Crossing the Death Valley of publication process in cornea and ocular surface diseases: from abstracts presented at the Association for Research in Vision and Ophthalmology annual meeting to full-text manuscripts

PURPOSE

This study was conducted to analyze the profile and publication rate of abstracts in indexed journals presented in the cornea section at the Association for Research in Vision and Ophthalmology Annual Meeting and to further identify potential predictive factors for better outcomes.

METHODS

Abstracts accepted for presentation at the 2013 Association for Research in Vision and Ophthalmology Annual Meeting in the cornea section were sought via PubMed and Scopus to identify whether they had been published as full-text manuscripts. First author's name, time of publication, journal's name, and impact factor were recorded. A multivariate regression was performed to explore the association between variables and both the likelihood of publication and the journal's impact factor. A Kaplan-Meier analysis was performed to evaluate the time course of publication of abstracts.

RESULTS

Of the 939 analyzed abstracts, 360 (38.3%) were published in journals with a median impact factor of 3.4. The median time interval between abstract submission and article publication was 22 months. The multivariate analysis revealed that abstracts were more likely to be published if they were funded (OR=1.482, p=0.005), had a control group (OR=1.511, p=0.016), and had a basic science research scope (OR=1.388, p=0.020). The journal's impact factor was higher in funded studies (β=0.163, p=0.002) but lower in multicenter studies (β=-0.170, p=0.001). The Kaplan-Meier analyses revealed significant differences in the publication time distribution for basic science vs clinical abstracts (χ2=7.636), controlled vs uncontrolled studies (χ2=6.921), and funded vs unfunded research (χ2=13.892) (p<0.05).

CONCLUSION

Almost 40% of Association for Research in Vision and Ophthalmology abstracts were published within 5 years from submission. Funding support, basic research scope, and controlled design were the determinants of better outcomes of publication.

In Vivo and Ex Vivo Comprehensive Evaluation of Corneal Reinnervation in Eyes Neurotized With Contralateral Supratrochlear and Supraorbital Nerves

PURPOSE

To use an automated morphometric analysis system of in vivo confocal microscopy (IVCM) images for evaluating reinnervation occurring at the subbasal nerve plexus (SNP) after direct corneal neurotization (DCN) and to further report neurophysiological and histopathological findings.

METHODS

Prospective interventional case series including 3 eyes with neurotrophic keratitis that underwent DCN. Deep anterior lamellar keratoplasty was performed 18 months after DCN in patient 1. The following evaluations were performed before and at 3, 6, and 12 months after DCN: clinical evolution of keratitis; corneal sensitivity; IVCM images of the SNP analyzed with "ACCMetrics;" neurophysiological study of corneal reflex. Protein gene product 9.5 immunofluorescence staining assay and transmission electron microscopy were conducted on the neurotized button excised during deep anterior lamellar keratoplasty.

RESULTS

Complete healing was obtained in all patients by 3 months postoperatively. Corneal sensitivity was absent preoperatively in all eyes and improved after surgery, reaching an average value of 30 mm 1 year postoperatively. The corneal SNP was not visible at IVCM in any of the cases preoperatively and became visible by 3 months postoperatively, showing IVCM metrics comparable to normal contralateral eyes at 1 year. In all cases, neurophysiological evaluation showed a partial recovery of the electrical activity of the cornea. In patient 1, protein gene product (PGP) 9.5 staining of neurotized cornea showed nerve fascicles at the SNP, whereas transmission electron microscopy showed amyelinic nerve axons and nerve endings.

CONCLUSIONS

The corneal SNP exhibited IVCM metrics comparable to the normal contralateral eye 1 year after DCN. Ex vivo histopathological assessment of neurotized corneas confirmed the presence of nerves with normal ultrastructure.

Choroidal Vascular Changes in Arteritic and Nonarteritic Anterior Ischemic Optic Neuropathy

PURPOSE

To compare choroidal vascularity index (CVI) in patients with arteritic anterior ischemic optic neuropathy (A-AION), nonarteritic anterior ischemic optic neuropathy (NA-AION), and control subjects.

DESIGN

Retrospective cross-sectional study.

METHODS

This study was conducted at the Ophthalmology Unit of the S.Orsola-Malpighi University Hospital (Bologna, Italy). Macular and optic nerve head optical coherence tomography (OCT) scans of 20 patients with A-AION secondary to giant cell arteritis (biopsy-proven), 20 patients with NA-AION, and 20 control subjects were acquired with Heidelberg Spectralis (Heidelberg Engineering, Heidelberg, Germany). Images were binarized using ImageJ software, and total choroid area (TCA), luminal area (LA), and stromal area (SA) were segmented. The main outcome measure was CVI, defined as the ratio of LA to TCA.

RESULTS

Patients with A-AION showed a significantly lower macular and peripapillary CVI compared to both patients with NA-AION (respectively, 67.17 ± 2.35 vs 69.66 ± 4.18, P = .048; 63.51 ± 3.29 vs 67.67 ± 3.07, P < .001) and control subjects (respectively, 67.17 ± 2.35 vs 70.00 ± 2.95, P = .021; 63.51 ± 3.29 vs 68.69 ± 3.19, P = .002). Conversely, no significant difference in macular and peripapillary CVI was found between patients with NA-AION and controls (respectively, P = .942 and P = .570). After adjustment for age, the difference of peripapillary CVI among groups remained statistically significant (P < .001), while the difference in macular CVI did not (P = .060).

CONCLUSIONS

Macular and peripapillary CVI are reduced in patients with A-AION. These parameters may be useful to quantitatively evaluate choroidal vascular dysfunction in A-AION, serving as a new additional diagnostic tool to distinguish A-AION from NA-AION.

Corneal biomechanical alterations in patients with chronic ocular Graft Versus-Host Disease

Purpose

To compare corneal biomechanics between patients with ocular graft versus-host disease (oGVHD) and healthy subjects (controls), and to further correlate these values with ocular and hematological characteristics.

Materials and methods

The following procedures were performed in oGVHD patients and controls: Schirmer test (ST), break-up time (BUT), corneal and conjunctival staining, tear matrix metalloproteinase-9 (MMP-9) assay (InflammaDry test, Rapid Pathogen Screening, Inc, Sarasota, FL). Corneal biomechanics were calculated by using ocular response analyzer (ORA, Reichert Instruments, Depew, New York, USA). The Mann-Whitney U test was used to compare continuous variables between oGVHD patients and controls. Correlations of corneal biomechanics with ocular and hematological parameters were examined using Spearman's correlation.

Results

A total of 45 oGVHD patients (mean age ± SD, 51.5 ± 7.1 years) and 34 controls (47.8 ± 6.1 years) were included. Patients with oGVHD showed significantly lower values of corneal hysteresis (CH) and corneal resistance factor (CRF) compared to controls (respectively, 9.4 ± 1.8 mmHg vs 11.6 ± 1.6 and 9.7 ± 1.4 mmHg vs 12.3 ± 1.3; always p<0.001). Twenty-nine of the oGVHD eyes (64.4%) were strong-positive for MMP-9, while 16 (35.6%) were weak-positive. Conversely, only 4 of the control eyes (11.8%) were weak-positive for MMP-9. In patients with oGVHD, CH was significantly correlated with corneal staining (Rs = -0.316, p = 0.035), conjunctival staining (Rs = -0.437, p = 0.003), ST (Rs = 0.390, p = 0.008), BUT (Rs = 0.423, p = 0.004), oGVHD severity grade (Rs = -0.383, p = 0.009), and MMP-9 positivity grade (Rs = -0.429, p = 0.003), while CRF was correlated only with corneal staining (Rs = -0.317, p = 0.034).

Conclusions

Corneal biomechanics are reduced in patients with oGVHD, and CH is negatively correlated with disease severity grade and MMP-9 tear levels.

Intraocular inflammation after Ultrasound Cyclo Plasty for the treatment of glaucoma

This is a prospective interventional clinical study evaluating intraocular inflammation developed after Ultrasound Cyclo Plasty (UCP) for the treatment of glaucoma. Eighteen eyes of 18 patients were treated with UCP second-generation probes (Eye OP1). After treatment, the mean intraocular pressure (IOP) significantly decreased from 26.8±7.2 to 18.8±6.1 mm Hg at day 1 and to 14.7±3.4 mm Hg at month 6 (all P<0.001). Mean laser flare-cell photometry value steeply increased after surgery from 12.1±7.5 to 64.1±53.9 ph/ms (P=0.001) at day 1, and then progressively decreased to respectively 60.6±49.7 at day 7, 43.5±38.5 at day 14 and 28.2±18.3 at month 1 (all P<0.05), returning at levels similar to baseline ones at month 3 and month 6 (respectively 16.7±6.2 and 12.8±10.2, both P>0.05). A significant negative correlation was found between postoperative increase of aqueous flare values and anterior chamber depth (R=-0.568, P=0.014). This timeframe may be considered reasonable for repeating UCP treatment, when required.

Comparison among different diagnostic criteria for chronic ocular graft-versus-host disease applied with and without pre-transplant ophthalmological examination

PURPOSE

To compare the proportion and the agreement rate in the diagnosis of chronic ocular graft-versus-host disease (GVHD) among three criteria applied with and without ophthalmological examination before hematopoietic stem cell transplantation (HSCT).

