Nikolaos Mavrakanas

Corneal Collagen Cross-Linking for Ectasia after LASIK and Photorefractive Keratectomy: Long-Term Results

PURPOSE To report the long-term results of corneal collagen cross-linking (CXL) in ectasia after LASIK and photorefractive keratectomy (PRK). DESIGN Retrospective, interventional cases series. PARTICIPANTS Twenty-six eyes of 26 patients (18 male, 8 female) with postoperative ectasia after LASIK (23 eyes) and PRK (3 eyes) were included with a mean age of 35 ± 9 years at the time of treatment and a mean follow-up of 25 months (range, 12-62 months). METHODS All consecutive patients treated with CXL for progressive ectasia after LASIK or PRK at the Institute for Refractive and Ophthalmic Surgery, Zurich, Switzerland between 2004 and 2010 were included. MAIN OUTCOME MEASURES Corrected distance visual acuity (CDVA), maximum keratometry readings (K(max)), minimum radius of curvature (R(min)), and 6 corneal topography indices were assessed in this study. RESULTS Mean CDVA before CXL was 0.5 logarithm of the minimum angle of resolution (logMAR) units, which improved to a mean of 0.3 logMAR units (P<0.001). Corrected distance visual acuity improved 1 line or more in 19 cases and remained unchanged in 7 patients. Mean K(max) after CXL of 50.9 ± 4.9 diopters (D) was significantly lower (P<0.001) than mean pre-CXL K(max) of 52.8 ± 5 D. The R(min) after CXL was increased significantly (P = 0.006), whereas the index of surface variance (P = 0.03), the index of vertical asymmetry (P = 0.04), the keratoconus index (P = 0.03), and the central keratoconus index (P = 0.016) were reduced significantly. CONCLUSIONS Ectasia after LASIK and PRK was arrested by CXL with stabilization or improvement of CDVA and K(max) after a mean follow-up of 25 months. There were improvements in 4 topography indices, suggesting a more regular corneal surface.

Postoperative IOP is related to intrascleral bleb height in eyes with clinically flat blebs following deep sclerectomy with collagen implant and mitomycin

Aim To investigate the relationship between intrascleral bleb height and intraocular pressure (IOP) following deep sclerectomy with collagen implant (DSCI) and mitomycin C (MMC) in eyes with clinically flat blebs. Methods The records of 25 eyes of 22 consecutive patients presenting with clinically flat blebs following DSCI with MMC for primary or secondary open angle glaucoma were reviewed. Anterior segment optical coherence tomography (AS-OCT) scans were used to evaluate postoperative intrascleral bleb height and its relation to IOP control. Eyes requiring postoperative bleb manipulations, needling or goniopunctures were excluded. Results The mean age of the patients was 71.9±12.6 years, and the mean preoperative IOP was 25.3±5.6 mm Hg. The mean time of the AS-OCT examination from the operation was 8±4.9 months, and the mean IOP at that time was 13.8±4.2 mm Hg (p<0.001). All operated eyes manifested an intrascleral bleb with AS-OCT. The mean intrascleral bleb height was 0.58±0.16 mm. IOP and intrascleral bleb height were found to be inversely correlated (p<0.001, r=−0.626). None of the eyes had subconjuctival blebs, and 17/25 eyes showed microscopic conjuctival fluid collections. Conclusion The authors report a positive inverse correlation between intrascleral bleb height and postoperative IOP in eyes presenting clinically flat blebs following DSCI with MMC, suggesting an important role for intrascleral filtration in lowering IOP. Further studies are warranted to evaluate this relationship at different postoperative time points and possibly with different types of implants.

