Michele Figus

Blindness following cosmetic injections of the face.

Background: Complications following facial cosmetic injections have recently heightened awareness of the possibility of iatrogenic blindness. The authors conducted a systematic review of the available literature to provide the best evidence for the prevention and treatment of this serious eye injury. Methods: The authors included in the study only the cases in which blindness was a direct consequence of a cosmetic injection procedure of the face. Results: Twenty-nine articles describing 32 patients were identified. In 15 patients, blindness occurred after injections of adipose tissue; in the other 17, it followed injections of various materials, including corticosteroids, paraffin, silicone oil, bovine collagen, polymethylmethacrylate, hyaluronic acid, and calcium hydroxyapatite. Conclusions: Some precautions may minimize the risk of embolization of filler into the ophthalmic artery following facial cosmetic injections. Intravascular placement of the needle or cannula should be demonstrated by aspiration before injection and should be further prevented by application of local vasoconstrictor. Needles, syringes, and cannulas of small size should be preferred to larger ones and be replaced with blunt flexible needles and microcannulas when possible. Low-pressure injections with the release of the least amount of substance possible should be considered safer than bolus injections. The total volume of filler injected during the entire treatment session should be limited, and injections into pretraumatized tissues should be avoided. Actually, no safe, feasible, and reliable treatment exists for iatrogenic retinal embolism. Nonetheless, therapy should theoretically be directed to lowering intraocular pressure to dislodge the embolus into more peripheral vessels of the retinal circulation, increasing retinal perfusion and oxygen delivery to hypoxic tissues. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, V.

Incorporating corneal pachymetry into the management of glaucoma

Intraocular pressure (IOP) results from a dynamic balance between aqueous humor formation and outflow. The simplest technique to measure IOP is indentation tonometry. Another technique is applanation. These methods are related to the elasticity of the eye, which mainly depends on its thickness and hysteresis. For several decades, Goldmann applanation tonometry has been the most accepted method of measuring IOP; the Goldmann tonometer is still used in all important trials. The relationship between IOP values and central corneal thickness (CCT) is well known; Goldmann stated that this relationship only holds for an average corneal thickness of 520 microm measured by optical pachymetry. The Ocular Hypertension Treatment Study (OHTS) showed that CCT is an important risk factor for a change from ocular hypertension to primary open-angle glaucoma. In a multivariate model that included IOP, CCT was the most powerful component of the predictive model. In the Early Manifest Glaucoma Trial (EMGT) with an 11-year follow-up, CCT was a significant predictive factor for glaucoma progression in patients with higher baseline IOP but not in those with lower baseline IOP. Clinical trials such as the OHTS and EMGT cannot prove that CCT is linked to a risk for glaucoma on a biological level. Thus, in eyes with glaucoma, IOP must be treated because it has a significant influence on progression of glaucoma, regardless of the baseline IOP and CCT.

In vivo analysis of conjunctiva in gold micro shunt implantation for glaucoma

Aims To describe the conjunctival epithelial features seen with in vivo confocal microscopy (IVCM) after gold micro shunt (GMS) implantation in the suprachoroidal space, in patients with uncontrolled glaucoma. Methods This was an observational case series study. Fourteen eyes of 14 consecutive glaucomatous patients with a history of multiple failed incisional surgeries followed by GMS implantation were evaluated with a digital confocal laser-scanning microscope (HRT II Rostock Cornea Module). Patients were divided into two groups: successful implantations (Group 1: eight patients, eight eyes), defined as a one-third reduction in preoperative intraocular pressure (IOP) with or without antiglaucoma medications and failed implantations (Group 2: six patients, six eyes) as a less than one-third reduction in preoperative IOP with maximal tolerated medical therapy. The examination was performed from 3 to 20 months (mean 15.4±5.4) postoperatively. Conjunctival mean microcyst density (MMD: cysts/mm2) and mean microcyst area (MMA: μm2) were the main outcome measurements. Results The mean postoperative IOP was statistically different between the two groups (p<0.05), with the values of 14.3±2.77 and 32.3±8.01 mm Hg in Groups 1 and 2, respectively. When comparing successful with failed implantation, the IVCM analysis showed a greater MMD (p<0.01) and MMA (p<0.01). Clinical evidence of filtering bleb was not found in any of the patients. Conclusions Successful GMS implantation significantly increased conjunctival microcysts density and surface at the site of the device insertion. These findings suggest that the enhancement of the aqueous filtration across the sclera may be one of the possible outflow pathways exploited by the shunt.