METHODS

National Institutes of Health (NIH), International Consensus Criteria on ocular GVHD (ICCGVHD) and TFOS Dry Eye Workshop (DEWS) II criteria were used for the diagnosis of ocular GVHD according to two protocols: ophthalmological examination after HSCT (Protocol A), or before and after HSCT (Protocol B). Proportion of GVHD diagnosis and inter-rate agreement coefficient Kappa (K) among the criteria were calculated.

RESULTS

One hundred nine patients undergone HSCT were included. NIH, ICCGVHD and DEWS II criteria diagnosed ocular GVHD in 14.7%, 17.4% and 59.6% of the patients (Protocol A), whereas in 11.9%, 15.6% and 33.0% of the HSCT patients (Protocol B). The coefficient K for the proportion of patients diagnosed with ocular GVHD by NIH and ICCGVHD criteria was K = 0.626 (Protocol A) and K = 0.615 (Protocol B). The K coefficient by NIH and DEWS II criteria was K = 0.144 (Protocol A), and K = 0.233 (Protocol B). The K coefficient by ICCGVHD and DEWS II criteria was K = 0.250 (Protocol A) and K = 0.499 (Protocol B). The K coefficient for ocular GVHD diagnosis applying Protocol A and B was K = 0.881 if NIH criteria were used, K = 0.933 if ICCGVHD criteria were used and K = 0.501 if DEWS II criteria were used.

CONCLUSIONS

The diagnosis of ocular GVHD varied significantly in our cohort of hematological patients according to both the diagnostic criteria used and the visit protocols applied.

The Comparative Efficacy and Tolerability of Diclofenac 0.1% and Bromfenac 0.09% Ophthalmic Solutions after Cataract Surgery

PURPOSE

To compare the efficacy and tolerability of diclofenac and bromfenac ophthalmic solutions as adjunctive therapy after cataract surgery.

MATERIALS AND METHODS

This prospective randomized controlled study included 130 patients who underwent cataract surgery. One hundred patients were randomized to receive postoperatively diclofenac 0.1% (four times daily for 28 days, Group 1) or bromfenac 0.09% (twice daily for 14 days, Group 2) ophthalmic solutions in addition to steroid-antibiotic combination. Thirty patients instilled only steroid-antibiotic combination (Control Group 3). Laser flare-cell photometry and optical coherence tomography scans with central foveal thickness (CFT) measurement were performed before (V0) and 7 (V1), 14 (V2) and 28 days (V3) after surgery. Treatment tolerability was scored using the Ocular Comfort Grading Assessment.

RESULTS

Laser flare-cell photometry values were significantly higher at V1, V2 and V3 compared to V0 in all the groups (respectively 13.3 ± 1.0, 12.7 ± 0.9 and 9.6 ± 0.9 vs 8.4 ± 0.6 ph/ms for Group 1; 13.4 ± 1.0, 12.7 ± 0.9 and 12.7 ± 1.0 vs 8.1 ± 0.6 for Group 2; 15.9 ± 0.8, 15.4 ± 0.7 and 14.5 ± 0.7 vs 7.5 ± 0.5 for Group 3) (p < 0.001); flare increase was significantly lower in Group 1 compared to Groups 2 and 3 (p < 0.001). CFT values were higher after surgery in all the three groups; the increase was significantly lower in Group 1 compared to Groups 2 and 3 (p < 0.0002). The percentage of symptoms-free patients after study treatment was significantly higher in Group 2 compared to Group 1 (respectively 74% vs 14% of the total; p < 0.001).

CONCLUSION

The addition of diclofenac or bromfenac ophthalmic solutions contributed to further reduce both inflammation and cystoid macular edema after cataract surgery compared to steroid-antibiotic combination alone. Diclofenac appeared to be more effective in reducing postoperative intraocular inflammation with a more intense and prolonged regimen, while bromfenac more tolerated with lower daily dose and treatment duration.

Neurotrophic keratitis: current challenges and future prospects

Neurotrophic keratitis (NK) is a degenerative corneal disease caused by damage of trigeminal corneal innervation, which leads to spontaneous epithelial breakdown and corneal ulceration. The impairment of corneal sensory innervation causes the reduction of both protective reflexes and trophic neuromodulators that are essential for the vitality, metabolism, and wound healing of ocular surface tissues. A wide range of ocular and systemic conditions, including herpetic keratitis, ocular chemical burns, corneal surgery, diabetes, multiple sclerosis, and neurosurgical procedures, can cause NK by damaging trigeminal innervation. Diagnosis of NK requires careful investigation of any ocular and systemic condition associated with the disease, complete ocular surface examination, and quantitative measurement of corneal sensitivity. The clinical stages of NK range from corneal epithelial alterations (stage 1) to persistent epithelial defect (stage 2) and ulcer (stage 3), which may progress to corneal perforation. Management of NK is based on clinical severity, and the aim of the therapy is to halt the progression of corneal damage and promote epithelial healing. Although several medical and surgical treatments have been proposed, no therapies are currently available to restore corneal sensitivity, and thus, NK remains difficult and challenging to treat. The purpose of this review is to summarize available evidence on the pathogenesis, diagnosis, and treatment of NK. Novel medical and surgical therapies including the topical administration of nerve growth factor and corneal neurotization are also described.

Comparison of growth factor and interleukin content of adult peripheral blood and cord blood serum eye drops for cornea and ocular surface diseases

INTRODUCTION

Various blood-derived products have been proposed for the topical treatment of ocular surface diseases. The aim of the study was to compare the different content of Growth Factors (GFs) and Interleukins (ILs) in peripheral blood (PB-S) and Cord Blood (CB-S) sera.

MATERIALS AND METHODS

Sera were obtained from 105 healthy adult donors (PB-S) and 107 umbilical/placental veins at the time of delivery (CB-S). The levels of epithelial-GF (EGF), fibroblast-GF (FGF), platelet-derived-GF (PDGF), insulin-GF (IGF), transforming-GF alpha (TGF-α,) and beta 1-2-3 (TGF-β1-β2-β3), vascular endothelial-GF (VEGF), nerve-GF (NGF), Interleukin (IL)-1β,IL-4,IL-6,IL-10, and IL-13 were assessed by Bio-Plex Protein Array System (Bio-Rad Laboratories, CA, USA). The Mann-Whitney test for unpaired data was applied to compare GFs and ILs levels in the two sources. The associations among each GF/IL level and the obstetric data for CB-S and hematological characteristics for PB-S were also investigated.

RESULTS

The levels of EGF, TGF-α, TGF-β2, FGF, PDGF, VEGF, NGF, IL-1B, IL-4, IL-6, IL-10, and IL-13 were significantly higher in CB-S compared to PB-S. Conversely, the levels of IGF-1, IGF-2, and TGF-β1 were significantly higher in PB-S. The female sex and the weight of the child showed a significant association in predicting EGF and PDGF levels.

CONCLUSION

A significantly different content in those GFs and ILs was demonstrated in the two blood sources. Since each GF/IL selectively regulates different cellular processes involved in corneal healing, the use of PB-S or CB-S should be chosen on the basis of the cellular mechanism to be promoted in each clinical case.

In vivo assessment of changes in corneal hysteresis and lamina cribrosa position during acute intraocular pressure elevation in eyes with markedly asymmetrical glaucoma

Purpose

To investigate the biomechanical response of the cornea, lamina cribrosa (LC), and prelaminar tissue (PT) to an acute intraocular pressure (IOP) increase in patients with markedly asymmetrical glaucoma and in healthy controls.

Patients and methods

A total of 24 eyes of 12 patients with markedly asymmetrical primary open-angle glaucoma (POAG) and 12 eyes of 12 healthy patients were examined with spectral-domain optical coherence tomography (SD-OCT) and ocular response analyzer (ORA) at baseline and during acute IOP elevation by means of an ophthalmodynamometer. The displacement of the LC and PT and the change in corneal hysteresis (CH) and corneal resistance factor (CRF) were evaluated.

Results

Following a mean IOP increase of 12.3±2.4 mmHg, eyes with severe glaucoma demonstrated an overall mean anterior displacement of the LC (−6.58±26.09 µm) as opposed to the posterior laminar displacement in eyes with mild glaucoma (29.08±19.28 µm) and in healthy eyes (30.3±10.9; p≤0.001 and p=0.001, respectively). The PT displaced posteriorly during IOP elevation in all eyes. The CH decreased in eyes with severe glaucoma during IOP elevation (from 9.30±3.65 to 6.92±3.04 mmHg; p=0.012), whereas the CRF increased markedly in eyes with mild glaucoma (from 8.61±2.30 to 12.38±3.64; p=0.002) and in eyes with severe glaucoma (from 9.02±1.48 to 15.20±2.06; p=0.002). The increase in CRF correlated with the anterior displacement of the LC in eyes with severe glaucoma.

Conclusion

Eyes with severe glaucoma exhibited a mean overall anterior displacement of the anterior laminar surface, while eyes with mild glaucoma and healthy eyes showed a posterior displacement of the LC during IOP elevation. The CH decreased significantly from baseline only in eyes with severe glaucoma, but the CRF increased significantly in all glaucomatous eyes. The CRF increase correlated with the anterior displacement of the LC in eyes with severe glaucoma.