Topiramate-induced acute bilateral angle closure and myopia: pathophysiology and treatment controversies

Purpose TO discuss the unusual features of topiramate-induced acute angle closure glaucoma, its pathophysiologic mechanisms, and treatment controversies, and to report the first anterior segment optical coherence tomography (OCT) of this condition. Methods Literature review and case report with OCT findings. Results Topiramate-induced angle closure is usually bilateral and associated with acute myopia; the ocular pressure is often not very highly elevated. Ciliochoroidal detachment with ciliary body anterior rotation is typically present and was demonstrated easily in our case with anterior segment OCT. Pilo-carpine exacerbates this condition and peripheral iridotomy is not indicated, nor is iridoplasty Treatment consists of replacing topiramate with appropriate medication, strong cycloplegia, and topical steroids. Conclusions It is important to recognize this form of acute secondary angle closure in order to treat it properly, avoiding harmful medication and unnecessary surgery.

Bilateral combined central retinal artery and vein occlusion in systemic lupus erythematosus resulting in complete blindness

Bilateral combined central retinal artery and vein occlusion in systemic lupus erythematosus resulting in complete blindness

Intravitreal ranibizumab and bevacizumab for bilateral subretinal neovascularization secondary to idiopathic juxtafoveal telangiectasia type 2A.

Editor, I diopathic juxtafoveal telangiectasia (IJT) type 2A is characterized by the presence of bilateral acquired ectatic capillaries that involve the temporal half of the fovea (Yannuzzi et al. 2006). Neovascularization and foveal atrophy may occur with progression of the disease and cause severe visual loss (Yannuzzi et al. 2006). We report the successful use of intravitreal ranibizumab and bevacizumab in a case of IJT, complicated by bilateral and simultaneous subretinal neovascularization (SRN). A 62-year-old woman presented at our department with a 2-month history of bilateral visual loss and metamorphopsia. A diagnosis of IJT 2A had been made 7 years earlier. Visual acuity (VA) had remained stable at 20 ⁄25 in both eyes during the subsequent period. At the time of presentation, best corrected Snellen VA (BCVA) was 20 ⁄ 80 in the right eye (RE) and 20 ⁄ 50 in the left eye (LE). Anterior segment biomicroscopy was unremarkable in both eyes. Fundus examination showed dilated rightangled retinal vessels (mainly venules) dipping deep into the retina, whitish elevated subretinal tissue in both eyes and a retinal haemorrhage in the RE (Fig. 1A, B). Fluorescein angiography (FA) revealed telangiectatic perifoveal capillaries associated with SRN with leakage in both eyes (Fig. 1C–F). Macular optical coherence tomography (OCT) (Stratus OCT; Carl Zeiss Meditec, Dublin, CA, USA) showed deep intraretinal and subretinal neovascular tissue associated with increased macular thickness and subretinal fluid (Fig. 2A, B). Central retinal

Are ocular injection anesthetic blocks obsolete? Indications and guidelines.

Purpose of review In this era of topical anesthesia for ocular surgery, anesthetic ocular blocks are still important when profound anesthesia and akinesia are required. Although injection ocular blocks, retrobulbar and peribulbar anesthesia, have been supplanted for most ocular surgery in many centers by sub-Tenons irrigation block because of its superior safety profile, still worldwide, injection blocks remain popular. Recent findings We present here the results of a survey of the literature published over the last 5 years to assess current international preferences for ocular anesthesia injection blocks. We discuss the reasons why sub-Tenons anesthesia is not more universally popular and advocate for its greater acceptance because of safety. Specific narrow indications for performing injection ocular blocks are presented. Also, guidelines for performing retrobulbar anesthesia which reduce the risk of serious ocular complications are provided as well as our rationale for preferring retrobulbar to peribulbar anesthesia. Summary Sub-Tenons block should be performed in the operating theatre in preference to retrobulbar or peribulbar anesthesia except for limited indications. When injection ocular block is deemed necessary, we feel that retrobulbar anesthesia with the technique described may be safer than peribulbar anesthesia.

Pediatric Ocular Rosacea

A case of severe pediatric ocular rosacea was effectively treated after 2.5 years of misdiagnosis. A high index of suspicion should be maintained in children with ocular surface disease, with or without dermatologic rosacea, to correctly diagnose ocular rosacea and avoid morbidity and complications.

