Paolo Capris

Comparison of Three Techniques for Repair of Involutional Lower Lid Entropion: A Three-Year Follow-Up Study

Objective: The aim of this study was to quantify the efficacy of three different surgical techniques for entropion repair in a 3-year follow-up study: (1) the Fox procedure, (2) everting sutures and (3) a modified technique of lower lid retractor plication. Methods: We included in our study 32 eyelids of 32 consecutive patients with involutional lower lid entropion; 10 lids underwent the Fox procedure, 13 the everting sutures and 9 the modified retractor plication. We evaluated the pre- and postoperative horizontal lid laxity (HLL), the pre- and postoperative lower lid excursion (LLE) and the number of recurrences in each patient group. Statistical analysis was performed with the non-parametric Mann-Whitney test and the exact Fisher’s test where appropriate. Results: Only the modified retractor plication technique showed statistically significant differences in HLL and LLE (p < 0.05). In the group treated with this technique, there was a lower incidence of entropion recurrence (p < 0.05). The everting suture technique showed a statistically significant improvement of the LLE only (p < 0.05). The Fox procedure did not show any statistically significant improvement of the studied parameters. Conclusions: The modified retractor plication technique gave the best results in terms of improvement of HLL and LLE and a lower incidence of entropion recurrence compared to the two other techniques studied.

Choroidal abnormalities in neurofibromatosis type 1 detected by near‐infrared reflectance imaging in paediatric population

To investigate choroidal abnormalities in paediatric patients with neurofibromatosis type 1 (NF1) detected by near‐infrared reflectance (NIR) retinography in order to evaluate diagnostic accuracy.

Agreement to detect glaucomatous visual field progression by using three different methods: a multicentre study.

Aim To examine the level of agreement among nine clinicians in assessing progressive deterioration in visual field (VF) overview using three different methods of analysis. Methods Each visual field was assessed by Humphrey Field Analyzer (HFA), program 24-2 SITA Standard. Nine expert clinicians assessed the progression status of each series by using HFA ‘overview printouts’ (HFA OP), the Guided Progression Analysis (GPA) and the Guided Progression Analysis (GPA2). VF series were presented in random order, but each patients VF remained in chronological order within a given field series. Each clinician adopted his personal methods based on his knowledge to evaluate VF progression. The level of agreement between the clinicians was evaluated by using weighted κ statistics. Results A total of 303 tests, comprising 38 visual field series of 7.9±3.4 tests (mean±SD), were assessed by the nine glaucoma specialists. When the intra-observer agreement was evaluated between HFA OP and GPA, the mean κ statistic was 0.58±0.13, between HFA OP and GPA2, κ was 0.55±0.06 and between GPA and GPA2 it was 0.56±0.17. When the inter-observer agreement was analysed κ statistic was 0.65 for HFA OP, 0.54 for GPA and 0.70 for GPA2. Conclusions Using any procedure for evaluating the progression of a series of VF, agreement between expert clinicians is moderate. Clinicians had higher agreement when GPA2 was used, followed by HFA OP and GPA printouts, but these differences were not significant.

Agreement in detecting glaucomatous visual field progression by using guided progression analysis ?and Humphrey overview printout.

Purpose To examine the level of agreement among 3 clinicians in assessing glaucoma visual field progression by using 2 different methods. Methods Each visual field was assessed by Humphrey Field Analyzer (HFA), program SITA standard 30–2 or 24–2. In each printout the first 3 fields were excluded to minimize learning effect: the fourth and fifth full-threshold or SITA Standard examinations were used as baseline. Three clinicians assessed the progression status of each series using both HFA overview printouts and the guided progression analysis (GPA). The level of agreement among the clinicians was evaluated using a weighted kappa statistic (κ). Results A total of 510 tests, comprising 83 eyes with an average of 6.1 tests each, was assessed by the 3 specialists. The mean follow-up time was 5.8±1.75 years (mean ± standard deviation). When the intraobserver intermethod agreement was evaluated, κ ranged from 0.5 to 0.7. When the interobserver agreement was analyzed, if HFA overview printouts were used, κ ranged from 0.4 to 0.7. But when GPA was used, κ ranged from 0.2 to 0.6. The level of agreement on progression status between the clinicians was always higher when they used HFA overview printouts (median κ = 0.54) than when they used GPA (median κ=0.37). Conclusions Agreement among expert clinicians about visual field progression status was moderate when GPA printouts were used. Clinicians’ agreement about patients’ visual field progression status was better when HFA overview printouts were used than with GPA printouts.

