Prospective Randomized Clinical Trial Evaluating Efficacy and Safety of A New Ophthalmic Viscosurgical Device In Patients Undergoing Cataract Surgery

PURPOSE

To evaluate the efficacy and safety of Bio-Hyalur LVD compared to Viscoat® ophthalmic viscosurgical device (OVD) in patients undergoing routine cataract surgery.

SETTING

Two tertiary eye care hospitals in Italy.

DESIGN

Prospective randomized clinical trial.

METHODS

This study compared the outcomes of Bio-Hyalur LVD versus Viscoat® ophthalmic viscosurgical device in patients undergoing standard cataract surgery with phacoemulsification and intraocular lens implantation from January 2021 to April 2022. The primary outcome was mean change in IOP at 6 hours. Secondary outcomes included 1-, 7-, 30- and 90-day mean intraocular pressure (IOP), 7-, 30- and 90-day best corrected visual acuity, endothelial cell density (ECD), change in central corneal thickness (CCT) and complications including intraocular inflammation.

RESULTS

A total of 84 eyes of 84 patients (n = 41 in the Bio-Hyalur LVD group and n = 43 in the Viscoat group) were screened, enrolled, randomized, and included in the analysis. Mean change in IOP was significantly higher in the Viscoat group than in the Bio-Hyalur LVD group 6 hours (p = 0.034), 7 days (p < 0.001), 30 days (p < 0.001) and 90 days (p = 0.003) postoperatively. Mean change in UDVA and CDVA was significantly higher in the Bio-Hyalur LVD group 30 and 90 after surgery. No significant differences in ECD, CCT and complication rates were observed between groups at any time point.

CONCLUSION

Bio-Hyalur LVD OVD is safe and effective for use in patients undergoing routine cataract surgery. Bio-Hyalur LVD OVD did not confer a higher risk of postoperative increase in IOP.

Clinical, Genotypic, and Imaging Characterization of the Spectrum of ABCA4 Retinopathies

PURPOSE

To investigate the clinical and genotypic differences in the spectrum of ABCA4-associated retinopathies (ABCA4Rs).

DESIGN

Observational, cross sectional case series.

PARTICIPANTS

Sixty-six patients (132 eyes) carrying biallelic ABCA4 variants.

METHODS

Patients underwent visual acuity measurement and multimodal imaging. Clinical records were reviewed for age at onset, presenting symptoms, genetic variants, and electroretinogram (ERG). Each eye was assigned to a phenotype based on age at onset, imaging and ERG: cone dystrophy-bull's-eye maculopathy (CD-BEM, 40 eyes), cone-rod dystrophy (CRD, 12 eyes), Stargardt disease (SD, 28 eyes), late-onset SD (LO-SD, 38 eyes), and fundus flavimaculatus (14 eyes). Images were analyzed for: peripapillary sparing, retinal pigment epithelium (RPE) atrophy (definitely decreased autofluorescence, DDAF), flecks patterns using autofluorescence; type of atrophy according to Classification of Atrophy Meeting reports, macular and choroidal thickness on OCT; and choriocapillaris flow deficits on OCT angiography.

MAIN OUTCOME MEASURES

Primary outcome was to report the demographic, genotypic, and imaging characteristics of the different ABCA4R phenotypes. Secondary objectives included the assessment of imaging biomarkers as outcome measures for clinical trials.

RESULTS

Age at onset was lower in CRD (12 ± 8 years) and higher in patients with LO-SD (59 ± 9 years) (all P < 0.01). Central vision loss was a common presenting symptom in CD-BEM and SD, whereas patients with LO-SD primarily complained of difficult dark adaptation. Missense variants were more frequent in CD-BEM, and splice site in CRD and LO-SD (P < 0.05). Peripapillary sparing was absent in 3 eyes with LO-SD (8%). Cone dystrophy-bull's-eye maculopathy eyes typically had complete outer retinal atrophy alterations (98%), whereas CRD and SD eyes showed both complete outer retinal atrophy and complete RPE and outer retinal atrophy (cRORA) (71%-100%). Patients with LO-SD had larger areas of DDAF (100% cRORA) and of choriocapillaris flow deficits (all P < 0.01). Repeatability of DDAF measurements was low for some phenotypes (CD-BEM and CRD) and atrophic areas <7.5 mm2. Resorbed flecks were significantly associated with CRD and LO-SD (P < 0.01).

CONCLUSIONS

This research provides a thorough evaluation of the spectrum of ABCA4R. Our findings suggest that certain phenotypes show preferential photoreceptor degeneration (e.g., CD-BEM), whereas others have substantial RPE and choriocapillaris alterations (e.g., LO-SD). We recommend that clinical trial end points take into consideration these imaging features to improve the interpretation of their results.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Tissue informative cell-free DNA methylation sites in amyotrophic lateral sclerosis

Cell-free DNA (cfDNA) is increasingly recognized as a promising biomarker candidate for disease monitoring. However, its utility in neurodegenerative diseases, like amyotrophic lateral sclerosis (ALS), remains underexplored. Existing biomarker discovery approaches are tailored to a specific disease context or are too expensive to be clinically practical. Here, we address these challenges through a new approach combining advances in molecular and computational technologies. First, we develop statistical tools to select tissue-informative DNA methylation sites relevant to a disease process of interest. We then employ a capture protocol to select these sites and perform targeted methylation sequencing. Multi-modal information about the DNA methylation patterns are then utilized in machine learning algorithms trained to predict disease status and disease progression. We applied our method to two independent cohorts of ALS patients and controls (n=192). Overall, we found that the targeted sites accurately predicted ALS status and replicated between cohorts. Additionally, we identified epigenetic features associated with ALS phenotypes, including disease severity. These findings highlight the potential of cfDNA as a non-invasive biomarker for ALS.

Optimising subjective grading of corneal staining in Sjögren's syndrome dry eye disease

AIM

To assess whether smaller increment and regionalised subjective grading improves the repeatability of corneal fluorescein staining assessment, and to determine the neurological approach adopted for subjective grading by practitioners.