Predictive role of tear protein expression in the early diagnosis of Sjögren’s syndrome

Background

The contribution of tear protein expression in patients with presumed diagnosis of Sjögren syndrome is underestimated. We aimed to evaluate the role of tear proteins in the Sjögren syndrome early diagnosis.

Methods

Charts from 110 patients suspected of Sjögren syndrome were analysed and the subsequent diagnosis retrieved. Subjective symptoms (ocular surface disease index, OSDI), tear film break-up time (TFBUT), Schirmer test, Jones test, tear clearance (TC), corneal (NEI score) and conjunctival staining (van Bjerstelveldt score), esthesiometry, cytology, tear protein analysis (total protein [TP] content, lysozyme-C [LYS-C], lactoferrin [LACTO], lipocalin-1 [LIPOC-1] and albumin [ALB]) were analysed. The diagnostic performance with area under the curve (AUC) and odds ratio (OR) for each parameter were calculated.

Results

Thirty-five patients (31.8%) had been diagnosed as affected by Sjögren syndrome. Clinical tests showed lower diagnostic performance (OSDI > 44 [AUC 0.57], Schirmer ≤ 5 mm [0.59], TFBUT ≤ 3 s [0.72], TC > 1/16 [0.68], Jones ≤ 4 mm [0.68], corneal staining > 2 [0.51], conjunctival staining > 2 [0.78]) compared with tear proteins (LYS-C ≤ 1.5 mg/mL [0.79], LACTO ≤ 20% [0.94], LIPOC-1 ≤ 10% [0.89], ALB ≥ 15% [0.79]). LYS-C, LACTO, LIPOC-1 and ALB showed a significant association in predicting Sjögren syndrome vs. not-Sjögren syndrome dry eye (OR, respectively, 4.9, 5.5, 7.2, 6.7).

Conclusions

Tear proteins’ concentrations showed a significant higher accuracy compared with the traditional ocular clinical tests for reaching Sjögren syndrome’s diagnosis. In particular, LACTO and LIPOC-1 provided an excellent diagnostic performance and thus could likely be considered promising biomarkers of Sjögren syndrome.

Ultrasound Cyclo Plasty in Eyes with Glaucoma

Glaucoma is a chronic disease caused by the progressive degeneration of the optical nerve fibers, resulting in decreased visual field that can lead to severe visual impairment, and eventually blindness. This manuscript describes a simple, surgeon-friendly, non-incisional technique, named Ultrasound Cyclo Plasty (UCP), for reducing intraocular pressure (IOP) in glaucoma patients. The technique determines a selective coagulation necrosis of the ciliary body; in addition, the stimulation of supra-choroidal and trans-scleral portions of the uveo-scleral outflow pathway has been recently proposed. UCP shows several technical improvements in ultrasound technology compared to previous techniques, providing more precise focusing on the target zone. The procedure is performed in the operating room under peribulbar anesthesia. Briefly, the coupling cone is put in contact with the eye and the ring probe, that contains six piezoelectric transducers which produce the ultrasound beams, is inserted inside it. Their proper centering over the ocular surface represents a crucial step for the correct targeting of the ciliary body. Sterile balanced salt solution is used to fill the empty spaces to ensure ultrasound acoustic propagation. Surgical treatment consists in the sequential automatic activation of each of the six transducers, for a total duration of less than 3 min. The patient leaves the hospital 1 h after the procedure with the treated eye patched. In the present study, 10 patients with open-angle glaucoma were followed-up during at least 12 months after the procedure. IOP was reduced at each interval compared to pre-operative, as well as the number of hypotensive medications. Twenty percent of patients did not respond to the treatment, and needed subsequent surgery to better control IOP. Treatment tolerability was good, with no cases of hypotony or phthisis. The UCP procedure is simpler, faster, safer, and less invasive than traditional cyclodestructive procedures with similar results in reducing IOP.

Visual Recognition Time in Strabismus: Small-Angle versus Large-Angle Deviation

Purpose

To measure the possible differences in monocular detection time of a threshold visual acuity stimulus (recognition time [RT]) between patients with small-angle and large-angle strabismus.

METHODS

Ten patients with free alternating esotropia were tested (10 to 18 years old): five with small-angle esotropia (≤7°), five with large-angle esotropia (15° to 20°). Six age-matched normal subjects served as controls. The RT of the threshold stimulus was measured in both eyes sequentially for stimuli presented in the center of a computer monitor (RT 1). Moreover, we measured the time necessary for identifying the same threshold visual acuity stimulus generated on the computer screen in the moment in which fixation is taken up by one eye after occlusion of the second eye (RT 2). Using the same setting, RT was also measured monocularly in all strabismic and normal subjects who were originally looking at a luminous fixation point positioned horizontally at 6.5 and 15 degrees from the center of the monitor (RT 3).

Results

The multivariate analysis of variance for repeated measures indicated that there was no statistical difference in RT 1 between groups. The mean RT2 was significantly longer (p<0.001) in large-angle strabismic eyes when compared with that of normal control eyes. The mean RT 2 in small-angle strabismic eyes did not differ significantly from that of normal eyes. Finally, RT 3 (both at 6.5° and 15° of eccentricity) did not show any significant difference in the three different study groups.

CONCLUSIONS

The authors hypothesized that alternating strabismus patients may have a significant advantage in maintaining a small-angle deviation, as a large-angle deviation would require longer RT in the moment the deviated eye takes up fixation. It can be speculated that the extension of re-fixation movement, obviously shorter in small-angle strabismus patients, is the main factor responsible for longer RT occurring in large-angle strabismus patients.

Bilateral Parry-Romberg Syndrome Associated with Retinal Vasculitis

PURPOSE

To describe an unusual case of bilateral progressive facial hemiatrophy (Parry-Romberg syndrome (PRS)) associated with retinal vasculitis.

METHODS

In a 37-year-old man with bilateral PRS, retinal vasculitis of the right eye was evident on fundus examination and fluorescein angiography. Right temporalis muscle biopsy and needle electromyography of the masseter muscles were performed. The patient underwent immunosuppressive therapy and retinal laser photocoagulation.

RESULTS

Biopsy specimens showed large fibrosis with focal lymphohistiocytic infiltration of the muscle fibers. Electromyographic findings are consistent with a primary muscle disease. Visual acuity improved from 20/25 to 20/20 in the right eye with a follow-up of one year.

CONCLUSIONS

The evidence of retinal vasculitis and the histologic findings of facial changes observed in this PRS case could support the pathogenetic model of a chronic inflammatory process as a plausible explanation for progressive facial hemiatrophy.

Ocular surface analysis in hematological patients before and after allogeneic hematopoietic stem cell transplantation: implication for daily clinical practice

PurposeTo evaluate ocular surface parameters before and after hematopoietic stem cell transplantation (HSCT) and to correlate them with clinical and transplant variables.MethodsThis is a retrospective analysis of data from 93 patients affected by hematological malignancies undergoing HSCT. Values from Ocular Surface Disease Index, Schirmer test, Break-up Time, ocular surface staining, and Meibomian Gland Dysfunction score obtained before HSCT and 3-6 months after were retrieved from charts. Diagnosis and staging of dry eye (DE) disease was performed according to Dry Eye WorkShop criteria. Graft-versus-host-disease (GVHD) was classified according to the NIH criteria. Odds ratios for DE onset after HSCT were estimated for demographic, ocular, hematological and transplant variables.ResultsDE was diagnosed before HSCT in 50 (53%) of the patients, mostly of hyperevaporative profile. After HSCT, all ocular parameters significantly worsened with no change in DE profile. A 51% incident cases (22 of the 43 non-DE subjects) were reported. Increasing recipient age and female sex, higher CD34+ cells infused, donor-recipient sex mismatch (males receiving from females), related donors, and peripheral blood cells as stem cell source were associated with a significant higher incidence of DE after HSCT. Systemic chronic GVHD was diagnosed in 42% while ocular GVHD in 35.5% of the patients, which decreased to 12% when taking into account only incident cases.ConclusionsHigh DE prevalence was shown already before HSCT. A pre-HSCT ocular surface assessment is recommended for early DE diagnosis and treatment. This new protocol also influences the prevalence of ocular GVHD.

Hydroxychloroquine for treatment of rheumatoid arthritis: multifocal electroretinogram and laser flare-cell photometry study

Purpose

To evaluate early changes in multifocal electroretinogram (mfERG) and subclinical aqueous humor flare and cellularity in patients receiving hydroxychloroquine (HCQ) as treatment for rheumatoid arthritis.

Methods

Ten patients receiving treatment with HCQ and no ophthalmic symptoms were enrolled. After complete ocular examination, mfERG and laser flare-cell photometry were performed. Patients were also divided into two subgroups with HCQ cumulative dose (CD) higher or lower than 500 g. Results obtained were compared with a control group of ten healthy subjects and statistical analysis was performed.

Results

In patients receiving HCQ treatment, mfERG P1-wave in ring 2 showed a significant reduction in amplitude and a significant increase in latency compared to healthy control subjects, respectively resulting in 1.143 μV vs 1.316 μV (P=0.040) and 38.611 ms vs 36.334 ms (P=0.024). These changes are highly related to CD. Furthermore, when using the laser flare-cell photometry, a significant increase in aqueous humor flare and cellularity was shown in patients with CD higher than 500 g, resulting in a mean value of 14.4 ph/ms compared to 8.1 ph/ms in patients with CD lower than 500 g (P=0.0029). These reports appear highly related to CD (P=0.001). Receiver operating characteristic curve analysis showed mfERG P1-wave amplitude in ring 2 as the most sensitive value in detecting early HCQ-related retinopathy.