Supraciliary shunt in refractory glaucoma

Aims This study aimed to evaluate the efficacy of Gold Micro Shunt (GMS) for suprachoroidal drainage in patients with refractory glaucoma. Methods This is a prospective uncontrolled case series study. Fifty-five eyes of 55 patients were included. Study eyes underwent GMS implantation in the supraciliary space. Follow-up visits were performed on day 1, week 1 and months 1, 3, 6, 12 and 24; patients underwent slit-lamp examination, Goldmann applanation tonometry, ultrasound biomicroscopy and gonioscopy. Results Before inclusion, the eyes underwent an average (±SD) of 1.9±0.7 (range 1–5) previous glaucoma surgery procedures. Forty eyes were pseudophakic, 12 were phakic and 3 were aphakic. The mean baseline intraocular pressure was 30.8±8.8 mm Hg (range 22–58 mm Hg) despite maximal medical treatment. After 2 years of follow-up, qualified success was achieved in 37 eyes (67.3%) and complete success was achieved in 3 eyes (5.5%). In success group patients, mean intraocular pressure decreased from 27.6±6.9 at baseline to 13.7±2.98 mm Hg after 2 years of follow-up; the mean (±SD) number of medications was 1.4±0.7 in the postoperative phase, compared with a value of 2.5±0.9 in the preoperative phase. Mild side effects occurred in 21 patients, with mild or moderate postoperative hyphema being the most frequent one. Development of a thin membrane, obstructing the anterior holes, was the most important factor affecting the efficacy of this device; it was found to be present in 12 patients from the failure group (66.7% of failures). Conclusion GMS achieved qualified success in about 67.3% of eyes with uncontrolled refractory glaucoma with a low rate of complications.

Pharmacogenetics of antiangiogenic and antineovascular therapies of age-related macular degeneration

Age-related macular degeneration (AMD), the most common age-related disease causing irreversible visual loss in industrialized countries, is a complex and multifactorial illness. Researchers have found components of the complement alternative pathway inside drusen and Bruchs membrane of AMD patients, underlying a possible important role of complement factor H in the pathogenesis of AMD. The neovascular (wet) AMD is the most destructive form and it is characterized by invasion of new blood vessels into subretinal spaces with subsequent exudation and bleeding, resulting in scarring of the macular region and loss of the central vision. The hallmark of the neovascular form is the choroidal neovascularization, where VEGF-A has an important role in the pathogenesis of the disease. SNPs of these genes have recently been investigated as potential pharmacogenetic markers of the antiangiogenic and antineovascular therapy of AMD, which includes verteporfin photodynamic therapy and anti-VEGF-A drugs, such as pegaptanib, bevacizumab and ranibizumab. The CFH rs1061170 CT and TT genotypes have been associated with an improvement of visual acuity in bevacizumab or ranibizumab treated patients, whereas patients harboring VEGF-A rs699946 G allele responded better to bevacizumab-based therapy if compared with patients carrying the A allele. In conclusion, the discovery of pharmacogenetic markers for the personalization of the antiangiogenic and/or antineovascular therapy could be, in the future, a key issue in ophthalmology to obtain a personalization of the therapy and to avoid unnecessary costs and adverse drug reactions.

Optic nerve head changes in early glaucoma: a comparison between stereophotography and Heidelberg retina tomography.

