Ricardo Cuiña-Sardiña

Ultrasound biomicroscopy examination of posterior chamber phakic intraocular lens position

OBJECTIVE To better elucidate the in vivo position of the Collamer posterior chamber phakic intraocular lens (PCPIOL) and its relationship to the iris and the crystalline lens and to analyze possible variations over time. DESIGN Prospective observational case series. PARTICIPANTS Eighteen eyes of nine patients were included. INTERVENTION A Staar Collamer implantable PCPIOL was implanted for the correction of high myopia. MAIN OUTCOME MEASURES The eyes were studied with a 50-MHz ultrasound biomicroscopy UBM 840. The exact PCPIOL position and the distances between it and the crystalline lens were measured at 3, 6, and 12 months after surgery. RESULTS There were no intraoperative complications. In 13 eyes (72.22%), contact between the PCPIOL and the crystalline lens was found at some time during follow-up. In 3 eyes (16.6%), central contact could be demonstrated. We also observed that the contact zone and its extension can vary over time. In 2 eyes, rotation of the lens was observed. CONCLUSIONS We found contact between the PCPIOL and the crystalline lens in a high percentage of cases. There was also mobility of the lens in the posterior chamber, especially in the anteroposterior plane, and, as a consequence, both the contact zone and its extension would vary over time.

Ultrasound biomicroscopy of silicone posterior chamber phakic intraocular lens for myopia

Purpose: To study the intraocular position and anatomic relationships of PRL‐III (phakic refractive lens) (PRL) posterior chamber phakic intraocular lens (PCP IOL) for high myopia using ultrasound biomicroscopy (UBM). Setting: Centro Oftalmológico Real Vision, and Instituto de Investigaciones Oftalmológicas Ramón Castroviejo, Universidad Complutense de Madrid, Madrid, Spain. Methods: Sixteen phakic myopic eyes that had had PRL implantation were examined by UBM 1 month after surgery. The PRL position, PRL–crystalline lens peripheral distance, and central distance between the corneal endothelium and the PRL were measured. Results: Both haptics were on the zonule in 6 eyes, in the ciliary sulcus in 5 eyes, and impacted in the ciliary body in 1 eye. In the 4 remaining eyes, the haptics were in mixed positions. The mean PCP IOL crystalline lens peripheral distance in the minor axis was 588.1 &mgr;m ± 232.5 (SD), and the mean PCP IOL–endothelium central distance was 2082.8 ± 277.6 &mgr;m. Conclusions: Phakic refractive lens implantation should be done carefully because of the sulcus location of the haptics in many cases. This, with the iris–PRL contact, suggests caution for the long‐term outcome.

Peritubular filtration as cause of severe hypotony after Ahmed valve implantation for glaucoma

PURPOSE To report peritubular filtration as the cause of severe hypotony after Ahmed valve implantation. METHODS Interventional case report. In a 65-year-old man with primary open-angle glaucoma, ultrasound biomicroscopy was used to image the peritubular region of his right eye that had severe hypotony during the early postoperative period after an Ahmed valve implantation. RESULTS The ultrasound biomicroscopy examination showed peritubular filtration. Additional surgery consisting of tube extraction, closure of the previous insertion opening, reformation of the anterior chamber with viscoelastic, and reintroduction of the tube through a new paracentesis was performed to solve this complication. Twenty-four hours postoperatively, the intraocular pressure increased to 10 mm Hg. During the 6-month follow-up, the mean intraocular pressure was 16.36 mm Hg (standard deviation, 1.45). CONCLUSION The possibility of peritubular filtration should be considered in eyes with severe hypotony after restrictive valve implantation.

Measuring intraocular pressure after intrastromal corneal ring segment implantation with rebound tonometry and Goldmann applanation tonometry.

Purpose: The aim of this study was to compare intraocular pressure (IOP) measurements in patients with ectatic corneas after intrastromal corneal ring segment (ICRS) implantation using the Rebound tonometers (RBTs) Icare and Icare Pro, compared with Goldmann applanation tonometry (GAT) and to assess the influence of central corneal thickness (CCT), corneal curvature (CC), and corneal astigmatism (CA) on IOP. Methods: This prospective cross-sectional study consecutively included 60 eyes of 60 patients with corneal ectasia having ICRS for at least 6 months from January 2011 to December 2013. All subjects underwent GAT, Icare, and Icare Pro IOP measurements in a random order, and CCT, CC, and CA evaluation using a Pentacam. The Bland–Altman method and multivariate regression analysis logistic method were used to assess intertonometer agreement and the influence of corneal variables on IOP measurements. Results: Icare significantly underestimated IOP compared with GAT [GAT − Icare 1.2 ± 3.0 mm Hg, P = 0.002 (95% confidence interval, 0.5–2.0)], whereas Icare Pro showed no statistical differences compared with GAT [GAT − Icare Pro 0.1 ± 3.1 mm Hg, P = 0.853 (95% confidence interval, −0.7 to 0.9)]. Both RBTs presented good concordance with GAT (intraclass coefficient correlation > 0.6). All tonometer measurements were influenced by CCT values and age (P < 0.05); the number of ICRS implanted did not influenced IOP measurement with any of the 3 tonometers. Conclusions: Both RBTs could be an alternative to GAT in patients with corneal ectasia and ICRS; however, Icare Pro shows greater accuracy.

