Nikolaos Ziakas

Long-term follow up of autologous serum treatment for recurrent corneal erosions.

Purpose:  The aim of the study was to evaluate long‐term results of autologous serum treatment for recurrent corneal erosions.

Acrylic toric intraocular lens implantation: a single center experience concerning clinical outcomes and postoperative rotation

Purpose: To present clinical results of toric intraocular lens (IOL) implantation for preexisting astigmatism correction and determine the time of any postoperative rotation. Patients and methods: Twenty-nine eyes of 19 patients underwent uncomplicated phacoemulsification and were implanted with an Acrysof

Management of bullous keratopathy-related ulcer with autologous serum.

Purpose: The aim of this study was to report the use of autologous serum eyedrops (ASEs) for resolution of a corneal ulcer secondary to bullous keratopathy. Methods: This is a case report. Results: A 66-year-old patient presented with an infected ulcer and hypopyon while using a bandage contact lens for bullous keratopathy. Staphylococcus warneri infection was treated with systemic and topical antibiotics, and ASEs were subsequently administered to enhance reepithelialization and to avoid the need for a bandage contact lens. The ASE treatment led to closure of the epithelium layer within 3 weeks, and it was subsequently tapered over the next 3 months. The clinical picture remained stable subjectively and objectively during the 7 months of follow-up. Discussion: To the best of our knowledge, this is the first report of successful use of ASEs in treating and preventing recurrence of ulcers in the context of bullous keratopathy.

To remove or not to remove (the AC-IOL)? This is the question

We read with great interest the article by Droutsas et al. [1], and we would like to share our own experience and opinion with the authors and readers. Despite the promising results reported, we believe that there may be an alternative method in cases similar to those described; this entails the exchange of the existing intraocular lens with a posterior chamber type which would minimise endothelial damage and maximise the graft survival as already well described by Droutsas et al. [1] in the Discussion section. Descemet stripping endothelial keratoplasty (DSEK) and Descemet membrane endothelial keratoplasty (DMEK) are two techniques that have revolutionised the treatment of endothelial failure or dysfunction having largely replaced Penetrating keratoplasty (PK) for the management of these pathologies. Although surgery in cases of Anterior chamber Intraocular lens (AC-IOL) removal and replacement with a Posterior chamber intraocular lens (PC-IOL) can prove labour-intensive and difficult, especially in combination with DMEK or Pre-Descemet’s endothelial keratoplasty (PDEK) [2], newer advancements in PC-IOL secure placement (IOL gluing through scleral flaps) in the absence of posterior capsular support [3] with or without minimal iridoplasty allow combination with either DS(A)EK [4] or DMEK (and PDEK) surgery. We retrospectively reviewed our DSEK, DMEK and PDEK cases associated with the presence of an AC-IOL over a period of 18 months. During this time, there were four eyes undergoing DSEK with a retained AC-IOL (stable but with variable anterior chamber depths) as well as three DSEK and PDEK cases combined with removal of the AC-IOL and posterior placement of a PC-IOL through scleral flaps with and without iridoplasty. In the retained AC-IOL DSEK patients, there was a 25% secondary failure (one in four cases which was associated with shallow AC) over a period of 18 months, whereas in the AC-IOL exchange and replacement with PC-IOL group no secondary failures were noted over the same period for both two PDEK and one DSEK cases. Similarly, Wylegala et al. [5] showed no DSAEK primary or secondary failures when DSAEK surgery is combined with AC-IOL exchange and PC-IOL implantation over a period of 19.3 months, whereas Esquenazi et al. [6] suggested DSAEK to be safe and effective in cases of retained well-positioned and stable AC-IOLs in eyes with an AC depth of 3 mm or more. Another point that should be taken into account is that at least in conventional DS(A)EKs, the endothelial graft of 150–180 lm would further shallow the AC, thus making patient selection with deeper M. Tsatsos (&) I. Athanasiadis N. Ziakas Department of Ophthalmology, Aristotelian University of Thessaloniki, 54124 Thessalonı́ki, Greece e-mail: michaeltsatsos@gmail.com