Conclusion

MfERG was shown to be a very sensitive test in detecting early retinal toxicity and should be used for the screening of patients receiving HCQ treatment. Although less sensitive, laser flare-cell photometry can provide further information to evaluate early toxic retinal cell damage.

A 1-Year Review of Amblyopia and Strabismus Research

PURPOSE

This current review highlights some of the literature published in the past year from April 2013 to May 2014.

DESIGN

Literature Review.

METHODS

The present review is based on an extended search for pertinent articles on amblyopia and strabismus published during the specified period.

RESULTS

Many articles are often not very comparable to one another because of a lack of randomized clinical trials with most of the studies being retrospective in nature. There is often disagreement on some terminology. Typically, the definition of binocular vision is rarely related to the tests used for evaluating it.

CONCLUSIONS

The authors conclude that adult strabismus patients seem to gain benefits from corrective surgery not only for their ocular misalignment, but also for social anxiety levels that may be associated with improvements in their quality of life and disability levels.

Sex-steroid imbalance in females and dry eye

Dry eye (DE) is a multifactorial disorder of the ocular surface unit that results in eye discomfort, visual disturbance and ocular surface damage. It is one of the most common complaints in daily ophthalmic practice. The risk of DE increases with age in both sexes, while its incidence is higher among females. In addition, the condition of menopause in aging women may also contribute to DE onset or worsening as a consequence of an overall hormonal imbalance. Sex hormones play a key role in ocular surface physiology and they impact differently on ocular surface tissues. Reduced estrogen levels were historically thought to be responsible in age-related DE onset but more recent investigations have reconsidered the role of androgens that are present and exert a protective function on the ocular surface. Hormone levels themselves, withdrawal changes in hormone levels, and the changes in hormone-receptor responsiveness are all important factors but it remains to be fully elucidated how estrogen or androgen insufficiency act alone or together in a combined imbalance or interplay to raise the risk of disease. The purpose of this review is to briefly outline current scientific evidence on the influence of androgens and estrogens, on the Lachrymal and Meibomian glands and on ocular surface epithelia including conjunctival goblet cells during reproductive and menopausal periods. The role of sex steroids is also discussed in relation to the pathogenesis of different forms of DE and Sjogren's syndrome (SS). The impact of systemic hormone therapy (HT) in DE post-menopausal women still appears as a controversial issue, despite the many clinical studies. Finally, the outcomes of topical applications of steroid-based products are summarized, underlying the need for potential (tear) biomarker(s) in the rationale of DE-targeted therapy.

ET-1 plasma levels, choroidal thickness and multifocal electroretinogram in retinitis pigmentosa

AIM

To assess the relationship between both photoreceptor function and choroidal thickness and endothelin-1 (ET-1) plasma levels in patients with early stage retinitis pigmentosa (RP).

MAIN METHODS

We compared 24 RP patients (14 males and 10 females), 25 to 42 years of age (mean age: 34±7 years) with 24 healthy controls (12 males and 12 females) aged between 28 and 45 years (mean 36±6.8 years). All patients underwent visual field test, electroretinogram and multifocal-electroretinogram and choroidal thickness measurement by using spectral domain optical coherence tomography.

KEY FINDINGS

RP patients had a visual acuity of 0.95, a mean defect of the visual field of -7.90±1.75 dB, a pattern standard deviation index of 6.09±4.22 dB and a b-wave ERG amplitude of 45.08±8.24 μV. Notably RP subjects showed significantly increased ET-1 plasma levels and reduced choroidal thickness compared with controls: respectively, 2.143±0.258 pg/ml vs. 1.219±0.236 pg/ml; p<0.002 and 226.75±76.37 μm vs. 303.9±39.87 μm; p<0.03. Spearman's correlation test highlighted that the increase of ET-1 plasma levels was related with the decrease of choroidal thickness (r=-0.702; p<0.023) and the increase of implicit time in both ring 2 (r=-0.669; p<0.034) and ring 3 (r=-0.883; p<0.007) of mfERG.

SIGNIFICANCE

Increased ET-1 plasma levels may play a key role in the impairment of retinal and choroidal blood flow due to the vasoconstriction induced by ET-1. This could lead to worsening of the abiotrophic process of the macular photoreceptors.

Subtenon injection of natural leukocyte interferon α-2a in diabetic macular edema: a case report

BACKGROUND

To report the effect of subtenon injections of natural leukocyte interferon α-2a (IFNα) on best corrected visual acuity (BCVA) and central macular thickness (CMT) in a patient with diabetic macular edema (DME).

CASE PRESENTATION

A 66-year-old man affected by DME, with glycated hemoglobin (HbA1c) at 6.9%, refractory to laser grid treatment and intravitreal injections of triamcinolone, was selected to receive a cycle of three subtenon injections/week of IFNα (1×106 IU/ml). BCVA and CMT, using spectral domain ocular coherence tomography (SD-OCT), were evaluated preoperatively and at 1 week, 1 month, 4 months, and 1 year postoperatively. BCVA and CMT were significantly improved at 1 week after the three injections (20/200 vs. 20/40 and 498 μm vs. 237 μm, respectively). BCVA remained stable during the 1-year follow-up. CMT was slightly increased, but was still lower than the baseline value (215 μm, 255 μm, and 299 μm during the follow-up visits). No adverse events were recorded, with the exception of mild subconjunctival hemorrhage at the injection site.

CONCLUSIONS

IFNα, with its immunomodulatory, anti-proliferative and anti-angiogenic actions, was effective in improving BCVA and reducing CMT in refractory DME. Further randomized controlled studies are required to assess the effect of IFNα alone or in combination with other therapies for DME treatment.

TearLab® Osmolarity System for diagnosing dry eye

Dry eye (DE) disease is an impairment of the lachrymal unit function and one the most frequent eye problems. A major challenge is to find accurate diagnostic criteria to be able to define DE severity, as symptoms poorly correlate with clinical signs. Tear osmolarity is considered a key factor in DE onset and perpetuation; its measurement is now possible in clinical setting by an innovative electrical impedance-based lab-on-a-chip technology. This article outlines the features of DE disease and the limitations of current clinical tests. The role of tear osmolarity in DE etiopathogenesis is surveyed, and the pitfalls in measurement are discussed. Diagnostic performance, accuracy and clinical applications of the technology in focus are critically reviewed. The instrument offers the possibility to measure tear osmolarity in a rapid and reliable way in daily practice. As scientific evidence grows, it is expected in the future that it will represent an objective indicator of ocular surface health in the management of DE disease and in clinical trials.

Incidence rates of surgically treated rhegmatogenous retinal detachment among manual workers, non-manual workers and housewives in Tuscany, Italy

Purpose

Candidate risk factors for idiopathic rhegmatogenous retinal detachment (RRD) include heavy manual handling (requiring Valsalva’s maneuver). We assessed incidence rates of surgically treated idiopathic RRD among manual workers, non-manual workers and housewives resident in Tuscany, Italy.

Methods

We retrieved all hospital discharge records bearing a principal diagnosis corresponding to RRD coupled with retinal surgery for any resident of Tuscany during 1997–2009. After elimination of repeated admissions and patients with coexistent, associated conditions (including recent trauma), subjects aged 25–59 years were classified as manual workers, non-manual workers or housewives. Population data were extracted from the 2001 census.

Results

We identified 1,946 eligible cases (1,142 men). Among men, manual workers experienced a 1.8-fold higher age-standardized rate per 100,000 person-years than non-manual workers [17.4 (95 % confidence interval (CI) 16.1–18.7) vs. 9.8 (95 % CI 8.8–10.8)]. Age-standardized rates among women were 1.9-fold higher for manual workers [11.1 (95 % CI 9.8–12.3)] and 1.7-fold higher for housewives [9.5 (95 % CI 8.3–10.8)] than in non-manual workers [5.7 (95 % CI 4.8–6.6)].

Conclusions

This large population-based study suggests that manual workers are affected by idiopathic RRD requiring surgical treatment more often than non-manual workers. The higher rates of surgically treated RRD experienced by manual workers are in accord with the hypothesis that heavy manual handling may have a causal role.

Diagnostic performance of a tear protein panel in early dry eye

PURPOSE

To evaluate the tear protein pattern in patients with recent subjective symptoms of dry eye (DE) and with poor distinctive DE clinical signs.

METHODS

One hundred sixty patients suspected of suffering from mild to moderate DE according to the Dry Eye Workshop (DEWS report 2007) severity grade and 45 matched normal volunteers were included in the study. Subjective symptom score (Ocular Surface Disease index score), Schirmer test I, tear film break-up time, cornea and conjunctiva staining (National Eye Institute score); and tear protein analysis were performed. Statistical evaluation of data was performed with Mann-Whitney unpaired and Student t tests, (significance p<0.05). Correlations between variables were evaluated by using Pearson's (r) or Spearman's (ρ) correlation coefficients. Thresholds were selected from receiver operating curves; sensitivity, specificity, likelihood ratio (LR+), and positive predictive values were calculated for each protein. The combination of variables was carried out by univariate analysis, representing the best combination of tests for early DE diagnosis.