METHODS

Experienced eye-care practitioners (n = 28, aged 45 ± 12 years), graded 20 full corneal staining images of patients with mild to severe Sjögren's syndrome with the Oxford grading scheme (both in 0.5 and 1.0 increments, globally and in 5 regions), expanded National Eye Institute (NEI) and SICCA Ocular Staining Score (OSS) grading scales in randomised order. This was repeated after 7-10 days. The digital images were also analysed objectively to determine staining dots, area, intensity and location (using ImageJ) for comparison.

RESULTS

The Oxford grading scheme was similar with whole and half unit grading (2.77vs2.81,p = 0.145), but the variability was reduced (0.14vs0.12,p < 0.001). Regional grade was lower (p < 0.001) and more variable (p < 0.001) than global image grading (1.86 ± 0.44 for whole increment grading and 1.90 ± 0.39 for half unit increments). The correlation with global grading was high for both whole (r = 0.928,p < 0.001) and half increment (r = 0.934,p < 0.001) grading. Average grading across participants was associated with particle number and vertical position, with 74.4-80.4% of the linear variance accounted for by the digital image analysis.

CONCLUSIONS

Using half unit increments with the Oxford grading scheme improve its sensitivity and repeatability in recording corneal staining. Regional grading doesn't give a comparable score and increased variability. The key neurally extracted features in assigning a subjective staining grade by clinicians were identified as the number of discrete staining locations (particles) and how close to the vertical centre was their spread, across all three scales.

Resolution of epiretinal membrane after anti-VEGF and photodynamic therapy of retinal hemangioblastoma

Purpose

To describe the clinical and multimodal imaging features in a case of resolution of pre-macular fibrosis after photodynamic therapy (PDT) of retinal hemangioblastoma (RH) not related to von-Hippel-Lindau (VHL).

Observations

A 25-year-old man presenting with blurred vision and central metamorphopsia in his left eye (LE) due to macular epiretinal membrane secondary to a peripheral RH. The patient had a comprehensive ophthalmic examination, including best corrected visual acuity (BCVA), wide-field fundus photography and autofluorescence (FAF), wide-field optical coherence tomography (OCT) and OCT angiography (OCTA), fluorescein angiography (FA) and indocyanine green angiography (ICGA) and ocular ultrasound. Baseline BCVA was 20/200 in his LE, and it improved to 20/40 nineteen months after anti-VEGF and photodynamic therapy were performed. The treatment led to a progressive shrinkage of the tumor and associated intraretinal exudation, and to a progressive resolution of the epiretinal membrane.

Conclusions and importance

Treatments performed on the peripheral retina may result in changes at the level of the vitreo-retinal interface in the macular region. In our patient, after an intravitreal anti-VEGF associated with PDT, a posterior vitreous detachment (PVD) was induced resulting in auto-peeling of the macular epiretinal membrane secondary to a peripheral RH. An accurate assessment of the macular area by OCT is highly recommended in the first days following treatments.

Outcomes of large-diameter deep anterior lamellar keratoplasty and converted two-piece mushroom penetrating keratoplasty for herpetic corneal scars

PURPOSE

To report the clinical outcomes of large diameter deep anterior lamellar keratoplasty (DALK) and converted two-piece microkeratome-assisted mushroom keratoplasty (MK) for herpetic corneal scars.

METHODS

In this single-centre study, large diameter (9 mm) DALK was attempted in consecutive patients with herpetic corneal scars. In case of macroperforation or unsatisfactory clearance of the optical zone, the procedure was intraoperatively converted to two-piece microkeratome-assisted MK. Outcome measures were best spectacle-corrected visual acuity (BSCVA), refractive astigmatism, endothelial cell density (ECD), immunologic rejection, herpetic recurrence and graft failure rates in the two groups.

RESULTS

DALK was successfully performed in 98 of 120 eyes, while the remaining 22 eyes required intraoperative conversion to MK. At 5 years, mean logMAR BSCVA was 0.10 ± 0.12 in the DALK group and 0.09 ± 0.15 in the MK group (P = 0.75). Refractive astigmatism at 5 years was 2.8 ± 1.4 D in the DALK group and 3.0 ± 1.7 D in the MK group (P = 0.67). ECD was higher in the DALK group than in the MK group at all time points (P < 0.001), with a mean annual cell loss of 10.9% after MK and 4.2% after DALK. The 5-year risk for immunologic rejection (DALK: 3%, MK: 5%, P = 0.38), herpetic recurrence (DALK: 6%, MK: 9%, P = 0.38), and graft failure (DALK: 4%, MK: 5%, P = 0.75) were comparable in both groups.

CONCLUSION

Large diameter (9 mm) DALK yields excellent visual and clinical outcomes in eyes with herpetic corneal scars. In case of intraoperative complications, DALK can be converted to two-piece microkeratome-assisted MK to maximize the refractive benefit of a large diameter graft while minimizing the risk of endothelial failure.

Noninvasive screening of ocular surface disease in otherwise healthy patients scheduled for cataract surgery

PURPOSE

To evaluate prevalence and characteristics of pathological ocular surface findings in healthy patients undergoing cataract surgery using a noninvasive ocular surface workup and a validated questionnaire.

DESIGN

Prospective single-centre study (sub-analysis clinical trial no. NCT05754437).

METHODS

Healthy patients undergoing senile cataract surgery were screened preoperatively by Oculus Keratograph (K5 M; Oculus GmbH, Wetzlar, Germany) for the evaluation of tear meniscus height (TMH), non-invasive keratograph break-up time (NIKBUT), and meibomian gland dropout. Ocular discomfort symptoms were scored by ocular surface disease index (OSDI) questionnaire.

RESULTS

120 eyes of 120 patients (62 females, 58 males; mean age 73.85 years, range 47-91 years) were included. All patients had at least 1 abnormal finding, while 19 (15.8%; 95% CI [0.09-0.22]) had alterations of all parameters. In detail, 39 patients (32.5%; 95% CI [0.24-0.41]) had pathological TMH (mean 0,15 mm [0.03 SD]), 102 (85%; 95% CI [0.79-0.91]) had pathological NIKBUT (mean 3.64 s [2.63 SD]), 117 (97.5%; 95% CI [0.95-1]) had some degree of gland dropout (mean 1.62 [0.70 SD]), 78 patients (65%; 95% CI [0.56-0.74]) had pathological OSDI scores (mean 28.63 [15.08 SD]). Using TFOS DEWS II criteria, 66 patients (55%; 95% CI [0.42-0.60]) resulted affected by dry eye.

