Patrizia Pichierri

An In Vivo Confocal Microscopy Analysis of Effects of Topical Antiglaucoma Therapy With Preservative on Corneal Innervation and Morphology

PURPOSE To evaluate the long-term effects of preservative-free and preservative-containing antiglaucoma eye drops on the tear secretion and ocular surface. DESIGN Comparative retrospective study. METHODS A total of 84 patients with bilateral primary open-angle glaucoma or ocular hypertension divided into 5 groups according to type of topical hypotensive therapy and 20 healthy age-matched volunteers were studied. Clinical tests (corneal sensitivity, Schirmer I test, and lachrymal film break-up time), and in vivo confocal microscopy were performed in all patients. RESULTS A significant reduction of the scores was found between groups on topical hypotensive therapy and the control group in all clinical parameters studied (P < .05). In particular, the clinical scores were significantly lower in the preservative medication groups than in the preservative-free group (P < .05). The density of superficial epithelial cells was reduced in all glaucomatous patients, except for the preservative-free group (P > .05), with respect to control subjects (P < .001). On the contrary, the density of basal epithelial cells of glaucomatous preservative therapy groups was higher than control and preservative-free groups (P < .05). Stromal keratocyte activation and the number of beads were higher in all glaucoma preservative groups (P < .05). The number of sub-basal nerves was lower in all glaucoma groups than in the control group (P < .05) and tortuosity was significantly higher in glaucoma than control groups (P < .05). Reflectivity of fibers did not show any significant difference between the 6 groups (P < .05). CONCLUSIONS Glaucomatous patients with chronic treatment show ocular surface alterations. The development of nontoxic antiglaucoma treatment may reduce damage to the ocular surface and improve the compliance and the adherence in the medical therapy.

Pseudoexfoliation syndrome: in vivo confocal microscopy analysis

Pseudoexfoliation (PEX) syndrome is a common ocular disease that also affects the cornea. A case of clinical PEX syndrome, studied by in vivo corneal confocal microscopy is reported. The morphological analysis of the confocal images demonstrated hyper‐reflective deposits and several dendritic cells in the basal epithelial layer. A fibrillar subepithelial structure was also found. The endothelial layer showed cell anomalies (polymegathism and pleomorphism) and hyper‐reflective small endothelial deposits. Confocal microscopy is an in vivo imaging method that may provide new information on corneal alterations in PEX, and detect early corneal features.

Corneal invasion of ocular surface squamous neoplasia after clear corneal phacoemulsification: In vivo confocal microscopy analysis

We describe an unusual case of ocular surface squamous neoplasia (OSSN) that occurred in a male patient after superonasal clear corneal phacoemulsification with extensive papillomatous corneal invasion near a side port. The features of the macroscopic invasion of the corneal superficial layers were analyzed by in vivo confocal analysis using the Heidelberg Retina Tomograph II. After OSSN was diagnosed, topical mitomycin-C 0.02% eyedrops were prescribed 4 times a day in a cyclic manner (3 cycles of 1 week on drops followed by 1 week off). After 1 month (second cycle), the natural visual acuity was 20/20, the corneal epithelium had healed completely, and the limbal lesion had regressed markedly. The patient remained asymptomatic without recurrence during a 6-month follow-up.

Inflammatory myofibroblastic tumor of the orbit.

The authors describe an unusual case of orbital inflammatory myofibroblastic tumor (IMT) in a 17-year-old patient who presented with a painful exophthalmos of the left eye. After complete surgical excision, the mass was diagnosed as an IMT based on morphological and immunohistochemical features. No tumor recurrence was evident during 28-month follow-up. The authors discuss histopathological and immunohistochemical characteristics and review the literature of orbital IMT.

Preoperative diagnosis of orbital cavernous hemangioma: a 99mTc-RBC SPECT study.

Purpose This study aimed to describe 99mTc-labeled RBC scintigraphy as a diagnostic method for orbital cavernous hemangiomas and to evaluate this diagnostic tool according to surgical outcomes. Methods Fifty-five patients with clinical and radiological (US, CT, and/or MRI) suspicion of unilateral cavernous hemangioma of the orbit underwent 99mTc-RBC SPECT study. Qualitative and semiquantitative evaluations were performed, and results were statistically analyzed. Results SPECT images showed focal uptake in the orbital mass in 36 of 55 patients. Nineteen patients had a negative scintigraphic pattern, with concordance of early and late absence of uptake of 99mTc-RBC. Our procedure showed 100% sensitivity and 88.9% specificity for the diagnosis of orbital cavernous hemangioma, with a positive predictive value of 90.9% and a negative predictive value of 100%. Conclusions 99mTc-RBC imaging is safe, easy to perform, and highly accurate in providing adequate clinical and surgical management. As a noninvasive and highly specific method for diagnosing orbital hemangioma, 99mTc-RBC scintigraphy can avoid more invasive imaging or biopsy.

