Nikolaos Chalvatzis

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.

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.

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.

Acute postoperative Staphylococcus schleiferi endophthalmitis following uncomplicated cataract surgery: first report in the literature.

Purpose We report a rare case of acute postoperative Staphylococcus schleiferi endophthalmitis following an uneventful cataract extraction. Methods An 83-year-old woman underwent uneventful phacoemulsification without receiving the usual intracameral cefuroxime solution due to cephalosporin intolerance. Two days postoperatively, she presented with acute ocular pain and blurred vision in the operated eye. Ophthalmic examination revealed signs of acute keratitis and endophthalmitis. Corneal scrapes and vitreous taps were sent for cultivation and analysis. The patient received intravitreal antibiotics at the same time. Results Cultivation grew S schleiferi, a pathogen commonly found in dogs. Following microbiological report, the patient received a repeated intravitreal injection of 1 mg/0.1 mL vancomycin combined with fortified topical vancomycin drops. One week later, the inflammation subsided completely while the corneal ulcer healed and visual acuity improved dramatically. Further examination revealed the existence of the same pathogen in a specimen obtained from the dog owned by the patients family. Conclusions This description of S schleiferi endophthalmitis highlights the need to provide alternative intracameral antibiotic solution in the operating room and avoid direct contact with dogs during the first postoperative period after intraocular surgery.

Safety and efficacy of combined immunosuppression and orbital radiotherapy in thyroid-related restrictive myopathy: two-center experience

Purpose To evaluate the safety and efficacy of oral steroids when combined with long-term oral azathioprine (AZA) and orbital radiotherapy in patients with active thyroid-related restrictive myopathy. Methods A total of 88 patients from adnexal outpatient clinics of Bristol Eye Hospital, UK, and 2nd Department of Ophthalmology at Aristotle University of Thessaloniki, Greece, were enrolled in a retrospective, twin-center study. All patients were diagnosed with active thyroid eye disease and concomitant restrictive myopathy. Treatment included oral AZA, low-dose steroids, and orbital radiotherapy (20 Gy). Clinical activity scores as well as orthoptic assessments were consistently evaluated. Clinical activity scores, improved levels of diplopia, and single muscle excursions were considered major criteria for treatment success. Results Clinical success was achieved in 54 (61.4%), 57 (64.8%), and 61 (69.3%) patients at 3-, 6-, and 12-month time points, respectively, after the initiation of the combined treatment. At 18 months following initiation of treatment, the percentage of treatment success reached 73.9% (n = 65). Nine patients developed AZA-related side effects. In 4 patients the drug had to be discontinued. Conclusions Combined immunosuppression with orbital radiotherapy appears to reduce morbidity in patients with marked restrictive myopathy by improving major motility parameters such as diplopia and duction amplitude.

Training of Resident Ophthalmologists in Cataract Surgery: A Comparative Study of Two Approaches

Purpose. To evaluate and compare the efficacy of two different training methods in resident-performed phacoemulsification surgery. Methods. 502 eyes of 467 patients who underwent resident-performed phacoemulsification were included in the study by reviewing their medical records. Residents were allocated into two groups according to the method applied during their training in cataract surgery; Group A included residents that were trained with the “step-by-step” method and Group B those trained with the “one-step” method. Primary outcome was the incidence of main complications, defined as posterior capsular ruptures and/or zonular dehiscence with vitreous loss. Results. Each resident performed a median of 63 phacoemulsification surgeries. A statistically significant difference (p = 0.0032) was noted in the main complications rate between the two groups, yielding a mean of 17.3% in Group A and 7.25% in Group B. Other intraoperative complications were not shown to differ statistically significantly between study groups (p > 0.05). Among the first 40 surgeries of each resident, main complications rate differed also statistically significantly (p = 0.0048) between Group A (21.67%) and Group B (8.5%), while a better surgical performance-yielding statistical significance in Group A (p = 0.017) was indicated in both groups between the 20th and the 30th procedure. Conclusions. Training in cataract surgery using the “one-step” method may lead to an improvement in surgical competency, when measured by complications rates and, therefore, to significantly better quality of training for resident ophthalmologists.

Association of Ocular Hypotensive Medication Types with Dynamic Contour Tonometry and Goldmann Applanation Tonometry Measurements in a Glaucoma and Ocular Hypertensive Population