CONCLUSIONS

This quick noninvasive screening documented the high prevalence of pathological ocular surface parameters in patients without risk factors or previous diagnosis of dry eye who are scheduled for cataract surgery.

Deep Anterior Lamellar Keratoplasty Using Dehydrated versus Standard Organ Culture-Stored Donor Corneas: Prospective Randomized Trial

PURPOSE

To compare the outcomes of deep anterior lamellar keratoplasty (DALK) using dehydrated versus standard organ culture-stored donor corneas for eyes with keratoconus.

DESIGN

Prospective, randomized, single-center trial conducted in Italy.

PARTICIPANTS

Adult patients (age ≥ 18 years) with keratoconus scheduled for elective DALK.

METHODS

Patients undergoing successful type 1 bubble pneumatic dissection using a standard DALK technique were randomized during surgery to receive either dehydrated (n = 30) or standard organ culture-stored (n = 30) donor corneas.

MAIN OUTCOME MEASURES

The primary study outcome was best spectacle-corrected visual acuity (BSCVA) 12 months after surgery. Secondary outcomes were refractive astigmatism (RA), endothelial cell density (ECD), and complication rates.

RESULTS

Postoperative BSCVA did not significantly differ between groups at both time points: mean difference at 6 months was 0.030 logarithm of the minimum angle of resolution (logMAR; 95% confidence interval [CI], -0.53 to 0.10 logMAR; P = 0.471) and at 12 months was -0.013 logMAR (95% CI, -0.10 to 0.08 logMAR; P = 0.764). No significant differences between groups were observed in terms of postoperative RA and ECD at all time points. In the first 3 days after DALK, an epithelial defect was present in 10 patients (33%) in the organ culture cornea group and in 29 patients (97%) in the dehydrated cornea group. Complete re-epithelialization was achieved by day 7 in all patients (100%) in both groups.

CONCLUSIONS

The study provides evidence that the use of dehydrated corneas is noninferior to the use of standard organ culture donor corneas for DALK. Corneal tissue dehydration represents a viable solution that can allow long-term cornea preservation and avoid wastage of unused corneas.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Incidence, associated disease burden and healthcare utilization due to Staphylococcus aureus prosthetic joint infection in European hospitals: the COMBACTE-NET ARTHR-IS multi-centre study

BACKGROUND

The aim of this study was to estimate the incidence, associated disease burden and healthcare utilization due to Staphylococcus aureus prosthetic joint infections (SA-PJI) after primary hip and knee arthroplasty in European centres.

METHODS

This study was conducted in patients who underwent primary hip and knee arthroplasty in 19 European hospitals between 2014 and 2016. The global incidence of PJI and SA-PJI was calculated. The associated disease burden was measured indirectly as infection-related mortality plus loss of function. For healthcare utilization, number and duration of hospitalizations, number and type of surgical procedures, duration of antibiotic treatments, and number of outpatient visits were collected. Subgroup and regression analyses were used to evaluate the impact of SA-PJI on healthcare utilization, controlling for confounding variables.

RESULTS

The incidence of PJI caused by any micro-organism was 1.41%, and 0.40% for SA-PJI. Among SA-PJI, 20.7% were due to MRSA with substantial regional differences, and were more frequent in partial hip arthroplasty (PHA). Related deaths and loss of function occurred in 7.0% and 10.2% of SA-PJI cases, respectively, and were higher in patients with PHA. Compared with patients without PJI, patients with SA-PJI had a mean of 1.4 more readmissions, 25.1 more days of hospitalization, underwent 1.8 more surgical procedures, and had 5.4 more outpatient visits, controlling for confounding variables. Healthcare utilization was higher in patients who failed surgical treatment of SA-PJI.

CONCLUSIONS

This study confirmed that the SA-PJI burden is high, especially in PHA, and provided a solid basis for planning interventions to prevent SA-PJI.

Unveiling the Hidden: Early Manifestations of Extensive Macular Atrophy with Pseudodrusen-like appearance

PURPOSE

To describe novel microperimetry and imaging findings in two patients affected by extensive macular atrophy with pseudodrusen-like appearance (EMAP) without signs of retinal pigment epithelium (RPE) atrophy.

METHODS

Case series. Both patients underwent mesopic and dark-adapted two-color scotopic microperimetry, followed by multimodal imaging assessment including ultra-widefield photography, fundus autofluorescence (AF), high-resolution optical coherence tomography (Hi-Res OCT), OCT angiography and high-magnification module (HMM).

RESULTS

Albeit normal visual acuity, both patients had a significant reduction of retinal sensitivity - especially under scotopic cyan conditions. One patient had macular pigment abnormalities, while the combination of blue and near-infrared AF modalities highlighted different patterns of pseudodrusen-like lesions.Of notice, Hi-Res OCT revealed a marked separation between the RPE and Bruch's membrane, containing a hyperreflective material with two different reflectivities. OCT angiography excluded the presence of macular neovascularization and documented several choriocapillaris flow voids. HMM images showed severe alteration of photoreceptors' mosaic in the perifovea.

CONCLUSIONS

Our comprehensive assessment of two stage 1 EMAP patients revealed a predominant damage of perifoveal rods over areas of RPE-Bruch's membrane separation. These findings underscore the importance of basal laminar deposits in the initial stages of EMAP, contributing to a deeper understanding of its underlying mechanisms.

Outcomes of low-level light therapy before and after cataract surgery for the prophylaxis of postoperative dry eye: a prospective randomised double-masked controlled clinical trial

BACKGROUND

Despite increasing evidence shows that optimising ocular surface before cataract surgery is fundamental in patients with pre-existing dry eye disease (DED) to achieve the desired postoperative outcomes, the prophylactic treatment of healthy patients undergoing surgery aiming at preventing iatrogenic DED is worth investigating.

METHODS

This was a prospective, interventional, randomised, controlled, double-masked clinical trial. Patients were randomly assigned 1:1 to receive either low-level light therapy (LLLT) or sham treatment (LLLT with a power output <30%). Patients underwent two treatment sessions: 7±2 days before cataract surgery (T0) and 7±2 days after (T1). Outcome measures evaluated 30±4 days after surgery (T2) included Ocular Surface Disease Index (OSDI) questionnaire, non-invasive break-up time (NIBUT), tear meniscus height, meibomian gland loss (MGL) and redness score.