RESULTS

TOTAL PROTEIN CONTENT (TP) AND THE FOLLOWING PROTEINS WERE RECOGNIZED IN ALL SAMPLES: lysozyme-C (LYS-C), lactoferrin (LACTO), tear lipocalin 1 (LIPOC-1), zinc-alpha-2-glycoprotein (ZAG-2), transferrin (TRANSF), and exudated serum albumin (ALB). A statistically significant decrease was demonstrated between normal subjects and patients with DE (mg/ml, mean±SD) for TP (9.89±2.28 versus 6.44±2.1), LYS-C (3.06±1.07 versus 2.15±0.78), LIPOC-1 (1.71±0.52 versus 0.98±0.5), ZAG-2 (0.43±0.24 versus 0.25±0.2), TRANSF (0.9±0.6 versus 0.33±0.3), and LACTO (2.11±0.74 versus 1.47±0.76), while an increase was found for ALB (0.21±0.5 versus 0.94±1.28). LIPOC-1 and ZAG-2 were strongly correlated to tear film break-up time. The proteins were related to the DEWS severity grade. Changes in each protein were a better predictor of early DE than were clinical variables; TP, LIPOC-1, and ALB exhibited the highest diagnostic performance either alone (LR+ 16.7, 12.3, 4.7, respectively) or when combined in a univariate analysis (LR+: 41.8, positive predictive value: 99.9).

CONCLUSIONS

Our results demonstrated in tears from patients with early DE a significant reduction in tear protein content as a whole, associated with a decrease in proteins with antibacterial and protective functions. A decrease in proteins with lipid binding properties and an increase in inflammatory-related proteins were also shown. Changes in the abundance of a panel of tear proteins with divergent functions was found to better diagnose early DE than did conventional clinical tests.

Aqueous flare and choroidal thickness in patients with chronic hepatitis C virus infection: a pilot study

PURPOSE

To investigate the status of the blood-aqueous barrier and to evaluate the subfoveal choroidal thickness (SCT) in patients with asymptomatic untreated chronic hepatitis C virus (HCV) infection without any anterior or posterior ocular involvement and to search for possible correlations.

DESIGN

Observational case-control study.

PARTICIPANTS AND CONTROLS

A total of 80 eyes of 20 HCV-positive patients (male-to-female ratio, 12:8; mean age, 46.9±7.23 years) and 20 healthy controls (male-to-female ratio, 10:10; mean age, 48.2±8.71 years) were examined.

METHODS

Participants underwent a complete ophthalmologic examination. Aqueous flare was quantified objectively by using the noninvasive laser flare cell meter FC-500 (Kowa Company Ltd, Tokyo, Japan), whereas SCT was evaluated by using enhanced depth imaging optical coherence tomography (Spectralis OCT; Heidelberg Engineering GmbH, Heidelberg, Germany). A Wilcoxon rank-sum test was performed to compare ocular findings between HCV patients and controls, and correlations were assessed by using the Spearman rank test.

MAIN OUTCOME MEASURES

Retinal and choroidal thickness and anterior chamber inflammation of HCV patients and healthy controls.

RESULTS

Patients with HCV showed significantly higher aqueous flare values (8.37±2.25 photon counts/ms vs. 4.56±1.45 photon counts/ms; P<0.0001) and a significantly increased SCT (362.7±46.5 μm vs. 320.25±32.82 μm; P<0.0001) than healthy controls. Moreover, subjects with liver fibrosis had higher flare values than those with no significant hepatic fibrosis (9.62±1.99 photon counts/ms vs. 6.97±2.19 photon counts/ms; P = 0.0003) and thicker choroids (379.15±44.75 μm vs. 346.3±43.27 μm; P = 0.024). Statistical analysis revealed that there was a positive correlation between aqueous flare values and SCT in HCV patients (r = 0.69; P<0.0001) and between flare and the degree of liver fibrosis (r = 0.67; P = 0.0001).

CONCLUSIONS

This study showed that impairment of the blood-aqueous barrier and thickened choroids are features of asymptomatic HCV patients, and that choroidal thickness increases as the degree of subclinical inflammation of the anterior chamber increases. Patients with significant liver fibrosis have the highest flare values and the thickest choroids.

Effectiveness of palmitoylethanolamide on endothelial dysfunction in ocular hypertensive patients: a randomized, placebo-controlled cross-over study

PURPOSE

We assessed the effect of palmitoylethanolamide (PEA) on systemic endothelial function in ocular hypertensive patients (OH).

METHODS

We enrolled in this randomized, double-blind, placebo-controlled, crossover single-center study 40 never-treated OH patients and 40 healthy age-matched controls. At baseline, each participant underwent endothelium-dependent flow-mediated vasodilation (FMD) measurement using a noninvasive high-resolution 2-dimensional ultrasonographic imaging of the brachial artery. OH patients were assigned randomly to receive either 300 mg PEA (Group A) or a matching placebo (Group B), twice a day for three months (T1). The first medication period was followed by a two-month washout period (T2), and then patients switched to PEA or placebo (depending on the first drug received) for another three months (T3). FMD evaluations were repeated at T1, T2, and T3.

RESULTS

At baseline FMD values in OH patients and controls were 6.06 ± 0.60% vs. 10.85 ± 1.80%, respectively (P < 0.001). At T1, FMD and IOP of Group A were, respectively, 8.46 ± 1.09% vs. 6.08 ± 0.62% (P < 0.001, r = 0.96) and 22.18 ± 1.26 vs. 23.03 ± 0.88 mm Hg (P < 0.001). At T2, Group A had better FMD values than at baseline (6.59 ± 0.33% vs. 6.08 ± 0.62%, P < 0.05). At T3, subjects in Group B showed better FMD and IOP than at T2 (8.52 ± 1.07% vs. 6.05 ± 0.68%, P < 0.001, r = 0.97; and 22.43 ± 1.17 vs. 23.03 ± 0.83 mm Hg, P < 0.01, respectively). No side effects were observed.

CONCLUSIONS

Three-month PEA intake reduced IOP and led to significantly improved FMD values in OH patients compared to placebo, by ameliorating peripheral endothelial function, and its positive effect lasted longer than the period of PEA consumption. No adverse events were recorded. (Controlled-trials.com number, ISRCTN72647928.).

A rapid standardized quantitative microfluidic system approach for evaluating human tear proteins

PURPOSE

To explore the potential of a chip-based miniaturized capillary gel electrophoresis device in a quantitative evaluation of the human tear protein profile and to validate the method.

METHODS

A total of 5 μl of tears were collected from 25 patients diagnosed as having mild to moderate dry eye according to Dry Eye Workshop guidelines and from 20 matched normal volunteers. Protein analysis was performed with the 2100 Bioanalyzer; different protein kit assays were evaluated (Protein 80 kit, Protein 230 kit, High Sensitivity Protein 250 kit) for sizing and quantifying protein samples from 5 to 80 kDa, 14 to 230 kDa, and 5 to 250 kDa, respectively. A standard protein ladder was loaded on each chip to allow an estimation of the appropriate molecular weight of the separated proteins; a sample buffer containing a lower and an upper marker was used to check the correct alignment of each lane. Virtual bands generated by the Bioanalyzer were identified and validated as follows: tear samples were run in parallel and proteins separated by one-dimensional and two-dimensional sodium dodecyl sulfate-PAGE and characterized by immunoblotting, enzymatic digestion, and analysis with liquid chromatography-mass spectrometry followed by a search of the SProt human protein database.

RESULTS

Analyses were successfully performed by using as small as a 2 μl tear sample. The Protein 230 kit was selected as the best chip kit, able to differentiate all the proteins of interest. The measurement noise parameters were low, and reproducibility and repeatability exhibited high accuracy (0.998 and 0.995, respectively) and precision (0.974 and 0.977, respectively). The coefficient of variability was slightly higher than that declared by the manufacturer (6.2% versus 5.0%). Total protein content and the following proteins were recognized in all samples: lipophilin A lysozyme C, tear lipocalin-1, zinc-alpha-2-glycoprotein, serotransferrin, lactotransferrin, and exudated serum albumin.

CONCLUSIONS

Our data demonstrate that this chip-based tear protein analysis is a reliable method of instrumental diagnosis in daily clinical activity and may provide supporting evaluation parameters for diagnosing and managing tear-based disorders.

Frequency doubling technology, optical coherence technology and pattern electroretinogram in ocular hypertension

BACKGROUND

To assess which of three methods, namely, optical coherence tomography (OCT), pattern electroretinogram (PERG) or frequency-doubling technology (FDT), is the most sensitive and specific for detecting early glaucomatous damage in ocular hypertension (OH).

METHODS

Fifty-two patients with OH (24 men and 28 women, mean age of 56 ± 9.6 years) with an intraocular pressure (IOP) > 21 mm Hg and fifty-two control patients (25 men and 27 women, mean age of 54.8 ± 10.4 years) with IOP < 21 mm Hg, were assessed. All the patients had normal visual acuity, normal optic disk and normal perimetric indices.All subjects underwent OCT, FDT and PERG. Data were analyzed with unpaired t-tests, Chi-square test and Receiver Operating Characteristic (ROC) curve analyses.