In vivo confocal microscopy in a patient with conjunctival lymphoma

A case of primary conjunctival mucosa‐associated lymphoid tissue lymphoma studied by in vivo corneal confocal microscopy (IVCM) is described for the first time. Examination of the lower mediobulbar and forniceal conjunctiva of the left eye of a 37‐year‐old female patient showed a typical salmon‐pink patch. IVCM examination of the conjunctival lesion showed irregular, polygonal, conjunctival bulbar epithelial cells with blurred edges and without visible nucleus. Many small, roundish, hyper‐reflective cells were also seen. These cells were arranged diffusely or in nests in cyst‐like hypo‐reflective spaces. A few highly reflective cells were also visible among deep stromal collagen fibres. The IVCM picture recalled the histological profile of low‐grade mucosa‐associated lymphoid tissue lymphoma, characterized by sheets of neoplastic cells around reactive follicles. IVCM enabled non‐invasive evaluation of the eye surface at high magnification and with good contrast, and could be useful for early differential diagnosis of conjunctival lesions.

In vivo confocal microscopy and anterior segment optical coherence tomography in a case of alternaria keratitis.

Purpose: To report a case of Alternaria alternata keratitis analyzed with in vivo confocal microscopy (IVCM) and anterior segment optical coherence tomography (OCT). Methods: A 68-year-old man with unilateral keratitis was evaluated using IVCM (Heidelberg Retina Tomograph II; Heidelberg, Germany) and anterior segment OCT (Visante OCT; Carl Zeiss Meditec, Dublin, CA). Results: IVCM demonstrated the presence of small, round, hyperreflective cells surrounded by hyporeflective irregular areas and highly reflective dendritic shaped cells at the level of the epithelium. Stromal examination revealed many hypereflective filamentous structures, and some hyporeflective perpendicular lines and hyperreflective oval bodies were clearly visible along the filaments. Anterior segment OCT examination demonstrated a thickened cornea due to diffuse edema and an irregular corneal surface corresponding to the ulcer. There were hyperreflective areas beneath the epithelium representing the infiltrate. Microbiological examination of corneal scrapings demonstrated the presence of Alternaria alternata. After 1 month of antifungal treatment, IVCM demonstrated a significant reduction of the inflammatory cells and a hyperreflective scar-like tissue. Branching hyphal infiltrates were no longer present. OCT also documented the healing process and the complete recovery of the central and peripheral stromal thickness. Conclusions: IVCM and anterior segment OCT could be useful for the early diagnosis and treatment of fungal keratitis.

A case of primary botryoid conjunctival rhabdomyosarcoma

BackgroundRhabdomyosarcoma is the most common childhood primary orbital malignancy, but the occurrence of this tumour in the conjunctiva is rare.MethodsA 14-year-old girl presented with a visible case of conjunctival mass in the left eye. The year before, the patient was referred to another hospital for a biopsy of a conjunctival mesenchymal tumour in the same site, which was periodically checked after the excision. We intervened by partially removing the conjunctival mass.ResultsThe histopathology revealed a botryoid rhabdomyosarcoma. The patient underwent chemotherapy and fractionated radiotherapy. The follow-up after three years revealed that the patient remained clinically tumor-free, with no ocular complication from the radiotherapy.ConclusionIt is evident that by not excising the tumour in its entirety it is therefore possible to preserve the underlying rectus muscles and not interfere with ocular motility. Subsequent radiotherapy and chemotherapy helped to destroy any residual tumour. Alternatively, surgical excision of the mass alone could lead to recurrence of the tumour after some months or years.

Orbital teratoma masquerading as lymphangioma

Orbital teratoma in a newborn produces rapid and unilateral proptosis, which, combined with poor eyelid closure, may lead to corneal exposure and vision loss. Early surgical excision of the mass is recommended to preserve visual function. We report a case of an orbital teratoma masquerading as a lymphangioma in 6-month-old girl. The lesion was entirely excised using a transconjunctival approach with good cosmetic and functional results.

Visual Field Loss Progression after Macular Hole Surgery

Purpose. To report a patient who experienced visual field loss progression after vitrectomy for an idiopathic stage II macular hole. Methods. Case report. A 68-year-old woman, with no history of glaucoma or any neuroophthalmological diseases, underwent a vitrectomy for a macular hole. Results. The patient showed macular hole closure and a resulting central visual acuity of 20/20. However, two months after surgery, she developed an inferotemporal visual field defect. Moreover, seven months after surgery, the patient noticed an enlargement of the temporal blind area: a nearly complete temporal defect was confirmed on visual field testing. Conclusions. Although the beneficial results of successfully treated macular holes are unquestionable, this report raises the possibility that visual field defects following macular hole surgery may be progressive.