RESULTS

Out of 153 patients randomised to receive LLLT (n=73) or sham treatment (n=80), 131 (70 men, 61 women, mean age 73.53±7.29 years) completed regularly the study. Patients treated with LLLT had significantly lower OSDI scores compared with controls at T1 and T2 (respectively, 7.2±8.8 vs 14.8±13.0 and 9.0±9.0 vs 18.2±17.9; both p<0.001), higher NIBUT values at T2 (12.5±6.6 vs 9.0±7.8; p=0.007) and lower MGL Meiboscore values at T1 (1.59±0.70 vs 1.26±0.69; p=0.008). Unlike controls, patients treated with LLLT had significantly lower OSDI scores and higher NIBUT values at T2 compared with T0 (respectively, 9.0±9.0 vs 21.2±16.1; p<0.001 and 12.5±6.6 vs 9.7±7.2; p=0.007).

CONCLUSION

Two sessions of LLLT performed before and after cataract surgery were effective in ameliorating tear film stability and ocular discomfort symptoms.

TRIAL REGISTRATION NUMBER

NCT05754437.

Risk of retinal vein occlusion following COVID-19 vaccination: a self-controlled case series

BACKGROUND

To evaluate the association between COVID-19 vaccination and retinal vein occlusion (RVO).

METHODS

This multicentre self-controlled case series included patients with RVO seen in five tertiary referral centres in Italy. All adults who received at least one dose of the BNT162b2, ChAdOx1 nCoV-19, mRNA-1273 or Ad26.COV2.S vaccine and had a first diagnosis of RVO between January 01, 2021, and December 31, 2021 were included. Incidence rate ratios (IRRs) of RVO were estimated using Poisson regression, comparing rates of events in a 28-day period following each dose of vaccination and in the unexposed control periods.

RESULTS

210 patients were included in the study. No increased risk of RVO was observed after the first dose (1-14 days IRR: 0.87, 95% CI: 0.41-1.85; 15-28 days IRR: 1.01, 95% CI: 0.50-2.04; 1-28 days IRR: 0.94, 95% CI: 0.55-1.58) and second dose of vaccination (1-14 days IRR: 1.21, 95% CI: 0.62-2.37; 15-28 days IRR: 1.08, 95% CI: 0.53-2.20; 1-28 days IRR: 1.16, 95% CI: 0.70-1.90). No association between RVO and vaccination was found in subgroup analyses by type of vaccine, gender and age.

CONCLUSIONS

This self-controlled case series found no evidence of an association between RVO and COVID-19 vaccination.

The State of Intraoperative OCT in Vitreoretinal Surgery: Recent Advances and Future Challenges

Since its first introduction more than 30 years ago, optical coherence tomography (OCT) has revolutionized ophthalmology practice, providing a non-invasive in vivo cross-sectional view of the structures of the eye. Mostly employed in the clinical setting due to its tabletop configuration requiring an upright patient positioning, the recent advent of microscope-integrated systems now allows ophthalmologists to perform real-time intraoperative OCT (iOCT) during vitreoretinal surgical procedures. Numerous studies described various applications of this tool, such as offering surgeons feedback on tissue-instrument interactions in membrane peeling, providing structural images in macular hole repair, and showing residual subretinal fluid or perfluorocarbon in retinal detachment surgery. This narrative review aims at describing the state of the art of iOCT in vitreoretinal procedures, highlighting its modern role and applications in posterior segment surgery, its current limitations, and the future perspectives that may improve the widespread adoption of this technology.

Universal DNA methylation age across mammalian tissues

Aging, often considered a result of random cellular damage, can be accurately estimated using DNA methylation profiles, the foundation of pan-tissue epigenetic clocks. Here, we demonstrate the development of universal pan-mammalian clocks, using 11,754 methylation arrays from our Mammalian Methylation Consortium, which encompass 59 tissue types across 185 mammalian species. These predictive models estimate mammalian tissue age with high accuracy (r > 0.96). Age deviations correlate with human mortality risk, mouse somatotropic axis mutations and caloric restriction. We identified specific cytosines with methylation levels that change with age across numerous species. These sites, highly enriched in polycomb repressive complex 2-binding locations, are near genes implicated in mammalian development, cancer, obesity and longevity. Our findings offer new evidence suggesting that aging is evolutionarily conserved and intertwined with developmental processes across all mammals.

STELLATE MULTIFORM AMELANOTIC CHOROIDOPATHY: Clinical and Multimodal Imaging Features

PURPOSE

To describe the clinical and multimodal imaging features of stellate multiform amelanotic choroidopathy (SMACH; also known as serous maculopathy due to aspecific choroidopathy).

METHODS

Retrospective observational case series of eyes presenting with SMACH. Multimodal imaging including fundus photography, optical coherence tomography (OCT), OCT angiography (OCTA), and indocyanine green angiography (ICGA) was analyzed.

RESULTS

Eighteen eyes from 18 patients (mean age: 28 ± 19 years) were included. The mean follow-up duration was 9 years. Ophthalmoscopy showed a yellowish orange, dendriform choroidal lesion. At presentation, subretinal fluid (SRF) was seen in 10 of 18 cases (56%). Eight patients (44%) showed no evidence of SRF during a mean follow-up of 6 years. Cross-sectional OCT showed hyperreflective fibrous-like changes within the inner choroid with choriocapillaris flow preservation on OCTA. En face OCT showed a hyperreflective choroidal lesion with finger-like projections oriented in a stellate configuration. On ICGA, SMACH showed early and late hypofluorescence. None of the cases showed lesion growth.

CONCLUSION

SMACH seems to be a unilateral choroidopathy characterized by distinctive multimodal imaging features. As SRF was absent in some cases, while a dendriform pattern was a consistent finding in all eyes, the authors propose renaming this entity "stellate multiform amelanotic choroidopathy," a name that retains its previous abbreviation "SMACH."

Long-term functional and structural outcomes after large chorioretinectomy for ruptured globe following blunt trauma

BACKGROUND

The purpose of this study was to present a modified surgical technique involving pars plana vitrectomy with large chorioretinectomy for eyes with rupture of the globe due to severe ocular blunt trauma.

