Piero Ceruti

Comparison of Goldmann applanation tonometry and dynamic contour tonometry in healthy and glaucomatous eyes

PurposeTo compare the measurements of intraocular pressure (IOP) with dynamic contour tonometry (DCT) and Goldmann applanation tonometry (GAT) in healthy and glaucomatous eyes and to evaluate the influence of corneal thickness (CCT), corneal curvature (CC), axial length (AL), and age on these tonometric alternatives.MethodsThree hundred eyes of 100 healthy subjects, 100 patients with primary open angle glaucoma, and 100 patients with primary angle-closure glaucoma underwent IOP evaluation with DCT and GAT, and measurements of CCT, CC, and AL. Bland–Altman plots were used to evaluate the agreement between tonometers. Regression analysis was used to evaluate the influence of ocular structural factors on IOP measurements obtained with both tonometers.ResultsBland–Altman plots indicated that the 95% limits of agreement between tonometers were −1.4 to 6.6 mmHg. DCT values measured 2.6±1.9 mmHg higher than GAT readings (P<0.001). The mean IOP difference between DCT and GAT (ΔIOP) was higher in healthy than in glaucomatous eyes and the magnitude of difference increased with increasing CCT. A significant reduction of ΔIOP with an increase in both CCT (P<0.001) and IOP values (P<0.001) was found. Regression analysis showed no effect of CC, AL, and age on both DCT and GAT readings. In contrast to GAT (P<0.001), DCT measurements were not influenced by CCT (P=0.43).ConclusionsIOP readings obtained by DCT were higher and less affected by CCT than those by GAT. The ΔIOP was higher in healthy than in glaucomatous eyes and decreased in relation to increased CCT and IOP values.

Comparison of Dynamic Contour Tonometry and Goldmann Applanation Tonometry in Deep Lamellar and Penetrating Keratoplasties

PURPOSE To compare the measurements of intraocular pressure (IOP) with dynamic contour tonometry (DCT) and Goldmann applanation tonometry (GAT) in eyes with corneal graft and to evaluate the influence of corneal thickness (CCT), corneal curvature (CC), and astigmatism on these methods. DESIGN Prospective, observational cross-sectional study. METHODS Eighteen eyes of 18 patients after penetrating keratoplasty (PKP) and 14 eyes of 14 patients after deep lamellar keratoplasty (DLKP) underwent IOP evaluation with DCT and GAT, and measurements of CCT, CC, and astigmatism. Bland-Altman plots were used to evaluate the agreement between tonometers. Multivariate regression analysis was used to evaluate the influence of ocular structural factors and running suture on IOP measurements obtained with both tonometers. RESULTS IOP values obtained by DCT and GAT were strongly correlated in all eyes (r = .91; P < .001). DCT values measured 2.5 +/- 1.7 mm Hg higher than GAT readings (P < .001). A reduction of the mean IOP difference between DCT and GAT with an increase in IOP values (P < .001) was found. Regression analysis showed no effect of CCT, CC, astigmatism, and running suture on both DCT and GAT readings, either in DLKP or in PKP eyes. CONCLUSIONS We found a good overall correlation between both tonometers but the agreement between instruments differs in high or low IOP ranges. The wide and varying 95% limits of agreement between DCT and GAT indicates that DCT provides IOP measurements on deep lamellar and penetrating keratoplasties which can be used in the clinical practice.

Adherence to European Society for Cataract and Refractive Surgery recommendations among Italian cataract surgeons: a survey.

Purpose To survey the surgical routines with regards to prophylactic strategies in a sample of Italian hospitals and compare these with European Society for Cataract and Refractive Surgery (ESCRS) guidelines. Methods Six private and 18 public hospitals were included in this clinical-based retrospective study. The overall volume of cataract operations in the 24 centers in 2013 was 43,553. Main outcome measure was incidence of endophthalmitis per 1,000. An incidence of less than 0.13% was considered acceptable. Results Our study provides the first Italian data on the use of intracameral antibiotics in cataract surgery as recommended by the ESCRS. Thirteen centers (54%) used intracameral cefuroxime at the end of surgery. Of the 13 centers that used cefuroxime, 8 (62%) had an incidence of endophthalmitis less than 0.13%. Of the 7 (29%) centers that did not use intracameral cefuroxime, all had an endophthalmitis rate of greater than 0.13%. This difference was statistically significant (p<0.05). Among the 4 centers not included, 2 used vancomycin in the infusion bottle, 1 a fluoroquinolone, and the last a combination of antibiotics. The majority of surgeons (71%) used preoperative antibiotic eyedrops, but this measure was not shown to be significantly protective. Conclusions Slightly more than half of the centers surveyed in this study adhered to the recommendations of the ESCRS and routinely employed prophylactic intracameral cefuroxime. An incidence of endophthalmitis greater than 0.13% was encountered significantly more frequently among centers that did not employ intracameral cefuroxime.