Fifteen-minute consultation: congenital nasolacrimal duct obstruction

A 2-month-old infant is brought to consultation by its parents who report epiphora, that is, excessive tearing, as well as mucous discharge from the eye since the second week of life. Congenital nasolacrimal duct obstruction (CNLDO) is a common problem in the early years of life and one of the main causes of epiphora in infants,1 with an estimated incidence that varies widely (1.2% to 30%), depending on the diagnostic criteria used.2 It is thought to result from a delay in maturation of the nasolacrimal outflow system and, in particular, a failure of its canalisation process, more commonly at its lower end. It can be unilateral or bilateral.2 ,3 Apart from the watery eye due to tear drainage failure, typically appearing in the first 2–4 weeks of life, the main other sign is mucous discharge. This discharge can be either constant or intermittent, and can be associated with skin redness and excoriation around the eye, as well as stickiness of the childs lids and lashes following sleep. Frequent attacks of conjunctivitis, with mucopurulent discharge and red eye, often complicate the condition. If more severe infection occurs, there may be chronic or recurrent bacterial blepharitis, or dacryocystitis, that is, mucopurulent discharge from the eye, with redness and warmth of the skin over the lacrimal sac. The latter can, if uncontrolled, lead to orbital cellulitis.3 A rare variant of CNLDO, accounting for just 0.1% of cases, and regarded by some as a complication, is the development of a mucocele or dacryocystocele.2 ,3 This is formation of a dilated part of the lacrimal sac/duct, as a consequence of simultaneous proximal and distal obstruction. Its typical presentation is a bluish, cystic, firm mass below the medial canthus. Its clinical significance lies in the fact that if a cystic …

Frequency of spontaneous pulsations of the central retinal vein in the paediatric population.

vations of the same participants with adjustment for differences in the first recorded photocoagulation diameters. The rate of burn expansion in the conventional group was 1.18 0.15 versus 1.14 0.19 in the high-power short-duration group: this difference was significant (p = 0.030, Mann– Whitney’s U-test). The generalized estimating equation approach yielded an estimated area slope of 0.00028 in the conventional group and 0.00097 in the high-power short-duration group, with a significant difference between the groups (p = 0.025; Fig. 2). This analysis shows that despite any initial similarity in burn size between the conventional method and the highpower short-duration method of coagulation, the rate of expansion is greater with the conventional method. Our results differ from those reported by Muqit et al., who reported a significant reduction in burn size with use of the high-power short-duration method. The reason stated in a Muqit et al. report is that there is a possibility that the range of retinal oedema may decrease with the passage of time; this extra burn range has been added at the step of measuring the burn size. We believe that the discrepancy between our results and those reported by Muqit et al. stems from our decision to measure burn size some time after coagulation, which reflected a desire to avoid any potential measurement error induced by early retinal oedema. On the basis of this study, we emphasize the need to elaborate a standardized protocol for retinal photocoagulation that recognizes the differences in expansion rate between conventional and high-power short-duration methods.

Intra-operative assessment of toric intra-ocular lens implantation

We report a new procedure for intra-operative toric intra-ocular lens (IOL) axis assessment in order to achieve optimal implantation. IOL implantation procedure was directly recorded. An assessor estimated the angle formed by the marked 0–180 axis and the toric IOL axis after implantation with the use of the appropriate software. If IOL implantation was assessed to be inaccurate, the surgeon was advised to correct IOL positioning by rotating the IOL clockwise. The assessment procedure was repeated until accurate IOL positioning was achieved.

Interventions to control myopia progression in children: protocol for an overview of systematic reviews and meta-analyses

BackgroundMyopia is a common visual disorder with increasing prevalence among developed countries of the world. Myopia constitutes a substantial risk factor for several ocular conditions that can lead to blindness. The purpose of this study is to conduct an overview of systematic reviews and meta-analyses in order to identify and appraise robust research evidence regarding the management of myopia progression in children and adolescents.MethodsA literature search will be conducted in MEDLINE, EMBASE, The Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effects (DARE), and Health Technology Assessment (HTA) Database via Centre for Reviews and Dissemination (CRD). We will search for systematic reviews or meta-analyses that examine optical or pharmaceutical modalities for myopia control. Two independent overview authors will screen the titles and abstracts against the eligibility criteria. Individual study’s methodological quality and quality of evidence for each outcome of interest will be assessed by two independent authors using the ROBIS tool and GRADE rating, respectively. In cases of disagreement, consensus will be reached with the help of a third author. Our primary outcomes will be the mean change in refractive error, mean axial length change, and adverse events. A citation matrix will be generated, and the corrected covered area (CCA) will be estimated, in order to identify overlapping primary studies. Possible meta-biases and measures of heterogeneity will be described, and cases of dual co-authorship will be identified and discussed. If any recently published randomized controlled trials (RCTs) are detected, these will be appraised and their findings will be presented. An overall summary of outcomes will be provided using descriptive statistics and will be supplemented by narrative synthesis.DiscussionThis overview will examine the high level of existing evidence for treatment of myopia progression. Efficient interventions will be identified, and side effects will be reported. The expected benefit is that all robust recent research evidence will be compiled in a single study. The results may inform future research in this area, which should provide insight into the appropriate regimes for the administration of these modalities and contribute to future guideline development.Systematic review registrationPROSPERO CRD42017068204