METHODS

This retrospective study included consecutive patients with rupture of the globe due to blunt trauma who were treated at the King Khaled Eye Specialist Hospital (Riyadh, Saudi Arabia). All patients underwent 25-gauge pars plana vitrectomy with large chorioretinectomies involving all the tissue around the posterior scleral wounds. Outcome measures included best-corrected visual acuity (BCVA), anatomical success and globe survival, rates of complications.

RESULTS

15 eyes of 15 patients were included. Mean BCVA was 2.88 ± 0.13 logMAR at presentation, and significantly improved to 0.83 ± 0.28 logMAR (P < 0.001), with 10 patients (67%) achieving a final BCVA ≥ 20/200. Anatomical success and globe survival were achieved in 11 (73%) and 15 (100%) of eyes, respectively. Postoperative complications included retinal detachment in 6 eyes (40%), epiretinal membrane in 6 (40%), hypotony in 4 (26%), PVR in 2 (13%).

CONCLUSIONS

Pars plana vitrectomy with large chorioretinectomy is an effective treatment for globe rupture following severe blunt trauma, yielding good visual outcomes and anatomical success rates.

Impact of topographic hot spots on the refractive outcomes of combined DMEK and cataract surgery

PURPOSE

To compare the refractive results of combined Descemet membrane endothelial keratoplasty (DMEK) and cataract surgery in eyes with Fuchs endothelial corneal dystrophy (FECD) with and without topographic hot spots.

SETTING

"Villa Igea" Hospital, Forlì, Italy.

DESIGN

Interventional case series.

METHODS

57 eyes of 52 patients with FECD undergoing combined DMEK, cataract surgery, and monofocal intraocular lens (IOL) implantation were included in this single-center study. Patients were classified based on the presence or absence of topographic hot spots on the preoperative axial power map. Prediction error (PE) was calculated as the postoperative manifest spherical equivalent (SE) refraction minus the SE predicted refraction.

RESULTS

6 months postoperatively, mean PE was +0.79 ± 1.12 diopters (D). In eyes with hot spots, mean keratometry (K), K flat, and K steep significantly decreased after surgery (all P < .05), whereas no significant changes were observed in eyes without hot spots (all P > .05). Eyes with hot spots showed a significantly more hyperopic PE than eyes without hot spots (+1.13 ± 1.23 vs +0.40 ± 0.86 D; P = .013).

CONCLUSIONS

Combined DMEK and cataract surgery can result in a hyperopic refractive surprise. The presence of topographic hot spots before surgery is associated with a higher hyperopic shift.

A lack of an association between COVID-19 vaccination and corneal graft rejection: results of a large multi-country population based study

PURPOSE

The aim of the study was to present the rates of corneal transplant rejection from 2018 to 2022 at both Moorfields Eye Hospital UK, and Ospedali Privati Forli (OPF) "Villa Igea", Italy and evaluate the purported association between COVID-19 vaccination and rejection.

METHODS

We performed a retrospective review of rejection cases presenting to the two units. Monthly rates were correlated against regional vaccination programme rates. At OPF, conditional Poisson regression model was employed to estimate the incidence risk ratio (IRR) of graft rejection following COVID-19 vaccination risk period compared with the control period.

RESULTS

Between January 2018 and March 2022, there were 471 (Moorfields), 95 (OPF) episodes of rejection. From the start of vaccination programme in the UK in late January 2021, the median number of graft rejections per month at Moorfields was 6 (range: 5-9), which was not significantly different to post-lockdown, pre-vaccination programme (March 2020-January 2021), p = 0.367. At OPF, the median rates of rejection before and after initiation of the vaccination programme were not significantly different (p = 0.124). No significant increase in incidence rate of rejection in the risk period following COVID-19 vaccination was found (IRR = 0.53, p = 0.71).

CONCLUSION

No notable increase in rates of transplant rejection was noted in year 2021 when COVID-19 vaccination was broadly implemented. The apparent temporal relationship between COVID-19 vaccination and corneal graft rejection highlighted in several case reports may not represent a causative association.

Optical Coherence Tomography in Inflammatory and Neoplastic Lesions Deforming the Choroidal Profile

The choroid is the main part of the uvea, the vascular layer of the eye that lies between the retina and the sclera. The high vascular component of the choroid makes this structure susceptible to inflammation in multisystemic diseases, as well as the most common site of metastasis in the eye. Therefore, the choroid is involved in many pathological conditions, from uveitis to intraocular tumors. Differentiating between inflammatory and neoplastic lesions deforming the choroidal profile can sometimes be challenging. In addition, scleral disorders can also deform the choroidal profile. Choroidal imaging includes ophthalmic ultrasonography, indocyanine green angiography, and optical coherence tomography (OCT). Recent advances in choroidal imaging techniques, such as enhanced depth imaging optical coherence tomography (EDI-OCT) and swept-source optical coherence tomography (SS-OCT), have facilitated an in-depth analysis of the choroid. The purpose of this review article is to report on and highlight the most common OCT findings to help in the differential diagnosis between inflammatory and neoplastic lesions deforming the choroidal profile.

Microsporidial Stromal Keratitis in Post-Keratoplasty Eyes

PURPOSE

The purpose of this paper is to report the clinical manifestations, diagnostic evaluation, management and outcomes of microsporidial keratitis in post-keratoplasty eyes.

METHODS

This is a retrospective review of three patients diagnosed with microsporidial stromal keratitis in post-keratoplasty eyes between January 2012 and December 2021 at a tertiary referral center (Ospedali Privati Forlì "Villa Igea", Forlì, Italy).

RESULTS

All patients presented with fine multifocal granular infiltrates following keratoplasty for a presumed herpetic keratitis. No microorganisms were isolated from the corneal scrapings and no clinical response was observed with broad-spectrum antimicrobial therapy. In all cases, confocal microscopy demonstrated spore-like structures. The histopathologic examination of the excised corneal buttons confirmed the diagnosis of microsporidial stromal keratitis. Following therapeutic keratoplasty and treatment with an initial high dose and extended taper of topical fumagillin, clinical resolution was achieved in all eyes. The Snellen visual acuities at the final follow-up were 20/50, 20/63 and 20/32.