ObjectiveTo evaluate and compare the diagnostic accuracy of the Heidelberg retina tomograph (HRT) version 3 with that of glaucoma specialists using stereophotography in discriminating between normal eyes and patients with early glaucomatous visual field loss.MethodsA total of 105 eyes of 105 individuals were prospectively and consecutively recruited. The sample comprised 51 normal and 54 early glaucomatous eyes, as defined by intraocular pressure and standard automated perimetry results, regardless of optic disc appearance. Receiver operating characteristic (ROC) curves were plotted for the HRT3 parameters and a linear discriminant function (LDF) developed in our hospital. Best sensitivity–specificity pairs were compared between the HRT3 parameters, with the highest areas under the ROC curve (AUCs) and evaluation of optic disc stereophotographs. Agreement between methods for measuring vertical cup-to-disc ratio was evaluated with the Bland–Altman plot.ResultsThe average visual field mean deviation was -2.90 dB. The HRT3 parameters with the largest AUCs were our LDF (0.900), rim volume (0.883), and vertical cup/disk ratio (0.880), with no significant differences between these parameters. Sensitivity–specificity pairs were 79.6–100% (clinical evaluation), 83.3–86.3% (our LDF), 64.8–96.1% (final glaucoma probability score), and 68.5–90.2% (global Moorfields regression analysis).ConclusionsThe diagnostic accuracy for differentiating normal eyes from those with early visual field defects was similar between clinical evaluation of the optic disc and evaluation with the HRT3. The use of our LDF increased the sensitivity–specificity balance with respect to the HRT-provided parameters. The diagnostic accuracy of the HRT classifications was comparable to that of an experienced glaucoma specialist.

Long-term perimetric fluctuation in patients with different stages of glaucoma

Aim To evaluate the long-term perimetric fluctuation (LF) in patients with different stages of glaucoma according to the Glaucoma Staging System 2 (GSS2). Methods This multicentre retrospective study included 161 eyes of 161 stable glaucoma patients undergoing four visual-field tests (Humphrey SITA-Standard program over the central 24° or 30°) over a 2-year period. For each patient, the stage of the disease was classified according to GSS2. LF was then calculated as the mean of the standard deviations of point-to-point threshold sensitivities in the four repetitions. LF in GSS2 stages was compared using the t test. Results LF progressively increased from stage 0 to stage 4, and then decreased at stage 5. Stage 4 had a peak of 3.19±0.94 dB, with statistically significant differences compared with all the other stages. The lowest LF (1.65±0.60 dB) was found for normal subjects, whereas similar data were found for borderline patients and those at stages 1 and 5 (2.09±0.58, 2.13±0.57 and 2.22±0.89 dB, respectively; p>0.13). Visual fields with generalised defects had a lower LF (1.90±0.81) than those with mixed (2.84±0.87, p=0.0003) and localised (2.63±0.72, p=0.004) defects. Conclusions In this study, the authors showed that the lower the visual-field defect, the lower was LF, except at stage 5 of GSS2. As test–retest changes exceeding LF could represent a sign of progression, the authors suggest that clinicians using this classification system calculate LF, in order to better differentiate true progression from variability.

VEGF-A polymorphisms predict short-term functional response to intravitreal ranibizumab in exudative age-related macular degeneration

AIM To investigate the association between VEGF gene SNPs and early response to intravitreal ranibizumab for exudative age-related macular degeneration. MATERIALS & METHODS Sixty-four patients (64 eyes) were prospectively enrolled and treated for neovascular age-related macular degeneration with ranibizumab monotherapy. Visual acuity was measured using the ETDRS chart. A loading phase of 3 monthly intravitreal injections of ranibizumab 0.5 mg/0.05 ml was performed. The analyzed VEGF-A gene SNPs were rs699947 (-2578A/C) and rs1570360 (-1154G/A); the allelic discrimination was performed in real-time PCR platform. The difference of best corrected visual acuity (ETDRS letters) read before and after treatment was considered as functional outcome. RESULTS Ranibizumab was significantly more effective as measured by best corrected visual acuity in patients harboring the VEGF-A -2578C allele (from +6.26 to +7.44 ETDRS letters), whereas patients carrying the VEGF-A -2578AA genotype revealed an absence of early functional response to ranibizumab (-1.78 ETDRS letters; p = 0.0192). CONCLUSION This study suggests that the VEGF-A -2578A/C SNP may represent an important molecular determinant of the early functional outcome of ranibizumab. Original submitted 3 December 2012; Revision submitted 18 February 2013.