Letter to the Editor: Very Late Reactivation of Retinopathy of Prematurity After Monotherapy With Intravitreal Bevacizumab

Dear Editor, We read with great interest and concern the report by Snyder et al.1 describing a case of aggressive posterior retinopathy of prematurity (ROP) treated with bevacizumab (Avastin; Genentech, South San Francisco, CA) and found to recur as late as 2.5 years of age. We would be interested to know the frequency of follow-up examinations carried out before this devastating recurrence was noted, and whether any concerning ocular findings were noted at the last examination (eg, pre-plus at the disc or in the periphery). The authors say that the child was seen by another retinal specialist and sent to pediatric ophthalmology for follow-up after 80 weeks postmenstrual age (PMA); however, no description was given of this follow-up plan. It was also not mentioned whether the child had recurrent infections, breathing difficulties or hypoxia, or other conditions of oxidative stress predisposing to ROP recurrence during this followup. Finally, it was not described as to whether 2.5 years was the child’s corrected or uncorrected age;2 for an infant born at 24 weeks PMA, this makes a big difference. The above information would be useful in planning a better follow-up schedule for babies who have had similar disease severity treated with bevacizumab. As with screening guidelines for the assessment of ROP development in at-risk infants, the challenge here is to follow-up injected babies closely enough to detect recurrences promptly, but not unnecessarily closely. The authors encouraged prolonged and frequent follow-up, but no one really knows how prolonged and how frequent is appropriate. They also suggested that fluorescein angiography (FA) could be useful in patients where the peripheral retina is difficult to examine. Similar suggestions were made by Toy et al.3 in their recent study, where a pattern of “vascular arrest” was described in some patients, and prophylactic laser photocoagulation to the remaining avascular retinal periphery was suggested in these cases. However, FA is not available in every institution treating ROP. The case reported by Snyder et al. is somewhat shocking and raises real concern to clinicians using bevacizumab in ROP while they are perhaps not able to follow-up these patients themselves in the long term. With all of the emerging anti-vascular endothelial growth factor injectable treatments, and augmentation of their usage since the BEAT-ROP study, we believe that it is time a panel of experts evaluates all current knowledge and establishes a set of follow-up and treatment guidelines to assist physicians less experienced with ROP management. This will also help convince parents to adhere to their follow-up, as well as to treatment suggestions. Asimina Mataftsi, MD, PhD, MRCOphth Evangelia Koulali, MD Elena Papageorgiou, MD Nikolaos Ziakas, MD, PhD Periklis Brazitikos, MD, PhD

Phytotherapy and intraoperative floppy iris syndrome: the implications

Intraoperative floppy iris syndrome (IFIS) was first recognised and described in 2005.1,2 It is characterised by poor pupil dilatation, billowing of iris stroma, iris prolapse through corneal incisions, and progressive intraoperative pupillary constriction.1 The incidence of IFIS can vary, representing between 2–3% of the entire cataract population, but it can be 450% in patients taking Tamsulosin—a selective α1-adrenergic blocker, compared to other nonselective α-adrenergic blockers such as Alfuzosin, Doxazosin, and Terazosin.1,3,4 Alpha-adrenergic antagonists are commonly used in the treatment of benign prostate hyperplasia (BPH).5 The last few years have seen a rise in the use of herbal treatment for BPH, with Saw Palmetto being the most common herbal alternative treatment. Saw Palmetto has been shown to have an α-adrenergic effect.6 As herbal medications and supplements are often not considered as medications by the patients and thus omitted during history taking unless directly prompted to do so, it is important for the surgeon to be aware of all medications and supplements that could potential cause IFIS.7