CONCLUSIONS

Prior to definitive surgery, confocal microscopy can be employed for the in vivo detection of pathogenic microorganisms such as Microsporidium. In post-keratoplasty eyes, therapeutic keratoplasty and an initial high dose of topical fumagillin with extended taper can allow the resolution of microsporidial stromal keratitis with a satisfactory visual prognosis.

Accurate prognosis for localized prostate cancer through coherent voting networks with multi-omic and clinical data

Localized prostate cancer is a very heterogeneous disease, from both a clinical and a biological/biochemical point of view, which makes the task of producing stratifications of patients into risk classes remarkably challenging. In particular, it is important an early detection and discrimination of the indolent forms of the disease, from the aggressive ones, requiring post-surgery closer surveillance and timely treatment decisions. This work extends a recently developed supervised machine learning (ML) technique, called coherent voting networks (CVN) by incorporating a novel model-selection technique to counter the danger of model overfitting. For the challenging problem of discriminating between indolent and aggressive types of localized prostate cancer, accurate prognostic prediction of post-surgery progression-free survival with a granularity within a year is attained, improving accuracy with respect to the current state of the art. The development of novel ML techniques tailored to the problem of combining multi-omics and clinical prognostic biomarkers is a promising new line of attack for sharpening the capability to diversify and personalize cancer patient treatments. The proposed approach allows a finer post-surgery stratification of patients within the clinical high-risk category, with a potential impact on the surveillance regime and the timing of treatment decisions, complementing existing prognostic methods.

Comparison of the new Hoffer QST with 4 modern accurate formulas

PURPOSE

To investigate the new Hoffer QST (Savini/Taroni) formula (HQST) and compare it with the original Hoffer Q (HQ) and 4 latest generation formulas.

SETTING

I.R.C.C.S.-G.B. Bietti Foundation, Rome, Italy.

DESIGN

Retrospective case series.

METHODS

Refractive outcomes of the HQST, Barrett Universal II (BUII), Emmetropia Verifying Optical (EVO) 2.0, HQ, Kane, and Radial Basis Function (RBF) 3.0 formulas were compared. Subgroup analysis was performed in short (<22 mm) and long (>25 mm) axial length eyes. The SD of the prediction error (PE) was investigated using the heteroscedastic method.

RESULTS

1259 eyes of 1259 patients divided in a White group (n=696), implanted with the AcriSof SN60AT (Alcon Labs), and an Asian group (n=563), implanted with the SN60WF (Alcon Labs), were investigated. In the Asian group, the heteroscedastic method did not disclose any significant difference among the SD of the 4 modern formulas (range from 0.333 to 0.346 D), whereas the SD of the HQ formula (0.384 D) was significantly higher. Compared with the original HQ formula, in both White and Asian groups, the HQST formula avoided the mean myopic PE in short eyes and the mean hyperopic PE in long eyes.

CONCLUSIONS

The new HQST formula was superior to the original HQ formula and reached statistical and clinical results comparable with those achieved by the BUII, EVO, Kane, and RBF formulas.

Cenegermin for the treatment of dry eye disease

Dry eye disease (DED) is the most common ocular surface disorder affecting millions of people worldwide. Due to its chronic nature, the management of DED still represents a challenge in the ophthalmic practice. Nerve growth factor (NGF), which is expressed along with its high-affinity TrkA receptor on the ocular surface complex, has been widely studied for the treatment of neurotrophic keratopathy, and a novel recombinant human NGF (rhNGF) has recently received full market authorization in this setting. Since NGF has shown in both in vitro and in vivo studies to promote corneal healing, to enhance conjunctival epithelium differentiation and mucin secretion, and to stimulate tear film production and functionality, it could provide potential benefits also in patients with DED. A recent phase II clinical trial has assessed the role of rhNGF in DED patients, demonstrating significant improvements of DED signs and symptoms after 4 weeks of treatment. Further clinical evidence will be provided by the 2 ongoing phase III clinical trials. This review aims at comprehensively illustrating the rationale of use along with the efficacy and safety profile of topical NGF in patients with DED.

Practical guidance for imaging biomarkers in exudative age-related macular degeneration

We provide an overview of current macular imaging techniques and identify and describe biomarkers that may be of use in the routine management of macular diseases, particularly exudative age-related macular degeneration (n-AMD). This perspective includes sections on macular imaging techniques including optical coherence tomography (OCT) and OCT angiography (OCTA), classification of exudative AMD, and biomarkers in structural OCT and OCTA. Fluorescein angiography remains a vital tool for assessing the activity of neovascular lesion, while indocyanine green angiography is the preferred option for choroidal vessels imaging in neovascular AMD. OCT provides a non-invasive three-dimensional visualization of retinal architecture in vivo and is useful in the diagnosis of many imaging biomarkers of AMD-related neovascular lesions including lesion activity. OCTA is a recent advance in OCT technology that allows accurate visualization of retinal and choroidal vascular flow. OCT and OCTA have led to an updated classification of exudative AMD lesions and provide several biomarkers that help to establish a diagnosis and the disease activity status of neovascular lesions. Individualization of therapy guided by OCT and OCTA biomarkers has the potential to further improve visual outcomes in exudative AMD. Moving forwards, integration of technologically advanced imaging equipment with AI software will help ophthalmologists to provide patients with the best possible care.

Discharge Monitoring in Open-Channels: An Operational Rating Curve Management Tool

An aspect correlated with climate change is certainly represented by the alternation of severe floods and relevant drought periods. Moreover, there is evidence that changes in climate and land cover are inducing changes in stream channel cross-sections, altering local channel capacity. A direct consequence of a significant change in the local channel capacity is that the relationship between the amount of water flowing at a given point in a river or stream (usually at gauging stations) and the corresponding stage in that section, known as a stage-discharge relationship or rating curve, is changed. The key messages deriving from the present work are: (a) the more frequent and extreme the floods become, the more rapid the changes in the stream channel cross-section become, (b) from an operational point of view, the collection and processing of field measurements of the stage and corresponding discharge at a given section in order to quickly and frequently update the rating curve becomes a priority. It is, therefore, necessary to define a control system for acquiring hydrological data capable of keeping river levels and discharges under control to support flood early warnings and water management. The proposed stage-discharge management system is used by the Civil Protection Service of the Marche Region (east-central Italy) for the monitoring of river runoff in the regional watersheds. The Civil Protection Service staff performs stage-discharge field measurements using water level sensors and recorders (e.g., staff gauges, submersible pressure transducers, ultrasound and radar sensors) and a current meter, acoustic doppler velocimeter, acoustic doppler current profilers, portable mobile radar profiler and salt dilution method equipment, respectively. Power functions are fitted to the stage-discharge field data. Furthermore, extrapolation is performed to cover the full range of flow measurements; in general, extrapolation is not an easy task because of sharp changes in the stream cross-section geometry for very high or very low stages. In the present work, we also focused attention on the application problems that occur in practice and the need for frequent updating.