Ocular Surface Changes in Glaucomatous Patients Treated With and Without Preservatives Beta-Blockers

PURPOSE To determine whether there were ocular surface changes in glaucomatous patients treated with preservatives beta-blockers who switched to preservative-free beta-blockers. METHODS This was a prospective, longitudinal, open-labeled study. One hundred thirty-two patients with primary open angle glaucoma treated with a preserved beta-blocker were enrolled. All the patients underwent perimetric and gonioscopic examination, complete ophthalmologic examination, intraocular pressure (IOP) measurements, evaluation of ocular surface, Schirmers test, blood pressure and heart rate at baseline and 1-3 months after changing the medical treatment to a preservative-free timolol 0.1% (Timogel 0.1; Thea). At baseline, after 1 month and at the end of the study (3 months), all patients underwent a questionnaire on the visual quality and symptoms and on the quality of life (QoL). Data were analyzed by t-test when the distribution of the data was normal, by Mann-Whitney when the distribution was not normal. RESULTS No significant difference was found for IOP before switching from preserved beta-blockers to preservative-free ones. No significant difference was found in blood pressure and heart rate. However, a statistically significant difference was found for abnormal fluorescein staining of the cornea and conjunctiva, eyelid erythema, conjunctival hyperemia, and follicular hyperplasia. A significant difference was found for break-up time (from 9.38±4.7 s at baseline to 10.64±4.7 s after 3 months) and Schirmers test (from 12.9±5.96 mm at baseline to 14.2±5.87 mm after 3 months). The questionnaire showed that the patient improved the dryness and foreign body sensation. CONCLUSION In glaucomatous patients, preservative-free 0.1 timolol treatment improved their QoL. Similar dry eye signs or symptoms improved after 3 months of treatment reducing dryness, hyperemia, follicular hyperplasia, and foreign body sensation.

Can mean central corneal thickness and its 24-hour fluctuation influence fluctuation of intraocular pressure?

PurposeTo evaluate the influence of central corneal thickness (CCT) and its 24-hour fluctuation on 24-hour intraocular pressure (IOP) fluctuation in primary open-angle glaucoma. MethodsForty consecutive patients underwent 24-hour evaluation (8 PM, midnight, 4 AM, 8 AM, noon, and 4 PM) of supine and sitting IOP, measured with handheld Perkins and Goldmann tonometer respectively, and of CCT measured using ultrasonic pachymeter. Thirty patients were treated with timolol 0.5% twice daily and latanoprost 0.005% once daily; 10 patients were untreated. Measurements were taken in both eyes, but only one eye per patient was used for analytical purposes. Three IOP curves were drawn: sitting position, supine position, and habitual body position (diurnal sitting measurements and nocturnal supine measurements). Fluctuation was calculated as the SD over the 24-hour curve. Differences in the 2 groups were inspected by means of t test; the correlations between IOP fluctuation and mean CCT, respectively, and its fluctuation were evaluated by means of regression analysis. ResultsUntreated patients had higher IOP than the treated group (habitual body position: 22.1±5.1 mm Hg vs. 16.0±3.0 mm Hg, P=0.004), but no differences were found for IOP fluctuations (habitual body position: 2.5±1.2 mm Hg vs. 2.3±0.8 mm Hg, P=0.32), mean CCT (542±38 μm vs. 534±39 μm, P=0.44), and CCT fluctuation (8.7±5.6 μm vs. 6.5±3.0 μm, P=0.09). The correlation between IOP fluctuation and mean CCT and its fluctuation was not statistically significant at supine, sitting and habitual body positions (P≥0.07; R2≤0.20). ConclusionsTwenty-four–hour IOP fluctuation was independent from CCT parameters in both treated and untreated glaucoma patients, regardless of body position at which IOP was measured.