RESULTS

In patients with OH, OCT showed retinal nerve fiber layer (RNFL) thinner than in control group in the superior quadrant (130.16 ± 10.02 vs 135.18 ± 9.27 μm, respectively; p < 0.011) and inferior quadrant (120.14 ± 11.0 vs 132.68 ± 8.03 μm; p < 0.001). FDT showed a significantly higher pattern standard deviation (PSD) (3.46  ± 1.48 vs 1.89 ± 0.7 dB; p < 0.001). With respect to PERG, only the amplitude showed significant differences (p < 0.044) between the two groups. ROC curve analysis revealed a sensitivity and specificity of 92% and 86%, respectively, for FDT-PSD (with an area under the ROC curve of 0.940), whereas with OCT, a sensitivity of 82% and a specificity of 74% was recorded in the inferior RNFL quadrant (with an area under the ROC curve of 0.806) finally with PERG amplitude we found a sensitivity of 52% and specificity of 77% (with an area under the ROC curve of 0.595).

CONCLUSIONS

FDT is the most sensitive and specific method for detecting early glaucomatous damage in eyes with OH, and together with OCT, can be useful in identifying those patients who may develop glaucoma.

TRIAL REGISTRATION

ISRCT number: ISRCTN70295497.

Subfoveal choroidal blood flow and central retinal function in early glaucoma

PURPOSE

To assess subfoveal choroidal blood flow (ChBF) in patients with early manifest glaucoma (EMG) and to compare blood flow with functional measures of central retinal integrity, standard automated perimetry (SAP) and pattern electroretinogram (PERG).

METHODS

Subfoveal ChBF was determined by confocal, real-time laser Doppler flowmetry in 24 patients with EMG [>-6 dB mean deviation (MD), age range: 29-77 years, visual acuity: 20/25-20/20] and 23 age-matched control subjects. All patients had a therapeutically (topical beta-blockers with or without prostaglandin analogues) controlled intraocular pressure (IOP < 20 mmHg). Subfoveal choroidal blood volume (ChBVol), velocity (ChBVel) and ChBF were determined as the average of three 60 second recordings. In all patients and controls, the PERG and SAP (Humphrey 30-2), following standardized protocols, were also recorded.

RESULTS

  In patients with EMG, reductions in average ChBVel and ChBF were roughly equal, respectively, by 30% and 33.4% (p < 0.01), when compared to control subjects, so that there was no significant difference in ChBVol between the two groups. Pattern electroretinogram amplitudes were reduced by 46% (p < 0.01) in patients compared to controls. No correlation was found between any of the ChBF parameters and PERG amplitude, or Humphrey 30-2 MD and pattern standard deviation.

CONCLUSION

  The results suggest a significant alteration of both ChBVel and ChBF in EMG, which does not appear to be associated with the severity of central retinal dysfunction. These findings may contribute to a better understanding of the pathophysiology of early glaucomatous damage in EMG and have implications for the treatment of this pathologic condition.

Endothelin-1 plasma levels and vascular endothelial dysfunction in primary open angle glaucoma

AIMS

To assess the relationship between endothelial dysfunction, endothelin 1 (ET-1) plasma levels and subclinical inflammation in primary open angle glaucoma (POAG) patients.

MAIN METHODS

We enrolled 40 POAG patients with progressive visual field damage, although well controlled intraocular pressure (IOP) and compared to age and sex matched healthxy subjects. Each patient underwent an ophthalmological examination, a standard achromatic perimetry (SAP), blood sampling to assess ET-1 plasma levels, an objective assessment of cellularity within the anterior chamber (FLARE) and measurement of flow mediated dilation (FMD) with high resolution 2-dimensional ultrasonographic imaging of the brachial artery.

KEY FINDINGS

At baseline, POAG patients, compared to healthy controls, showed an increase of ET-1 plasma levels: 2.83 ± 0.28 pg/ml vs. 1.75 ± 0.25 pg/ml (p<0.001), lower FMD values 4.46 ± 1.28% vs. 13.18 ± 2.80% (p<0.001) and increased FLARE values 9.98 ± 0.97 photons/ms vs. 5.87 ± 0.64 photons/ms (p<0.001). A follow up after 1 year revealed a further increase of ET-1 plasma levels (to 3.68 ± 0.60; p<0.001) and decrease of FMD (3.52 ± 1.28; p>0.001).

SIGNIFICANCE

The increase of ET-1 in POAG patients is related to vascular dysfunction (r=0.942; p=0.001) and vascular dysfunction is related to sub-clinical intraocular inflammation (r=0.968; p=0.001). Thus ET-1 and vascular dysfunction related to sub-clinical inflammation may play a key role in determining a progressive visual field damage in POAG patients who present a well-controlled IOP.

Secondary IOL Implantation without Capsular Support: A Laser Flare Cell Meter Study

Phacoemulsification and the contemporary implantation of intraocular lens (IOL) within the capsular bag represent the standard of care in cataract surgery, but sometimes a primary IOL implant is not possible due to intraoperative complications or preexisting conditions so that a secondary implantation of IOL within the anterior or posterior chamber is necessary. The aim of our study was to assess the degree of inflammation due to a secondary implant of claw lenses, angle-supported IOLs, and scleral-fixated IOLs by means of an objective, repeatable, and noninvasive device, the laser flare cell meter, which evaluates aqueous flare and cells within the anterior chamber in vivo and to show the contribution of the single IOLs to the genesis of inflammation.

Multifocal electroretinogram and Optical Coherence tomography spectral-domain in arc welding macular injury: a case report

Background

the purpose of this study was to report a binocular photic retinal injury induced by plasma arc welding and the follow-up after treatment with vitamin supplements for a month. In our study, we used different diagnostic tools such as fluorescein angiography (FA), optical coherence tomography (OCT) and multifocal electroretinogram (mfERG).

Case presentation

in the first visit after five days from arc welding injury in the left eye (LE) the visual acuity was 0.9 and 1.0 in the right eye (RE). FA was normal in both eyes. OCT in the left eye showed normal profile and normal reflectivity and one month later, a hyperreflectivity appeared in the external limiting membrane (ELM). The mfERG signal in the LE was 102.30 nV/deg2 five days after the injury and 112.62 nV/deg2 after one month and in the RE respectively 142.70 nV/deg2 and 159.46 nV/deg2.

Conclusions

in cases of retinal photo injury it is important for the ophthalmologist to evaluate tests such as OCT and the mfERG in the diagnosis and follow-up of the patient because the recovery of visual acuity cannot exclude the persistence of phototoxic damage charged to the complex inner-outer segment of photoreceptors.

Hyperosmolar stress upregulates HLA-DR expression in human conjunctival epithelium in dry eye patients and in vitro models

PURPOSE

To investigate the immune response of human conjunctival epithelium to hyperosmolar stress.

METHODS

Tear osmolarity was measured in 15 normal subjects and 25 dry eye (DE) patients; conjunctival imprint cytology samples were obtained at the nasal bulbar area. Subconfluent primary human conjunctival epithelial cells (pHCECs) and human conjunctival organ cultures (hCOCs), both cultured in iso-osmolar medium (305 mOsm/L), were exposed for 24 hours to media with progressively higher osmolarity, with or without the ion channel inhibitor ruthenium red (RuR). Human leukocyte antigen (HLA)-DR expression was evaluated by immunocytochemistry, on imprints from subjects, on primary human conjunctival epithelial cells, on formalin fixed-paraffin embedded hCOCs, and by RT-PCR. Statistical evaluation was performed by applying the unpaired Student's t test, as well as Spearman's rho and Pearson's r correlation coefficients (significance P < 0.05).

RESULTS

HLA-DR expression increased in DE subjects with respect to control (% mean ± SD, respectively, 46.16 ± 7.2 vs. 7.48 ± 1.14, P < 0.0001) and exhibited significantly high correlations with tear osmolarity values (r = 0.614; P < 0.0001). In vitro experiments showed a progressive increase in HLA-DR expression as the osmolarity of the medium was increased from 6.75 ± 1.16 (% mean ± SD) in iso-osmolar-cultured cells to 9.96 ± 1.37 and 12.94 ± 4.04 in cells cultured in, respectively, 350 and 400 mOsm/L (P < 0.05). A stepwise progressive increase was also found in hCOCs. Results were confirmed by RT-PCR. Ruthenium red significantly reduced HLA-DR expression in hyperosmolar-cultured cells.

CONCLUSIONS

Data from complementary techniques demonstrate that extracellular hyperosmolarity induces HLA-DR overexpression in human conjunctival epithelial cells in both DE patients and in vitro cell culture models.

One month use of Systane improves ocular surface parameters in subjects with moderate symptoms of ocular dryness

OBJECTIVE

To evaluate the efficacy of Systane((R)) Lubricating Eye Drops in improving the symptoms of moderate ocular dryness.

METHODS

Fifty subjects with moderate symptoms of ocular dryness were enrolled in this open label study. The mean age of subjects was 57.6 +/- 15.4 years. To be eligible, subjects' tear film break-up time (TFBUT) had to be <10 seconds, and subjects had to have at least one ocular discomfort symptom in addition to dryness. Saline was used for a washout period of 3-5 days. Subjects were re-examined, and those continuing to meet the inclusion criteria were dispensed Systane((R)) and re-examined again after 28 days. At each visit, slitlamp examination was conducted, and ocular discomfort symptoms and TFBUT were evaluated. Subjects rated their overall satisfaction at baseline and on the last visit.