Management of Concomitant Cataract and Glaucoma

The coexistence and management of cataract and glaucoma represents a challenging and unsolved problem. The surgical management of this problem is based on both visual field defect and loss of visual acuity. The surgical options currently available are: (1) cataract extraction alone; (2) cataract extraction followed by glaucoma surgery; (3) glaucoma surgery and afterwards, if necessary, cataract extraction; (4) combined surgery of cataract and glaucoma by one site or by two separate sites. Phacoemulsification alone is suggested when glaucoma can be sufficiently controlled by medication and visual field defect is moderate and not progressive. When glaucoma needs three or more types of medication to reduce intraocular pressure (IOP) or when the offset is unpredictable, phacoemulsification associated with glaucoma surgery at two different times allows a higher IOP reduction than that with a cataract extraction alone. Finally, when glaucoma is prevailing and the surgeon fears that an IOP spike after phacoemulsification may cause significant damage to the optic nerve, combined surgery allows to achieve a greater IOP decrease than phacoemulsification alone and a more predictable low-IOP range in the immediate postoperative period.

Role of cysteine in corneal wound healing after photorefractive keratectomy.

Aims: To evaluate the efficacy of cysteine oral supplements in corneal wound healing after photorefractive keratectomy (PRK). Methods: A total of 200 eyes (100 patients) underwent PRK. We divided patients into 2 groups; each group was composed of 50 patients (100 eyes). Group 1 patients were assigned to use oral L-cysteine, with a daily dose of 200 mg (100-mg pills to be taken twice a day) for a duration of 14 days, starting from the week preceding the operation; the patients in group 2 were used as a control, and received the oral supplementation of 40-mg placebo pills to be taken twice a day for a duration of 14 days, starting from the week preceding the operation. Results: All the eyes of patients treated with cysteine oral supplements showed shorter times to re-epithelization than the eyes of the control group. The mean time of corneal wound healing observed in group 1 was 102 ± 15 h, compared to an average of 159 ± 9 h in group 2. Conclusion: Our research showed that oral cysteine supplementation, in a daily dose of 200 mg, reduces mean corneal wound healing time in patients after PRK.

Hess Area Ratio and Diplopia: Evaluation of 30 Patients Undergoing Surgical Repair for Orbital Blow-Out Fracture

Purpose: To determine if the Hess area ratio is effective in predicting postoperative diplopia in patients undergoing surgery for orbital blow-out fracture. Methods: Our retrospective, interventional case series study involved 30 consecutive cases affected by orbital fractures and diplopia undergoing surgical correction within 7 days after injury. To evaluate ocular motility disturbance, we measured the involved ocular motility range by use of a manual Hess screen test before and 4 months after surgery. The percentage of Hess area ratio % was used to express the range of ocular motility in a numerical value. Results: All patients with preoperative Hess area ratio >85% had no postoperative diplopia, and most patients (57%) having a preoperative Hess area ratio <65% had postoperative diplopia. When the Hess area ratio was between 65% and 85%, surgical outcomes were variable and most patients (55%) described no problematic diplopia in the peripheral visual field. Conclusions: The Hess area ratio is a useful procedure to convert Hess graphic representation in a numerical value so that Hess chart data can be compared among clinicians and used to predict surgical outcomes in patients undergoing surgery for orbital blow-out fractures.

Simultaneous bilateral acute angle-closure glaucoma in a patient with subarachnoid hemorrhage.