Serial Sessions of a Novel Low-Level Light Therapy Device for Home Treatment of Dry Eye Disease

INTRODUCTION

This study aimed to evaluate the changes that a recently developed at-home device using low-level light therapy (LLLT) produced in signs and symptoms of patients with dry eye disease (DED) owing to meibomian gland dysfunction (MGD).

METHODS

In this prospective study, patients with DED owing to MGD not successfully responding to first-line therapy (tear substitutes and eye lid hygiene) were treated with four serial sessions (every other day) of mask based on LLLT technology and dedicated for home use (my-mask^®, Espansione Marketing S.p.A., Bologna, Italy). Non-invasive ocular surface examination was carried out by means of Keratograph 5M (Oculus, Wetzlar, Germany) before and after four mask sessions for the evaluation of (i) tear meniscus height (TMH); (ii) first and average non-invasive Keratograph breakup time (NIKBUT); (iii) meibomian gland loss (MGL). Ocular Surface Disease Index (OSDI) questionnaire was used to assess ocular discomfort symptoms.

RESULTS

Overall, 17 patients (3 male, 14 female; mean age 61.47 ± 11.93 years) were enrolled and all of them regularly completed the entire cycle of four sessions without reporting any adverse event. The mean values of NIKBUT first and NIKBUT average increased significantly after treatment (from 5.29 ± 2.60 at T0 to 9.04 ± 3.49 s at T1 [P = 0.001] and from 9.40 ± 3.81 to 11.28 ± 2.81 s [P = 0.017]); in parallel, the mean value of TMH increased significantly from 0.27 ± 0.06 to 0.32 ± 0.09 mm (P = 0.029). Conversely, there were not statistically significant differences for MGL (P = 0.346). In addition, the mean value of OSDI score decreased after treatment (from 32.00 ± 7.96 at T0 to 20.71 ± 8.03 at T1; P < 0.001).

CONCLUSIONS

One week of serial sessions of a newly developed LLLT device for home use significantly improved tear film production and stability along with ocular discomfort symptoms in patients with DED owing to MGD. These findings open up a new scenario for patients with MGD who can enjoy the unique benefits of LLLT at home.

Low-Level Light Therapy Versus Intense Pulsed Light for the Treatment of Meibomian Gland Dysfunction: Preliminary Results From a Prospective Randomized Comparative Study

PURPOSE

The purpose of this study was to evaluate and compare the safety and efficacy of low-level light therapy (LLLT) and intense pulsed light (IPL) for the treatment of meibomian gland dysfunction (MGD).

METHODS

Forty eyes of 40 patients with MGD were randomized to receive either LLLT or IPL. Four weekly sessions of LLLT (MY MASK-E, Espansione Marketing S.p.A., Bologna, Italy) and IPL (Eye-light device, Espansione Marketing S.p.A., Bologna, Italy) were performed. The following parameters were evaluated before and 2 weeks after the last session for each treatment: Standard Patient Evaluation of Eye Dryness questionnaire, noninvasive break-up time, tear meniscus height, redness score, meiboscore, and meibomian gland loss.

RESULTS

All patients completed regularly all the scheduled sessions, and no adverse events were reported in any of the groups. The Standard Patient Evaluation of Eye Dryness score significantly decreased after both LLLT and IPL (P < 0.001) although the improvement was significantly greater in the LLLT compared with the IPL group (-9.9 ± 3.2 vs. -6.75 ± 4.5; P = 0.014). Patients in the LLLT group showed a significantly higher increase in tear meniscus height compared with those in the IPL group (0.06 ± 0.10 mm vs. -0.01 ± 0.014; P = 0.040). In both groups, the noninvasive break-up time, redness score, meiboscore, and meibomian gland loss did not vary significantly after treatment (all P > 0.05).

CONCLUSIONS

Both LLLT and IPL were safe and effective in improving ocular discomfort symptoms in patients with MGD; however, the former determined a greater improvement in symptoms and an improvement of tear volume.

Choroidal Lymphoma: Diagnostic Value of Combined Indocyanine Green Angiography and Optical Coherence Tomography

OBJECTIVE

To compare multimodal imaging findings in patients with choroidal lymphoma (CL).

METHODS

Multicenter retrospective observational case series. Multimodal imaging features of patients with CL were reviewed with particular attention to the patterns of choroidal infiltration on indocyanine green angiography (ICGA) and optical coherence tomography (OCT).

RESULTS

Eighteen eyes of 15 patients were included in this study. Average tumor thickness on ultrasonography was 2.6 mm (range, 1.2-5.7 mm). Choroidal infiltration on ICGA was characterized by multifocal, round areas (300-500 microns diameter) of hypocyanescence in all cases, whereas OCT at the same region disclosed diffuse choroidal infiltration. By OCT, the tumor surface contour was primarily placid (22%), dome-shaped (11%), or undulating (67%).

CONCLUSIONS

In this analysis of eyes with CL, ICGA demonstrated multifocal sub-millimeter regions of choroidal hypocyanescence whereas OCT documented diffuse choroidal infiltration. This incongruence could be a distinctive diagnostic feature of choroidal lymphoma, assisting with differentiation from other pathological entities.

Effects of Serial Sessions of Activa Mask for the Treatment of Meibomian Gland Dysfunction

INTRODUCTION

To analyze outcomes on objective ocular surface parameters and subjective symptoms of serial weekly sessions using the Activa mask in patients with meibomian gland dysfunction (MGD).