Uvemaster: A Mobile App-Based Decision Support System for the Differential Diagnosis of Uveitis.

Purpose To examine the diagnostic accuracy and performance of Uvemaster, a mobile application (app) or diagnostic decision support system (DDSS) for uveitis. The app contains a large database of knowledge including 88 uveitis syndromes each with 76 clinical items, both ocular and systemic (total 6688) and their respective prevalences, and displays a differential diagnoses list (DDL) ordered by sensitivity, specificity, or positive predictive value (PPV). Methods In this retrospective case-series study, diagnostic accuracy (percentage of cases for which a correct diagnosis was obtained) and performance (percentage of cases for which a specific diagnosis was obtained) were determined in reported series of patients originally diagnosed by a uveitis specialist with specific uveitis (N = 88) and idiopathic uveitis (N = 71), respectively. Results Diagnostic accuracy was 96.6% (95% confidence interval [CI], 93.2-100). By sensitivity, the original diagnosis appeared among the top three in the DDL in 90.9% (95% CI, 84.1-96.6) and was the first in 73.9% (95% CI, 63.6-83.0). By PPV, the original diagnosis was among the top DDL three in 62.5% (95% CI, 51.1-71.6) and the first in 29.5% (95% CI, 20.5-38.6; P < 0.001). In 71 (31.1%) patients originally diagnosed with idiopathic uveitis, 19 new diagnoses were made reducing this series to 52 (22.8%) and improving by 8.3% the new rate of diagnosed specific uveitis cases (performance = 77.2%; 95% CI, 71.1-82.9). Conclusions Uvemaster proved accurate and based on the same clinical data was able to detect more cases of specific uveitis than the original clinician only-based method.

Annular herpetic keratitis after intracorneal ring segment implantation.

To the Editors: We present a 26-year-old man who underwent an intracorneal ring segment (ICRS) implantation for treatment of grade 2 keratoconus in his left eye by performing mechanical corneal dissection. The incision was performed at the 7-o’clock position, and the ICRS was placed inferonasally. His ophthalmological history was only remarkable for keratoconus treated with gas-permeable contact lenses and a history of herpetic keratitis 5 years previous to ICRS implantation. Five days after the surgery, the patient presented with intense left eye pain. On examination, an annular dendritic ulcer was observed (Fig. 1). The epithelial defect was just above the course of the stromal tunnel created at the time of ring implantation. Considering his medical history and the dendritic ulcer, a diagnosis of herpetic keratitis was made. Treatment was started immediately with topical acyclovir 5 times per day and artificial tears 6 times per day for 1 week. Three days after the treatment was completed, the patient reported no pain, and on exploration, there was no sign of herpetic ulcer. ICRS implantation has been reported to be a safe surgical technique for the treatment of keratoconus. There have been different reports describing bacterial infectious keratitis after ICRS implantation. To the best of our knowledge, this is the first case describing herpetic keratitis after ICRS implantation. Given the experience we have had with this case, in the future, we propose that herpes prophylaxis be considered before ICRS implantation in eyes with a history of herpetic keratitis. Early recognition and prompt treatment of the infection may be required to prevent serious sight-threatening complications of ICRS implantation. Financial disclosures/conflicts of interest: None reported.

Measuring Intraocular Pressure in Patients With Keratoconus With and Without Intrastromal Corneal Ring Segments.