RESULTS

No significant changes in TFBUT or ocular discomfort symptoms were observed after saline use, compared with screening visit. After 28 days of Systane((R)) use there was statistically significant improvement of TFBUT (p = 0.0001) compared with baseline. Subjects experienced significant symptomatic relief for all 6 ocular discomfort symptoms at the endpoint visit.

CONCLUSION

Systane((R)) effectively relieved the symptoms associated with moderate ocular dryness, with measurable improvement in objective TFBUT, subjective symptoms, and overall satisfaction.

Subfoveal choroidal blood flow and central retinal function in retinitis pigmentosa

PURPOSE

To determine whether subfoveal choroidal blood flow is altered in retinitis pigmentosa (RP) and whether this alteration is associated with central cone-mediated dysfunction.

METHODS

In 31 RP patients (age range, 15-72 years) with preserved visual acuity (range: 20/30-20/20), subfoveal choroidal blood flow was measured by real-time, confocal laser Doppler flowmetry, and focal macular (18°) electroretinograms (FERGs) were elicited by 41 Hz flickering stimuli. Twenty normal subjects served as controls. The following average blood flow parameters were determined based on three 60-second recordings: volume (ChBVol), velocity (ChBVel), and flow (ChBF), the last being proportional to blood flow if the hematocrit remains constant. The amplitude and phase of the FERG first harmonic component were measured.

RESULTS

On average, ChBF and ChBVel were reduced by 26% (P ≤ 0.02) in RP patients compared to controls, whereas ChBVol was similar in the two groups. FERG amplitudes were reduced by 60% (P < 0.01) in patients compared with controls. FERG phases of patients tended to be delayed (P < 0.08) compared with their values in the controls. In patients, FERG phase delays were correlated (r = 0.50, P < 0.01) with ChBF and ChBVel values. FERG amplitudes were correlated (r = 0.49, P < 0.01) with ChBVol values.

CONCLUSIONS

These data indicate significant alterations of subfoveal choroidal hemodynamic in RP and suggest a link between the alteration of ChBF and the RP-associated central cone-mediated dysfunction as assessed by the FERG.

Efficacy of two-month treatment with Xiloial eyedrops for discomfort from disposable soft contact lenses

Purpose:

To evaluate the efficacy and tolerability of Xiloial^® monodose eyedrops in the treatment of patients suffering from subjective symptoms of discomfort related to disposable soft contact lens (dSCL) wear.

Methods:

Fifteen (12 female, three male, medium age 39 ± 9 years) dSCL wearers were enrolled. Inclusion criteria were Ocular Surface Disease Index (ODSI) symptom questionnaire score >12, tear film break-up time (TFBUT) <10 sec, Schirmer test I >10 mm over five minutes, mild punctuate keratopathy, and conjunctival staining (Oxford grading ≤4). Monodose Xiloial eyedrops were administered three times daily for a two-month period. Patients were evaluated at enrollment, after three days of washout (baseline), and after one and two months of treatment, by OSDI score, Schirmer test I, TFBUT, ferning test, ocular surface damage (Oxford grade), and serum albumin in tears (index of passive exudation related to serum leakage).

Results:

At endpoint versus baseline, respectively, the mean ± standard deviation of all variables improved as follows: OSDI (8.5 ± 3 versus 20.2 ± 1.6); TFBUT (9.6 ± 1.1 versus 7.1 ± 1.0); Oxford grading (0.5 ± 0.1 versus 3.6 ± 0.8); ferning test (2 ± 1 versus 2.4 ± 0.5); and Schirmer test I (14.6 ± 1.1 versus 12 ± 2.1), with P < 0.05 for all variables (Friedman and Wilcoxon tests). Tolerability was high, with no adverse events noted.

Conclusions:

A two-month treatment with Xiloial showed good tolerance and appeared to reduce ocular surface damage and symptoms of discomfort.

Do bifocals reduce accommodative amplitude in convergence excess esotropia?

BACKGROUND

As therapy with bifocal lenses can generate a condition of acquired hypo-accommodation, we assessed the results of bifocal therapy in children with non-refractive accommodative esotropia in whom near point of accommodation (NPA) was measured before the prescription of the lenses and at the end of the study.

METHODS

We examined 28 consecutive patients orthophoric for far, but with esotropia due to excess convergence for near (group 1), and 28 matched controls, orthophoric for far and near (group 2). The patients were prescribed bifocal lenses between the age of 5 and 8. The NPA was measured at time zero and after 4 years of follow-up in both groups.

RESULTS

NPA values, measured at time 0, were lower than average (10 dioptres) in ten of the 28 patients in group 1, and increased over the 4 years of follow-up without exceeding 10 dioptres. Only one of the other 18 patients in group 1, with normal NPA, had a lower value at the end of the study, although the values were still above 10 dioptres.

CONCLUSIONS

In several patients, excessive convergence is secondary to the extra accommodative effort required due to the presence of a primitive NPA deficit. In these subjects, the prognosis can be made on the basis of NPA measurement, and treatment with bifocal lenses will always be required to compensate. Furthermore, the parents of these small patients should be informed, even before the prescription of bifocals, that prospective surgery of medial rectus muscles will not eliminate the need for bifocals.

ET-1 plasma levels and ocular blood flow in retinitis pigmentosaThis article is one of a selection of papers published in the two-part special issue entitled 20 Years of Endothelin Research

Retinitis pigmentosa (RP) is an inherited retinal disorder clinically characterized by a pale, waxy optic nerve head, attenuated retinal blood vessels, and bone spicule pigment in the retina. Hemodynamic studies have demonstrated that RP is associated with a reduction in the retinal and choroidal blood flow. Retinal hemodynamic impairment is also present in early stages of RP, and various hypotheses have been advanced as to the cause. The authors studied 20 patients, 12 males and 8 females, aged 26–42 years (mean 35.1 years) and affected by simplex RP. The patients had a visual acuity of 0.9 ± 0.1, visual field mean defect of –6.52 ± 3.58 dB, and b-wave electroretinogram amplitude of 260.08 ± 8.24 µV. An increase in plasma levels of endothelin-1 (ET-1) was found: 1.910 ± 0.317 pg/mL versus 1.180 ± 0.210 pg/mL in non-RP controls (p < 0.02). Moreover both an ocular and systemic vascular impairment was detected by means of color Doppler imaging and laser Doppler flowmetry performed during a cold pressor test. We found a correlation between the increase of ET-1 plasma levels in RP and the decrease of peak systolic velocity in the ophthalmic artery (p < 0.03) and in the posterior ciliary arteries (p < 0.006). It is thought that an increase of ET-1 and retinal oxygen levels in RP could lead to vasoconstriction and a decrease of the retinal blood flow, worsening the abiotrophic process.

Electrophysiological detection of delayed postretinal neural conduction in human amblyopia

PURPOSE

To evaluate macular function and neural conduction along postretinal visual pathways in amblyopic patients.

METHODS

Twenty-five anisometropic amblyopic patients (mean age, 7 ± 1.9 years; visual acuity [VA]: 0.44 ± 0.27 logMAR in amblyopic [AM] eyes and 0.023 ± 0.067 logMAR in sound [SE] eyes) and 25 age-similar control subject ([CE] eyes, VA of 0.0 ± 0.0 logMAR in both eyes) were enrolled. In AM, SE, and CE eyes, simultaneous pattern electroretinograms (PERGs) and visual evoked potentials (VEPs) were recorded in response to checks reversed at the rate of two reversals/second stimulating macular or extramacular areas (the check edge subtended 15 minutes and 60 minutes of visual arc, respectively).

RESULTS

Nonsignificant differences (ANOVA, P > 0.005) were observed in PERG, in VEP responses to the 60-minute stimulus, and in retinocortical time with the 60-minute stimulus (RCT; the difference between VEP P100 and PERG P50 implicit times) between AM, SE, and CE eyes. AM eyes showed a significant (P < 0.005) increase in VEP P100 implicit time and in RCT in response to the 15-minute stimulus, compared with the values observed in SE and CE eyes. In AM patients, the interocular difference in VA was significantly (Pearson's test, P < 0.005) related to the interocular difference VEP P100 latencies and RCT with the 15-minute stimulus.

CONCLUSIONS

Amblyopic eyes showed abnormal visual cortical responses only when the macular area was stimulated (increase in VEP P100 implicit times with the 15-minute stimulus). This functional impairment, in the presence of normal macular function (PERG responses similar to control eyes) may be attributable to a delay in postretinal neural conduction (increase in RCT).

Corneoscleral graft in Mooren's ulcer: a case report

INTRODUCTION

Mooren's ulcer is a rare disorder of unknown etiology that is refractory to treatment. It can affect not just the cornea but also the scleral tissue and can involve both eyes.

CASE PRESENTATION

We report a case of a 74-year-old man with a history of bilateral and malignant Mooren's ulcer. The patient had undergone an exenteratio bulbi of the left eye because of the perforation of a Mooren's corneal ulcer. The perforated Mooren's corneal ulcer also presented in the right eye and involved the adjacent scleral tissue. It was decided to perform a corneal-scleral graft to preserve the anatomical integrity of the eye.