Comparing continuous and stepwise luminance variation in static campimetry using the Grignolo-Tagliasco-Zingirian projection campimeter

In traditional static perimetry the remarkable precision achieved, resulting mainly from the lack of temporal factors related to latency, largely makes up for the relatively long time required to perform the test. Conversely, the increase in speed of the test and in the information content of the visual field charts counteract the lower precision attained with kinetic perimetry. If the influence of the latency time on responses could be kept at a low value, then adopting a static strategy, based on a continuous rather than discrete target luminance variation for threshold detection, could be justified. For this purpose a luminance variation time sequence designed to reproduce the conditions of the traditional static perimetric test was chosen. The test was performed on the Grignolo-Tagliasco-Zingirian projection campimeter, after comparing its clinical performance with the Goldmann perimeter. These two methods - one based on continuous variation, the other based on discrete target luminance variation - were compared using a 14-subject sample. We conclude that the presentation strategy based on continuous luminance variation can be regarded as a valid alternative to the traditional method.

Orbital and Periorbital Extension of Congenital Dacryocystoceles: Suggested Mechanism and Management.

Orbital and periorbital extension of congenital dacryocystoceles is rarely observed in neonatal infants. The authors describe 4 cases of congenital dacryocystocele that presented with extension to the orbital and periorbital regions. The first 3 newborns underwent marsupialization of the orbital and periorbital dacryocystoceles with aspiration of the purulent material followed by nasolacrimal duct probing after radiographic evidence of diffuse orbital or periorbital expansion. The fourth patient was successfully treated with an external dacryocystorhinostomy with excision of the enlarged cystic walls. Transconjunctival orbitotomy with sac marsupialization followed by nasolacrimal intubation can provide immediate and permanent resolutions of this unusual complication in most instances. External dacryocystorhinostomy may be required, however, when the orbital or periorbital dacryocystocele is complicated by acute or recurrent dacryocystitis.

Primary diffuse leptomeningeal gliomatosis in children: a clinical pathologic correlation.

Purpose: To describe a rare case of primary diffuse leptomeningeal gliomatosis (PDLG) presenting with progressive proptosis and direct involvement of the optic nerve sheath in a child and review of the relevant literature. Methods: Retrospective review of a single case and systematic literature review of 26 biopsy-proven cases reported in the MEDLINE-indexed English literature. A 10-year-old girl developed proptosis and progressive visual loss associated with thickening of the optic nerve sheaths and dilation of the subarachnoid spaces with multilobulated appearance of the brain meninges and thickened peripheral nerve root sheaths. Biopsy of the optic nerve sheath was diagnostic. The patient underwent chemotherapy combined with oral temozolomide and conformational radiotherapy to the brain and spine. She died 3 years after the onset of the disease. An extensive review of the published literature using the key words “primary diffuse leptomeningeal gliomatosis” and “optic nerve” confirmed the case herein reported to be the first case of primary diffuse leptomeningeal gliomatosis in which direct optic nerve infiltration was demonstrated during the course of the disease. Results: Immunohistochemistry demonstrated expression of CD56 and glial fibrillary acidic protein, and an elevated level of Ki-67; all the other markers were negative. Conclusions: According to a comprehensive literature review, we report the first case of PDLG that presented with bilateral proptosis and direct involvement of the optic nerve during the course of the disease. These new findings may explain an alternative mechanism of visual loss and proptosis in PDLG. We emphasize the importance of close collaboration between neurologists and ophthalmologists in all cases of visual symptoms associated with a neurologic condition. In case of optic nerve involvement, ophthalmologists could provide an easier route to achieve tissue specimen early in the course of this rare and fatal disease.

Comparison between relative dispersion analysis of high-pass resolution perimetry and standard threshold perimetry

Purpose To evaluate the correlation of the dispersion index (DI) of relative dispersion analysis (RDA), a new high-pass resolution perimetry (HRP) index, with other HRP indices and those of the Humphrey standard threshold perimeter (STP) parameters.Methods Sixty-eight eyes were randomly recruited. Thirty-one eyes were classified as glaucomatous (high intraocular pressure, abnormal visual field and/or optic disc) and 37 as ocular hypertensives (high intraocular pressure, normal visual field, normal optic disc). All the subjects were examined with Humphrey Perimeter, program 30-2, and HRP. The HRP data were also analysed with the RDA program. Statistical analysis was performed with Students t-test, Pearsons r correlation coefficient, Mann-Whitney non- parametric test and Spearman correlation coefficient when appropriate.Results Within the entire sample significant correlations were found between the RDA index (DI) and all the HRP indices (p < 0.001) and corrected pattern standard deviation (p < 0.01), pattern standard deviation (PSD) (p < 0.01), mean deviation (p < 0.05) and short- term fluctuation (p < 0.05) of STP. A stronger correlation was found in glaucomatous patients. In subjects with ocular hypertension D1 was only weakly correlated with PSD, local deviation and form index. No difference in D1 was found between glaucoma and ocular hypertension.Conclusion The D1 of HRP has the theoretical capacity to detect localised inhomogeneity of retinal sensitivity, but at present our data do not support this hypothesis. Before any clinical applications of this index further studies are needed.