Purpose: To compare intraocular pressure (IOP) measurements made using 5 tonometers in keratoconic eyes with and without intrastromal corneal ring segments. Methods and Patients: This was an observational case series study. A total of 147 eyes of 147 patients with keratoconus, 74 of which had undergone corneal ring segment placement, were prospectively evaluated. IOP was measured using the tonometers Tonopen XL, Pascal dynamic contour tonometer, iCare Pro, ocular response analyzer (ORA), and Goldmann applanation (GAT) in random order. The Bland-Altman method was used to examine interinstrument agreement. Effects on readings of central corneal thickness, corneal curvature, and corneal astigmatism were assessed by multivariate regression analysis. Results: Smallest mean IOP differences with GAT measurements in eyes without and with ring segments, respectively, were detected for iCare Pro [0.2 (2.9) mm Hg and 0.4 (3.0) mm Hg, P=0.914] and greatest differences for ORA Goldmann-correlated IOP [5.8 (3.3) mm Hg and 6.0 (3.1) mm Hg, P=0.363]. Best agreement with GAT was shown by iCare Pro (ICC=0.829; 95% CI, 0.721-0.896) and worse agreement by ORA corneal-compensated IOP (ICC=−0.145; 95% CI, −0.826 to 0.283). All but the dynamic contour tonometer readings were influenced by central corneal thickness, yet these measurements were affected by the presence of ring segments (P=0.017) and corneal astigmatism (P=0.030). Corneal curvature only affected ORA Goldmann-correlated IOP (P=0.029). Conclusions: All 5 tonometers provided reliable IOP readings in the keratoconic eyes regardless of the presence of corneal ring segments. iCare Pro readings were most consistent with GAT, whereas ORA readings were least consistent with this reference standard.

Intraocular pressure following intrastromal corneal ring segments

glaucoma. Moreover, we evaluated the expression level of APOE protein in the aqueous humour in POAG patient and in the control group. The study consisted of 30 patients with POAG and 30 healthy subjects. There were no differences in agematched between study and control groups (p > 0.05). Material for the study was the whole blood (3 ml) and the aqueous humour (45–80 ll). The level of mRNA expression was determined by QRT-PCR. The expression level of selected proteins was measured using enzyme immunosorbent assays – ELISA test. The study was approved by the Committee for Bioethics of the Medical University of Lodz (Permission number RNN/535/12/KB). All calculations were performed using STATISTICA 6.0 software (StatSoft, Tulsa, OK, USA). Evaluation of the level of mRNA and protein expression in the blood and serum (respectively) of POAGpatients and a control groupwas performed using the non-parametric Mann–Whitney U-test. p-values of less than or equal to 0.05 were considered to represent statistical significance. The results of APOE, BDNF and HSP70-1 mRNA expression level in the blood have shown no statistical differences between POAG patients and control subjects (p > 0.05; Fig. 1A). However, the analysis of protein level in the serum has showed a higher expression of APOE of POAG patients compared with the control group (p ≤ 0.05; 5106.07 ng/ml versus 4294.70 ng/ml) (Fig. 1B,a). Whereas, no statistical difference has been demonstrated in HSP70-1 and BDNF protein levels between glaucomatouspatients andcontrols (p > 0.05; Fig. 1B,b,c, respectively). Additionally, the analysis of APOE aqueous humour levels has showed no significant changes in the expression levels of APOE in the aqueoushumourbetweenPOAGpatients and the control subjects (p > 0.05) (Fig. 1C). However, we have observed a tendency to increase in concentration of APOE in the aqueous humour in POAG patients (262.12ng/ml) compared with controls (173.83 ng/ml). In conclusion, our research suggests that altered level of APOE may be related to the development of POAG. The obtained results can be very useful for the understanding the aetiology of glaucoma and biomarkers detection through which diagnosis of glaucoma will be possible at an earlier stage, and consequently allow for faster application of treatment.

Ciliochoroidal detachment following pure sulfur hexafluoride injection in Descemet stripping automated endothelial keratoplasty

Descemet stripping automated endothelial keratoplasty (DSAEK) is an effective and safe treatment for Fuchs dystrophy and pseudophakic corneal edema, among other ocular conditions. The most common complication of this surgical procedure is graft detachment, which may be effectively resolved in most cases by rebubbling with air or gas (or both) to reposition the graft. After endothelial transplantation, the injection of air or sulfur hexofluoride (SF6) in the anterior chamber has proven to be effective in fixing the graft to the host posterior cornea. Although the use of air compared with SF6 has been linked to a slightly higher rate of graft displacement on postoperative day 1, both methods are safe and usually free of complications. A 64-year-old woman with a history of Fuchs endothelial dystrophy, corneal decompensation, and cataract (Fig. 1A) underwent a triple procedure: phacoemulsification, posterior chamber intraocular lens placement, and DSAEK in the right eye. Axial length was 24.6 mm, and anterior chamber depth was 3.34 mm. An Nd:YAG laser iridotomy was performed before the surgery.