CONCLUSION

This report highlights how a corneal-scleral graft followed by systemic and local immunosuppressive treatment should be considered in monocular patients with malignant Mooren's ulcer where there is serious damage to the corneal and scleral tissue.

A novel scraping cytology score system (SCSS) grades inflammation in dry eye patients

PURPOSE

We propose a conjunctival Scraping Cytology Scoring System (SCSS) as a reliable method to diagnose and score ocular surface inflammation in dry eye.

METHODS

Twenty normal subjects and 46 patients with dry eye of various severities were included in the study. Clinical signs were scored 1-4; an Ocular Surface Disease Index (OSDI) questionnaire was used to grade subjective symptoms. Concentrations of serum albumin and interleukin-6 (IL-6) in tears were evaluated. Scraped conjunctival cytology samples were processed and examined with light microscopy. The number of inflammatory cells was staged and sub-scores were assigned. SCSS resulted from their sum and ranged from 0-12. Statistical evaluation was performed by applying the unpaired Student's t-test and the Spearman's correlation test (significance p < 0.05). SCSS was also analyzed for sensitivity, specificity, ROC curves, likelihood ratio LR+, positive (PPV) predictive value.

RESULTS

SCSS was positively correlated to clinical sign score, OSDI score, exudated serum albumin, and IL-6 in either control (Spearman's correlation test always p < 0.05) and in dry eye patients (respectively, p < 0.0001, p < 0.01, p < 0.05, and p < 0.0001). SCSS >or= 4 was selected as the cut-off value for moderate dry eye (LR+ 10,9; PPV 22,5), SCSS >or= 9 was selected as the cut-off value for severe dry eye (LR+ 15,6; PPV 26,2).

CONCLUSIONS

SCSS can be applied in any trained laboratory. It is correlated with clinical signs and symptoms, and it shows a diagnostic performance to grade inflammation in dry eye, comparable to more expensive cytokine assay.

Update on strabismus and amblyopia

This review analyzes progress in the field of infantile strabismus and amblyopia. Only works which are of clinical interest have been reviewed. A brief survey is provided also of subjects matter of international debate, as surgery for accommodative esotropia, the prism adaptation test and the use of sectors for amblyopia treatment. Mention is made of new developments in the field which are not yet applicable to clinical practice. Finally, progress in the approach towards ocular nystagmus is considered as well.

Matrix metalloproteinases and their tissue inhibitors after selective laser trabeculoplasty in pseudoexfoliative secondary glaucoma

BACKGROUND

The aim of this study was to assess changes in metalloproteinases (MMP-2) and tissue inhibitor of metalloproteinases (TIMP-2) following selective laser trabeculoplasty (SLT) in patients with pseudoexfoliative glaucoma (PEXG).

METHODS

We enrolled 15 patients with PEXG and cataracts (PEXG-C group) and good intraocular pressure (IOP) controlled with beta-blockers and dorzolamide eye drops who were treated by cataract phacoemulsification and 15 patients with pseudoexfoliative glaucoma (PEXG-SLT group). The PEXG-SLT patients underwent a trabeculectomy for uncontrolled IOP in the eye that showed increased IOP despite the maximum drug treatment with beta-blockers and dorzolamide eye drops and after ineffective selective laser trabeculoplasty (SLT). The control group consisted of 15 subjects with cataracts. Aqueous humor was aspirated during surgery from patients with PEXG-C, PEXG-SLT and from matched control patients with cataracts during cataract surgery or trabeculectomy. The concentrations of MMP-2 and TIMP-2 in the aqueous humor were assessed with commercially available ELISA kits.

RESULTS

In PEXG-SLT group in the first 10 days after SLT treatment a significant reduction in IOP was observed: 25.8 +/- 1.9 vs 18.1.0 +/- 1.4 mm/Hg (p < 0.001), but after a mean time of 31.5 +/- 7.6 days IOP increased and returned to pretreatment levels: 25.4 +/- 1.6 mm/Hg (p < 0.591). Therefore a trabeculectomy was considered necessary.The MMP-2 in PEXG-C was 57.77 +/- 9.25 microg/ml and in PEXG-SLT was 58.52 +/- 9.66 microg/ml (p < 0.066). TIMP-2 was 105.19 +/- 28.53 microg/ml in PEXG-C and 105.96 +/- 27.65 microg/ml in PEXG-SLT (p < 0.202). The MMP-2/TIMP-2 ratio in the normal subjects was 1.11 +/- 0.44. This ratio increase to 1.88 +/- 0.65 in PEXG-C (p < 0.001) and to 1.87 +/- 0.64 in PEXG-SLT (p < 0.001). There was no statistically significant difference between the PEXG-C and PEXG-SLT ratios (p < 0.671).

CONCLUSION

This case series suggest that IOP elevation after SLT can be a serious adverse event in some PEXG patients. The IOP increase in these cases would be correlated to the failure to decrease the TIMP-2/MMP-2 ratio.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN79745214.

Why do the eyes cross? A review and discussion of the nature and origin of essential infantile esotropia, microstrabismus, accommodative esotropia, and acute comitant esotropia

PURPOSE

To try to explain the long-term stability of bilateral medial rectus botulinum toxin (botox) chemo-denervation in essential infantile esotropia; to evaluate divergent fusion amplitude in accommodative esotropia and acute comitant esotropia of emmetropes; to look for accommodation anomalies in high AC/A ratio accommodative esotropia and acute comitant esotropia of myopes; and to discuss characteristics of microstrabismus.

METHODS

Retrospective analysis of 61 essential infantile esotropia patients with early treatment with one botox injection in both medial rectus; measurement of divergent fusion amplitude in accommodative esotropia and acute comitant esotropia; measurement of Near point of accommodation in high AC/A ratio accommodative esotropia and acute comitant esotropia of myopes.

RESULTS

Stable results were found in 85.24% of essential infantile esotropia treated patients; reduced divergent fusion amplitude was detected in accommodative esotropia and acute comitant esotropia; hypo-accommodation was found in some patients with high AC/A ratio accommodative esotropia and a convergence spasm in acute comitant esotropia of myopes.

CONCLUSIONS

Very early botox treatment probably eradicates the effect of an excessive convergence tonus in essential infantile esotropia. A prevention of accommodative esotropia with full retinoscopic correction is only mandatory with a significantly reduced amplitude of fusional divergence. A deficit in accommodation should be looked for in high AC/A ratio accommodative esotropia, before bifocal lenses prescription. Early diagnosed acute comitant esotropia of myopic patients can be treated as a convergence spasm. Only surgery treats acute comitant esotropia, in patients with emmetropia or moderate hypermetropia.

Intravitreal vs. subtenon triamcinolone acetonide for the treatment of diabetic cystoid macular edema

Background

To assess the efficacy of the intravitreal (IVT) injection of Triamcinolone Acetonide (TA) as compared to posterior subtenon (SBT) capsule injection for the treatment of cystoid diabetic macular edema.

Methods

Fourteen patients with type II diabetes mellitus and on insulin treatment, presenting diffuse cystoid macular edema were recruited. Before TA injection all focal lakes were treated by laser photocoagulation. In the same patients one eye was assigned to 4 mg IVT injection of TA and the fellow eye was then treated with 40 mg SBT injection of TA. Before and one, three and six months after treatment we measured visual acuity with ETDRS chart as well as thickness of the macula with optical coherence tomography (OCT) and intraocular pressure (IOP).

Results

The eyes treated with an IVT injection displayed significant improvement in visual acuity, both after one (0.491 ± 0.070; p < 0.001) and three months (0.500 ± 0.089; p < 0.001) of treatment. Significant improvement was displayed also in eyes treated with an SBT injection, again after one (0.455 ± 0.069; p < 0.001) and three months (0.427 ± 0.065; p < 0.001). The difference between an IVT injection (0.809 ± 0.083) and SBT injection (0.460 ± 0.072) becomes significant six months after the treatment (p < 0.001).

Macular thickness of the eyes treated with IVT injection was significantly reduced both after one (222.7 ± 13.4 μm; p < 0.001) and after three months (228.1 ± 10.6 μm; p < 0.001) of treatment. The eyes treated with SBT injection displayed significant improvement after one (220.1 ± 15.1 μm; p < 0.001) and after three months (231.3 ± 10.9 μm; p < 0.001). The difference between the eyes treated with IVT injection (385.2 ± 11.3 μm) and those treated with SBT injection (235.4 ± 8.7 μm) becomes significant six months after the treatment (p < 0.001).

Intraocular pressure of the eyes treated with IVT injection significantly increased after one month (17.7 ± 1.1 mm/Hg; p < 0.020), three (18.2 ± 1.2 mm/Hg; p < 0.003) and six month (18.1 ± 1.3 mm/Hg; p < 0.007) when compared to baseline value (16.1 ± 1.402 mm/Hg). In the SBT injection eyes we didn't display a significant increase of intraocular pressure after one (16.4 ± 1.2 mm/Hg; p < 0.450), three (16.3 ± 1.1 mm/Hg; p < 0.630) and six months (16.2 ± 1.1 mm/Hg; p < 0.720) when compared to baseline value (16.2 ± 1.3 mm/Hg).

Conclusion

The parabulbar subtenon approach can be considered a valid alternative to the intravitreal injection.

Trial registration

Current Controlled Trials ISRCTN67086909