Choroidal freckling in pediatric patients affected by neurofibromatosis type 1

Greater understanding of choroidal freckling in patients affected by neurofibromatosis type 1 (NF1) has changed the previous belief that choroidal lesions are unusual in eyes with this disease. In fact, the high frequency of freckling suggests that the choroid is a structure commonly affected in patients with NF1. A review of patients aged 16 years or younger was performed. Recent studies using near-infrared reflectance imaging have shown that choroidal freckling frequently occurred in pediatric patients. As a result of these findings, some authors have suggested that choroidal freckling should be considered as a new diagnostic criterion for NF1. [J Pediatr Ophthalmol Strabismus. 2016;53(5):271-274.].

Reply re: “Orbital and Periorbital Extension of Congenital Dacryocystoceles

To the Editor: We thank Baker and Allen for their interest in our report and for adding 1 more case of this rare but serious complication of an otherwise benign and common condition. Orbital expansion of a dacryocystocele is in fact rare, but posterior expansion of a lacrimal sac filled with infected material may have serious sequelae if not promptly recognized and appropriately managed. The similarity of presentation between the case reported by Baker and Allen and the ones presented in our previous report is noteworthy. Interestingly, imaging shows in all cases an evagination of the lacrimal sac toward the orbit or periorbital area. Both iatrogenic cases presented with an acute infection of the orbit, indicating that the digital pressure of the sac can cause a significant worsening of the dacryocystocele. The case reported by Baker and Allen is the second iatrogenic orbital expansion of a congenital dacryocystocele, indicating that the risk of a wrongful medical maneuver is not limited to one isolated “bad doctor,” but can occur anywhere when performed by physicians who are not familiar with the anatomical area. In regard to the question that Baker and Allen pose regarding the role of digital massage in these children, we do not have a definitive answer. All of the authors on this article concur that the internal pressure of the lacrimal sac is most likely already very high in most cases of dacryocystocele as evidenced by a rock-hard sac on palpation. For this reason, it is our collective belief that a sudden further increase of internal pressure from massage does increase the risk of breaking the lacrimal sac wall unpredictably, into the anterior nasolacrimal duct obstruction and a 1 week history of a dacryocystocele on the left. The dacryocystocele was aggressively decompressed by an outside physician on the day of referral which, per the patient’s parents, resulted in immediate erythema and edema on the left which worsened throughout the day. On examination the patient demonstrated erythema and tense edema on the left with chemosis (Fig. 1); he had a temperature of 38.9°C and a significantly elevated white blood cell count of 24.8 K/ml. A CT scan was obtained which was consistent with a left orbital cellulitis and dacryocystitis (Fig. 1). Blood, cerebrospinal fluid, and urine cultures were negative. The patient was started on intravenous vancomycin and clindamycin. The patient was taken urgently to the operating room where a probing and stenting of the lacrimal system was performed along with an anterior orbitotomy and drainage of an inferior orbital abscess. Cultures grew methicillin-sensitive Staphylococcus aureus. The patient improved postoperatively and entirely resolved without negative sequelae at the final 6 month follow-up (Fig. 2). The literature lacks a consistent, standard treatment of congenital dacryocystoceles. Many reports emphasize the importance of treating those patients with intranasal components that cause respiratory distress. The most recent comprehensive study was published by Becker in 2006 where he evaluated his treatment of congenital dacryocystoceles. He recommended “probing at the earliest possible age [to] reduce the incidence of dacryocystitis and cellulitis.” He also thought that “patients with dacryocystocele should have a probing on urgent basis if the lacrimal sac does not decompress into the nose with massage during the first examination.” We believe that the conclusions from Becker and the observations by Bernardini et al. highlight some important points: dacryocystoceles that are mismanaged may result in significant morbidity; dacryocystoceles should be decompressed