METHODS

This is a prospective study including patients with symptomatic MGD who were treated with four weekly sessions using the Activa mask (SBM Sistemi, Turin, Italy). Noninvasive ocular surface examination was carried out before (T0) and 2 weeks after the last mask session (T1) using Idra (SBM Sistemi, Turin, Italy) for the measurement of: (1) noninvasive break-up time (NIBUT); (2) lipid layer thickness (LLT); (3) tear meniscus height (TMH); (4) meibomian gland loss (MGL) of upper and lower eyelids. The I-Pen tear osmolarity system (I-Med Pharma Inc, Dollard-des Ormeaux, Quebec, Canada) was used to measure tear osmolarity values. Ocular discomfort symptoms were ascertained by means of the ocular surface disease index (OSDI) questionnaire.

RESULTS

All 25 patients (11 males, 14 females; mean age 57.1 ± 11.9 years) regularly completed the cycle of four mask sessions. No patients used prohibited medications, and no device-related adverse events were noted. At T1, mean values of NIBUT and LLT increased significantly compared to T0 (respectively from 6.0 ± 1.4 to 6.6 ± 1.2 s, P = 0.043, and from 53.2 ± 17.4 to 65.3 ± 16.3 nm, P < 0.001), while mean values of MGL and tear osmolarity decreased significantly (respectively from 17.1 ± 9.3 to 15.1 ± 8.0%, P = 0.014, and from 307.3 ± 12.2 to 301.5 ± 6.8 mOsm/l, P = 0.005). In parallel, OSDI score reduced significantly from 62.4 ± 11.7 at T0 to 34.5 ± 11.2 at T1 (P < 0.001).

CONCLUSION

Weekly serial sessions using the Activa mask significantly improved objective parameters of the ocular surface as well as subjective ocular discomfort symptoms in patients with recalcitrant MGD. As a further benefit from the treatment, patients were able to avoid the use of concomitant medications, apart from tear substitutes, throughout the study.

Stromal peeling for deep anterior lamellar keratoplasty in a post-penetrating keratoplasty eye with hematocornea

Purpose

To present a case of hematocornea occurring in a post-penetrating keratoplasty (PK) eye and to report the outcomes of deep anterior lamellar keratoplasty (DALK) performed by simple stromal peeling.

Observations

A 45-year-old female presented with hematocornea in the left eye that previously underwent PK 26 months prior for keratoconus. Clinical examination revealed a dense reddish-brown opacity within the PK graft which was associated with deep corneal neovascularization. Over 6 months, intracorneal hemorrhage developed a rust-colored appearance with minimal clearing. DALK was performed using the stromal peeling technique for post-PK eyes. Briefly, a dense partially organized hemorrhage was identified at the natural plane of separation, as confirmed by ex vivo histologic examination; after peeling of the deep corneal stroma and evacuation of the intracorneal hemorrhage, the residual bed appeared akin to pre-Descemet's layer-Descemet membrane-endothelium complex. One year after DALK, the graft remained clear with ECD of 1034 cells/mm².

Conclusions and Importance

Intracorneal hemorrhage is a rare but potentially sight-threatening complication following PK. Using the stromal peeling technique, DALK can be attempted to preserve functional endothelium in post-PK eyes. In the presence of a dense intracorneal hemorrhage, the spread of erythrocytic debris within the stroma can guide deep lamellar cleavage.

Large-Diameter Modified Big-Bubble Deep Anterior Lamellar Keratoplasty in Post-Radial Keratotomy Eyes

PURPOSE

To report the outcomes of our modified large-diameter (9-mm) big-bubble deep anterior lamellar keratoplasty (DALK) technique with improved success rates of pneumatic dissection in post-radial keratotomy (RK) eyes.

DESIGN

Retrospective case series.

METHODS

At Ospedali Privati Forlì, "Villa Igea," Forlì, Italy., modified big-bubble DALK was performed in consecutive post-RK eyes. The technique included large-diameter (9-mm) deep partial-thickness trephination based on the thinnest anterior segment optical coherence tomography pachymetry value at 9 mm, air injection through a cannula advanced 2 mm centripetally from the base of the trephination, limited stromal clearance of the central 6-mm optical zone, and suturing of a 9-mm anterior lamellar graft prepared by microkeratome dissection. Success rate of pneumatic dissection, corrected distance visual acuity (CDVA), keratometric astigmatism, and complications were recorded.

RESULTS

Eight eyes of 7 patients were included. Pneumatic dissection succeeded in 7 cases (87.5%). CDVA significantly improved from 0.94 ± 0.43 to 0.14 ± 0.06 logMAR (P < .001). All eyes reached Snellen CDVA ≥20/40, whereas 3 eyes (37.5%) reached ≥20/25. At the last follow-up, 5 eyes (62.5%) had a final keratometric astigmatism ≤4 diopters, whereas 2 eyes (25.0%) had ≤2 diopters.

CONCLUSION

Big-bubble DALK can be successfully performed in post-RK eyes with our standardized technique.

GAP score potential in predicting post-operative spinal mechanical complications: a systematic review of the literature

PURPOSE

In 2017, the GAP score was proposed as a tool to reduce mechanical complications (MC) in adult spinal deformity (ASD) surgery: the reported MC rate for the GAP proportioned category was only 6%, which is clearly lower to the MC rate reported in the literature. The aim of this study is to analyse if the most recent literature confirms the promising results of the original article.

MATERIALS AND METHODS

Using the PRISMA flow chart, we reviewed the literature to analyse GAP score capacity in predicting MC occurrence. We included articles clearly reporting ASD surgery MC stratified by GAP categories and the score's overall capacity to predict MC using the area under the curve (AUC). The quality of the included studies was evaluated using GRADE and MINORS systems.

RESULTS

Eleven retrospective articles (1,517 patients in total) were included. The MC distribution per GAP category was as follows: GAP-P, 32.8%; GAP-MD, 42.3%; GAP-SD, 55.4%. No statistically significant difference was observed between the different categories using the Kruskal-Wallis test (p = 0.08) and the two-by-two Pearson-Chi square test (P Vs MD, p = 0.300; P Vs SD, p = 0.275; MD Vs SD, p = 0.137). The global AUC was 0.68 ± 0.2 (moderate accuracy). The included studies were of poor quality according to the GRADE system and had a high risk of bias based on the MINORS criteria.

CONCLUSION

The actual literature does not corroborate the excellent results reported by the original GAP score article. Further prospective studies, possibly stratified by type of MC and type of surgery, are necessary to validate this score.