PURPOSE The aim of this study was to evaluate the association between different intraocular pressure (IOP)-lowering medications and IOP measurements by dynamic contour tonometry (DCT) and Goldmann applanation tonometry (GAT) in a glaucoma and ocular hypertensive population. METHODS In a prospective, observational case series study, 410 eyes from 410 consecutive patients with open-angle glaucoma (OAG) or ocular hypertension (OHT), were enrolled. All eyes included in the study received unaltered ocular hypotensive medication for at least 6 months before IOP measurement. All eyes underwent 2 GAT and 3 DCT measurements, and their means were used for the analysis. RESULTS DCT-GAT IOP difference (ΔIOP) did not differ statistically significantly (P=0.49) between OAG and OHT group yielding a mean±SD of 4.26±2.02 mmHg and 4.41±2.25 mmHg, respectively. The number of IOP-lowering agents did not have any statistically significant influence on ΔIOP (p=0.177), DCT (P=0.28) and GAT (P=0.13) measurements. A statistically higher ΔIOP was revealed in monotherapy patients receiving Carbonic Anhydrase Inhibitors (CAIs) (ΔIOP=5.75 mmHg) in comparison to patients receiving Prostaglandin Analogs (ΔIOP=4.09 mm Hg) or beta Blockers (ΔIOP=3.78 mmHg) as single topical therapy (F=4.373, P=0.005). Eyes treated with CAIs as a part of the ocular hypotensive therapy yielded a significantly greater ΔIOP (P=0.0035) than those without CAIs in the therapeutic schema. CONCLUSIONS The difference between DCT and GAT IOP measurements is found to be statistically significantly higher in patients receiving CAIs either as monotherapy or as a part of a combined ocular hypotensive treatment, while DCT and GAT readings remain unaffected. The type of diagnosis and the number of ocular hypotensive medications had no statistically significant influence on ΔIOP.

Isolated orbital fibrous dysplasia associated with ipsilateral keratoconus.

Introduction: Fibrous dysplasia is a primary orbital bone tumor, described as a benign disorder in which proliferation of fibrous tissue and osteoid replaces and distorts the bone from which it derives. Unilateral keratoconus is a rare entity. Herein, we report a case of an extensive ethmoidal fibrous dysplasia associated with ipsilateral keratoconus, and review the literature on the subject. Materials and methods: A 22-year-old man presented with left painless proptosis evolving over 10 years. There was associated ipsilateral epiphora and gradual visual loss. On examination his visual acuity was 20/20 OD and CF OS. His left globe was displaced lateraly 12 mm, with 9 mm of proptosis. The extraocular movements were normal. Left nasolacrimal duct obstruction was noted. Clinical signs of keratoconus were present only in the left cornea. High resolution corneal topography confirmed unilateral keratoconus and a CT scan showed an ovoid mass with a well defined sclerotic margin arising from the left ethmoid sinus and invading the orbit. Results: The patient underwent resection of the lesion via a modified Lynch incision. Complete regression of proptosis was observed immediately after surgery. Histopathological examination revealed irregular trabeculae of woven bone in different levels of maturation in a moderately cellular fibrous matrix without nuclear atypia. Trabeculae were without osteoblastic rimming or osteoclastic resorption. There has been no recurrence over a 2-year follow-up period. Conclusion: To our knowledge, the coexistence of unilateral isolated craniofacial fibrous dysplasia with ipsilateral keratoconus has not been reported so far.

Contribution of integrated teaching in the improvement of an undergraduate ophthalmology curriculum.

Purpose Conventional medical curriculum is the rule of medical teaching in Greek Medical Schools. Medical students are often taught irrelevant details with little or no reference to their potential clinical significance. Alternatively, integrated teaching warrants that the complete teaching material is covered by each faculty member not considering areas of personal expertise. The aim of this study was to evaluate the implementation of integrated teaching in ophthalmic training. Methods The main outcome measures of this retrospective study were a) comments and recommendations made anonymously by the fifth-year medical students in the evaluation questionnaires filled in at the end of their training, and b) scores obtained by students in their final examination at the end of their training in the 2nd Department of Ophthalmology as part of the core Curriculum of the Medical School of the Aristotle University of Thessaloniki. The latter outcome was analyzed with respect to the implementation of integrated teaching. Results The score obtained by students in the final examination, which is an objective outcome measure, increased significantly after the implementation of integrated teaching. The final grade (scores out of 10) of students who were trained with the integrated system (6.17±1.67, mean ± standard deviation) was significantly higher compared to those (5.52±2.20) trained with the conventional system (P<0.001). The positive outcome of this process was evident as there was a significant increase in the number of students satisfied with the teaching process compared to previous academic years. Conclusion Based on the experience of eight academic years and as a result of interactive assessment process our department has modified its medical student teaching process from conventional to integrated; all teaching staff members are involved in the teaching process, while students are divided in small groups. In conclusion, integrated teaching in small student groups appears to be an efficient teaching method (for both theoretical and clinical skills) of ophthalmic training for medical students.

Parosteal osteosarcoma of the orbit.

A 60-year-old woman was referred to Bristol Eye Hospital because of a progressive, painless, right proptosis. CT revealed a well-defined, hyperdense lesion adjacent to the lateral orbital wall. A marginal excision was performed. The mass was stony-hard, lobulated, and encapsulated. Histopathologic findings were consistent with a low-grade parosteal osteosarcoma. Parosteal osteosarcoma is a rare osteogenic tumor that usually affects the long bones. It represents a malignant, though well differentiated, tumor that has a relatively good prognosis after a wide excision. However, local recurrences are not rare and have been associated with dedifferentiation. The latter affects the prognosis adversely and, thus, regular follow-ups are strongly suggested after the initial tumor excision. In the present case, no further treatment was administered and the patient was reported disease free 26 months after surgery.