Posterior-assisted levitation in cataract surgery.

Purpose of review Posterior-assisted levitation (PAL) is a surgical maneuver for dealing with rupture of the posterior capsule or zonular dehiscence with threatened or actual subluxation of the nucleus or entire lens into the vitreous during phacoemulsification. PAL is often unknown or overlooked, especially by young or inexperienced surgeons. Recent findings The advantages of PAL are, first, that it often enables completion of phacoemulsification and intraocular lens placement without conversion to an open eye with nuclear expression and second, it prevents luxation of nucleus, nuclear fragments, or the lens into the vitreous avoiding the necessity for trans pars plana vitrectomy (TPPV)-lensectomy. PAL has recently been criticized by vitreoretinal surgeons as dangerous and to be avoided. However, there is no large series or controlled study showing that the PAL maneuver is associated with an excessive complication rate as compared to cases of nuclear or lens subluxation in the vitreous managed by TPPV-lensectomy with or without previous PAL. Summary PAL is a simple technique that can be extremely helpful. In cases in which the PAL maneuver is unsuccessful and in cases with complete luxation of nucleus or lens into the vitreous, the patient should be referred for TPPV-lensectomy.

Acute anticholinergic syndrome from Atropa belladonna mistaken for blueberries.

Purpose To report the first case in the ophthalmic literature of acute anticholinergic syndrome after ingestion of Atropa belladonna mistaken for blueberries. Methods A 36-year-old woman presented to our ophthalmic emergency department with complaints of blurry vision, lightning flashes, disorientation, loss of balance, agitation, and anxiety for 24 hours. Ophthalmic examination revealed bilateral pupillary dilatation and paresis of accommodation. Additional symptoms of the anticholinergic syndrome were elicited on further questioning. Results Anticholinergic intoxication was suspected and the patient admitted to have eaten six “blueberries” found in the forest the previous day. The patient identified Atropa belladonna as the source of the berries she had eaten when shown photographs of the plant and its fruit. The recommendations of the Swiss Toxicological Information Centre were followed and physostigmine, the antidote for severe poisoning when 10 or more berries are ingested, was not administered. Conclusions Accidental ingestion of Atropa belladonna berries may cause patients to first consult an ophthalmologist. It is important to recognize the anticholinergic syndrome caused by such intoxication in order to make a proper diagnosis, avoid unnecessary testing, and provide expedient appropriate treatment when required.

Bilateral multifocal retinal pigment epithelium detachments associated with systemic corticosteroids

Purpose To report an unusual case of central serous chorioretinopathy (CSC), presenting as bilateral and multifocal isolated serous retinal pigment epithelium detachments (RPEDs) following corticosteroid treatment. Methods An otherwise healthy 39-year-old man was evaluated for visual loss following blunt trauma of his right eye (RE). The patient underwent complete bilateral ophthalmologic examination, including optical coherence tomography and fluorescein (FA) and indocyanine green angiography (ICGA). Results At presentation, best-corrected visual acuity (BCVA) was 20/200 in the RE and 200/200 in the left eye (LE). Treatment included topical and oral corticosteroids. Three days later, the patient complained of metamorphopsia and further decrease in the VA of his RE. Fundus examination showed bilateral serous RPEDs. Optical coherence tomography, FA, and ICGA confirmed the diagnosis. Topical and oral corticosteroids were stopped and a follow-up examination 5 days later demonstrated marked resolution of the RPEDs in the RE. Five weeks later, RPEDs regressed in the RE while they persisted in the asymptomatic LE. Visual acuity in the RE further improved to 120/200. Nine months after the first visit, BCVA in the RE was 200/200. At that time, both eyes demonstrated retinal pigment epitheliopathy Conclusions Central serous chorioretinopathy is a known complication of corticosteroids. The classic variant of CSC consists of a shallow neuroretinal detachment located at the posterior pole of the fundus. Bilateral and multifocal isolated serous RPEDs represent an atypical form of CSC.