratectomy for the treatment of purely refractive accommodative esotropia

Purpose: To evaluate the results of photorefractive keratectomy (PRK) for the treatment of young adult patients with purely refractive accommodative esotropia. Setting: Private practice and university hospital, Milan, Italy. Methods: The medical records of consecutive patients who had PRK for hyperopia associated with purely refractive esotropia were reviewed retrospectively. Preoperative and postoperative visual acuity, alignment, and sensory data were recorded and analyzed. Surgical methods and complications were reviewed. Results: Sixteen eyes of 8 patients were treated. The mean patient age at the time of treatment was 24.6 years (range 17 to 38 years). All patients were followed for 1 year. At the 1‐year follow‐up evaluation, the uncorrected visual acuity was 20/40 or better in all eyes. No patient lost a line of best spectacle‐corrected visual acuity. The mean spherical equivalent was −3.7 diopters (D) preoperatively and −0.7 D postoperatively. All patients were within ±0.37 D of emmetropia at the 1‐year evaluation. Preoperatively, the mean esotropic deviation was 10.75 prism diopters. Postoperatively, all patients were orthophoric without correction. Stereopsis was unaffected by PRK in all patients. There were no intraoperative or postoperative complications. Conclusion: Photorefractive keratectomy was an effective treatment for esotropia associated with mild to moderate hyperopia in young adults with purely refractive accommodative esotropia. These findings should not be widely applied to children with accommodative esotropia.

Photorefractive keratectomy for the treatment of purely refractive accommodative esotropia: 6 years' experience

Aims To report the long term outcomes of photorefractive keratectomy (PRK) for the treatment of hyperopia associated with purely refractive accommodative esotropia. Methods This study was a retrospective chart review of 40 patients aged 17–39 years who underwent PRK to eliminate their dependence on glasses. Pre- and postoperative best spectacle corrected visual acuity (BSCVA), uncorrected visual acuity (UCVA), refractive spherical equivalent (SEQ), ocular alignment and stereoacuity were reviewed. Results Forty patients (80 eyes) with a mean age of 27.9 years were treated for a mean preoperative SEQ of +3.06 D hyperopia. The mean final postoperative SEQ was +0.06 D. Preoperative BSCVA was 0.04 logarithm of the minimum angle of resolution (logMAR), and did not change postoperatively. Mean UCVA significantly improved from 0.30 logMAR preoperatively to 0.08 logMAR post-operatively. Mean pre-operative esotropia at distance and near was 18.6 prism D. All patients were orthophoric without correction at the 1 month, 1 year and final postoperative evaluations. Visual acuity, refractive error and alignment remained stable after the 1 year postoperative examination. Stereoacuity was unchanged in 80% of patients postoperatively. There were no complications. Conclusion PRK can be used to treat low to moderate hyperopia associated with purely refractive accommodative esotropia in young adults.

Genetics of Congenital Cataract

Congenital cataract is a type of cataract that presents at birth or during early childhood, and it is one of the most easily treatable causes of visual impairment and blindness during infancy, with an estimated prevalence of 1-6 cases per 10,000 live births. Approximately 50% of all congenital cataract cases may have a genetic cause, and such cases are quite heterogeneous. Although congenital nuclear cataract can be caused by multiple factors, genetic mutation remains the most common cause. All three types of Mendelian inheritance have been reported for cataract; however, autosomal dominant transmission seems to be the most frequent. The transparency and high refractive index of the lens are achieved by the precise architecture of fiber cells and homeostasis of the lens proteins in terms of their concentrations, stabilities, and supramolecular organization. Research on hereditary congenital cataract has led to the identification of several classes of candidate genes that encode proteins such crystallins, lens-specific connexins, aquaporin, cytoskeletal structural proteins, and developmental regulators. In this review, we highlight the identified genetic mutations that account for congenital nuclear cataract.

Use of the Delphi process in paediatric cataract management

Purpose To identify areas of consensus and disagreement in the management of paediatric cataract using a modified Delphi approach among individuals recognised for publishing in this field. Design A modified Delphi method. Participants International paediatric cataract experts with a publishing record in paediatric cataract management. Methods The process consisted of three rounds of anonymous electronic questionnaires followed by a face-to-face meeting, followed by a fourth anonymous electronic questionnaire. The executive committee created questions to be used for the electronic questionnaires. Questions were designed to have unit-based, multiple choice or true–false answers. The questionnaire included issues related to the preoperative, intraoperative and postoperative management of paediatric cataract. Main outcome measure Consensus based on 85% of panellists being in agreement for electronic questionnaires or 80% for the face-to-face meeting, and near consensus based on 70%. Results Sixteen of 22 invited paediatric cataract surgeons agreed to participate. We arrived at consensus or near consensus for 85/108 (78.7%) questions and non-consensus for the remaining 23 (21.3%) questions. Conclusions Those questions where consensus was not reached highlight areas of either poor evidence or contradicting evidence, and may help investigators identify possible research questions.