PurposeTo present an unusual case of simultaneous bilateral acute angle-closure (AAC) glaucoma in a patient with subarachnoid hemorrhage due to an aneurysm involving the right middle cerebral artery. MethodsA 60-year-old woman with a clinically inexplicable bilateral nonreacting mydriasis after brain surgery underwent an ophthalmologic consultancy. The bilateral mydriasis was diagnosed as an unusual clinical presentation of simultaneous bilateral AAC glaucoma. One week after the AAC was bilaterally resolved, the patient underwent echographic examination because of the outbreak of a unilateral relapsed ocular hypertensive attack that required an ultrasound biomicroscopy (UBM) to be accurately diagnosed and treated. ResultsThe bilateral AAC regressed completely after pharmacologic therapy. UBM evaluation of the eye with recurrence of the angle-closure glaucoma attack was necessary to confirm the diagnosis of unilateral relapsed angle-closure glaucoma due to an unresolved pupillary block. A viscoelastic-aided opening of the angle and peripheral surgical iridectomy were performed. UBM and tonometry were performed intraoperatively to confirm the success of the surgical treatment. ConclusionsThe UBM allowed us to identify the pupillary block as the main mechanism involved in the pathogenesis of this unusual case of simultaneous bilateral AAC glaucoma. Despite the fact that drug-induced supraciliary uveal effusion and mydriasis due to surgical anesthesia have been frequently reported to contribute to this complication, we presumed that simultaneous intravenous administration of sedative drugs and adrenergic agonists, in a patient with individual biometric predisposing factors to the angle-closure, created the anatomic conditions which induced the pupillary block with obliteration of the trabeculum.

Long-term outcomes of a modified technique using the Baerveldt Glaucoma Implant for the treatment of refractory glaucoma

Purpose of the Study:The purpose of the study was to evaluate the long-term effectiveness and safety profile of Baerveldt glaucoma implant (BGI) in patients with refractory glaucoma operated using a modified technique to avoid postoperative complications. Patients and Methods:A total of 160 eyes from 147 glaucomatous patients were enrolled in a consecutive interventional noncomparative case series. All the patients were treated with a 350-mm2 BGI using a modified technique. Intraocular pressure (IOP), the number of medications, the complications, and the postoperative interventions were reported preoperatively and during the follow-up. Postoperative IOP and the rate of complications were the primary outcome measures. The complete and qualified surgical success was the second endpoint. Results:BGI obtained a mean IOP reduction from 31.8±6.4 mm Hg (baseline) to 14.4±3.5 mm Hg after a mean follow-up period of 38.4±9.6 months. The mean number of medications reduced between preoperative (n=3.17±1.03) and postoperative period (n=0.58±0.83) (P<0.0001). Cumulative probability of maintaining an IOP between 5 and 21 mm Hg and/or a 25% or greater reduction in IOP was 78.7% at 1 year and 72.1% at 4 years, including 39 eyes (24.4%) in which postoperative interventions were required (qualified success). If we exclude those eyes from the analysis, the probability of complete success was 93.4% at 1 year and 91.4% at 4 years in 75.4% of the eyes. Conclusions:This modified technique achieved a high percentage of surgical success during the whole follow-up time and was effective in preventing the most serious immediate complications of nonvalved tube shunts.

Simultaneous bilateral retinal detachment following coronary artery bypass graft: Case report

Purpose To present an unusual case of simultaneous bilateral retinal detachment (RD) following a coronary artery bypass graft in a patient with acute myocardial infarction (AMI). Methods A 78-year-old man was first seen for bilateral sudden visual loss after surgical treatment of AMI. The patient underwent ultrasound biomicroscopy (UBM) and ocular B-scan echographic examination. Results The ocular assessment showed a bilateral seclusion of the pupil with bombé of the iris, an anterior chamber without cells or flare, and hypotonia. The evaluation of the visual acuity revealed no light perception in the right eye (RE) and uncertain light perception in the left eye (LE). The UBM analysis of the anterior segment confirmed the presence of bilateral pupillary block due to the seclusion of the pupil and a peripheral serous choroidal detachment involving the RE. The echographic B-scan analysis of the posterior segment showed a bilateral closed funnel-shaped RD and confirmed the presence of the peripheral flat serous choroidal detachment in RE. Conclusions The cause for simultaneous bilateral RD remained unclear. It may have been a consequence of a persistent choroidal detachment with multiple swelling and “kissing” of retinal surface. The increased venous pressure caused by congestive heart failure due to AMI could have caused a bilateral uveal effusion. Alternatively, the absence of retinal tears, the presence of a closed funnel-shaped morphology, and seclusion of the pupils allowed us to suspect an exudative pathogenetic mechanism due to a previous unrecognized ocular inflammatory state.

Choosing wisely and the use of antibiotics in ophthalmic surgery: There is more than meets the eye:

Background: One of the directions of modern ophthalmology is toward an odontoiatric model, and new settings of eye care are becoming the standard of care: one day surgery and also office-based therapies. Methods: Retrospective analysis of three tertiary-care centers in Italy and analysis of the literature. Results: We provide readers with state-of-the-art measures of prophylaxis in ophthalmic surgery. Discussion and conclusion: Role of antibiotics is criticized in the light of stewardship antimicrobial paradigm.