RETINAL ASTROCYTIC HAMARTOMA: Optical Coherence Tomography Classification and Correlation With Tuberous Sclerosis Complex.

Purpose: To propose a classification of retinal astrocytic hamartoma based on spectral domain optical coherence tomography and correlate each class with systemic manifestations of tuberous sclerosis complex. Methods: Retrospective chart review conducted at four international referral medical retina centers. There were 43 consecutive patients with an established diagnosis of tuberous sclerosis complex based on presence of at least 2 major or 1 major and 2 minor features of the diagnostic criteria. Clinical and spectral domain optical coherence tomography features regarding retinal astrocytic hamartoma were documented. Results: The mean patient age at presentation was 16.2 years. The retinal astrocytic hamartoma was classified as Type I (n = 41), Type II (n = 25), Type III (n = 20), or Type IV (n = 12). Patients with Type II showed greater number of cutaneous fibrous plaques (odds ratio = 64.8; 92% confidence interval: 64.2–65; P < 0.001); those with Type III displayed higher incidence of subependymal giant-cell astrocytomas (odds ratio = 43.2; 95% confidence interval: 43.0–43.3; P < 0.001); and those with Type IV showed higher incidence of pulmonary lymphangiomyomatosis (odds ratio = 126; 95% confidence interval: 122–128; P < 0.001). Conclusion: Retinal astrocytic hamartoma can be classified into four morphologic groups, based on spectral domain optical coherence tomography. There are important systemic tuberous sclerosis complex correlations with each class.

Dry Eye in Vernal Keratoconjunctivitis: A Cross-Sectional Comparative Study.

Abstract The purpose of this comparative cross-sectional study was to investigate the use of standardized clinical tests for dry eye in pediatric patients with active and quiet vernal keratoconjunctivitis (VKC) and to compare them with healthy children. We recruited 35 active VKC, 35 inactive VKC, and 70 age-matched control healthy subjects. Each child underwent a complete eye examination, including visual analog scale symptoms assessment, biomicroscopy, fluorescein break-up time (BUT), corneal fluorescein and conjunctival lissamine green staining, corneal esthesiometry, Schirmer test with anesthetic, and meibomian glands inspection and expression. Active VKC patients showed significantly increased symptoms and signs of ocular surface disease, compared with the other 2 groups. Inactive VKC patients, compared with control subjects, showed increased photophobia (P < 0.05; Mann-Whitney U test), conjunctival lissamine green staining and Schirmer test values, and reduced BUT and corneal sensitivity [P < 0.05 by analysis of variance (ANOVA) least significant difference posthoc test for BUT and Schirmer; P < 0.001 by Mann-Whitney U test for lissamine green staining and corneal sensitivity]. Our results confirm the association between VKC and short-BUT dry eye. This syndrome seems to affect the ocular surface in quiescent phases too, determining abnormalities in tear film stability, epithelial cells integrity, and corneal nerves function. The very long-term consequences of this perennial mechanism of ocular surface damage have not been fully understood yet.

Torsional diplopia after orbital decompression and strabismus surgery.

Purpose. To investigate diplopia after orbital decompression in patients with thyroid-related orbitopathy. Methods. We retrospectively analyzed medical records of 45 consecutive patients who had undergone orbital decompression surgery (DS) and a subgroup of 10/45 patients who underwent disinsertion of the inferior oblique (IO) muscle during DS. Diplopia was assessed before DS and 1 and 3 months after DS. Residual strabismus defects were treated surgically approximately 3 months after DS with follow-up visits 1 week, 3 months, and 6 months postoperatively. Patients with horizontal or vertical diplopia were evaluated using the alternate prism-and-cover test and torsional diplopia (TD) using a double Maddox rod test to quantitate their strabismus. Results. Strabismus surgery was effective in treating the horizontal and vertical diplopia (13/40 cases with residual deviations required prism glasses), but did not resolve the TD. None of the patients with IO disinsertion during DS complained of TD before strabismus surgery. However, after strabismus surgery, TD occurred in all IO patients with IO disinsertion vs 8/30 patients without IO disinsertion (p<0.001, Fisher exact test). Overall, TD was induced in 18/45 (40%) of the DS cohort. Conclusions. Patients with IO disinsertion during DS may be at increased risk of developing TD postoperatively. We recommend sparing or reattaching the IO muscle during DS when possible to reduce the risk of developing untreatable TD.

Correction of congenital entropion of the lower eyelid: incisional versus rotational surgery.

Purpose When, at birth, the eyelid margin is rolled inward against the globe, the condition is referred to as congenital entropion. Upper eyelid involvement is commonly associated with a tarsal abnormality, while lower eyelid entropion is often associated with epiblepharon. Entropion does not resolve spontaneously, and may cause corneal pathology if untreated. The purpose of this study is to compare the two common techniques for the correction of congenital entropion. Methods The authors performed a pilot study of 24 consecutive patients with lower bilateral congenital entropion to compare the results of incisional versus rotational surgery. Results The rotational procedure was carried out in 14 patients; incisional surgery was performed in 10 patients. Twenty-one patients had good functional and cosmetic results. There were only three case of relapse after 3, 4, and 3 months. Conclusions The authors consider both techniques satisfactory, but the procedure of choice, considering the age of the patients and previous studies, remains rotational sutures because of its simplicity, quickness, and low risk of complication.

Pediatric Conjunctivitis and Air Pollution Exposure: A Prospective Observational Study.

ABSTRACT Purpose: To investigate, in pediatric patients, the rate and clinical features of unspecific conjunctivitis of unknown origin (UCUO) and to evaluate their relationship with air pollution. Methods: From January to December 2013, we consecutively screened all of the patients referred for symptomatic ocular surface inflammation. Inclusion criteria for this study were age<14, diagnosis of conjunctivitis, residence in the Lombardia region. UCUO was defined as conjunctivitis of unknown etiology, not clearly due to infection or allergy. Based on addresses of residence and sites of 73 automatic air pollution monitoring stations (locations and mean annual particulate matter (PM) 10 and 2.5 concentrations were provided by the Regional Environmental Protection Agency (ARPA) Lombardia), each patient was paired with a value of exposure to PM. Relationship between UCUO and PM exposure was investigated. Results: A total of 132 of 251 screened children were included in this study. UCUO was diagnosed in 48/132 patients. The most common symptoms and signs in UCUO children were foreign body sensation (37/48) and conjunctival hyperemia (45/48), respectively. PM10 exposure value was significantly higher in UCUO (33.5±5.4µg/m3) compared to other groups (P<0.001, ANOVA). UCUO/total conjunctivitis ratio was significantly higher in residents in areas with more than 75 (Q3) days/year exceeding 50µg/m3 (EU legal limit) compared to areas with less than 45 (Q1) exceedances/year: 24/39: 61% vs 8/35: 23%; P>0.001, Chi-square test. Conclusion: Our data suggest a relationship between UCUO and air pollution. This form of conjunctivitis is not rare in pediatric patients and may be the most frequent in most polluted areas.

Five-Year Follow-Up of a 30-Month Trial of Stability of Silicone Band Frontalis Suspension for the Treatment of Severe Unilateral Upper Eyelid Ptosis in Infants

Abstract Purpose: To evaluate the five-year stability of frontalis suspension of the upper eyelid with a silicone band for the treatment of severe congenital ptosis in infants. Methods: Chart review of pediatric patients with a follow-up of five years after unilateral frontalis suspension with silicone band was reviewed. Margin-reflex distance (MRD) and corneal staining were measured at different follow-up visits. Data were analyzed by analysis of variance and t test for paired data. Results: Twenty pediatric patients were included in this retrospective study. MRD was severely reduced before surgery in all cases: it ranged from −1 mm to −4 mm (−2.4 ± 0.8 mm). After surgery, MRD increased to 2.9 ± 0.3 mm, and then progressively decreased by 0.6 mm within the first three months (p < 0.001); a further reduction of 0.2 mm, occurring between three and 12 months after surgery, was not statistically significant (p < 0.001). Between the 12-month and the five-year follow-up visits (one visit every six months), no changes in MRD were found for any patient. After the five-years visit, no substantial changes were recorded in 18 patients (90%); in two patients, a second surgery to improve the deterioration was necessary. Corneal staining, which was present in five patients (25%) during the first two postoperative weeks, disappeared over five years of follow-up. Conclusions: During the five-year follow-up of this retrospective study, the frontalis suspension with a silicone band proved to be a stable procedure. After 30 months from the first observation, MRD values were stable, except for two patients that underwent a second surgery to stabilize the worsening ptosis.