Evaluation of warm compresses and topical cyclosporine treatment in meibomian gland dysfunction by confocal scanning laser microscopy

PURPOSE

The aim of our study is to confirm the utility of warm compresses (WC) and artificial tears (AT) in meibomian gland dysfunction (MGD) management and to understand if its association with topical cyclosporine A (CsA) improves outcomes.

METHODS

Patients with diagnosis of MGD-related dry eye were evaluated. In this prospective, randomized, double-masked study, patients were randomized in two treatments: AT plus WC (group A), and AT plus WC plus CsA 0.05% ophthalmic emulsion (group B). At baseline and at 1, 3, and 6 months, Ocular Surface Disease Index (OSDI) questionnaire was completed, and tear evaluation (BUT, Schirmer and osmolarity test), ocular surface evaluation (fluorescein and lissamine green staining), clinical (Shimazaki grading) and in vivo confocal microscopy (IVCM) evaluation of rete ridges (RRs) were performed.

RESULTS

A total of 40 eyes, 20 in each group, completed the study. Analysis of OSDI, tear test, ocular surface evaluation and clinical grading of MG showed significant improvement at 6 months, whereas no difference was found between the two groups at 6 months. The analysis of IVCM showed significant improvement in both groups, but significantly better results in group B were found compared to group A at 6 months.

CONCLUSION

WC performed 3 times daily during the 1st month and once daily afterwards, in addition to AT, were useful to manage the obstruction of MG and related signs and symptoms. Additional effects of CsA were visible in IVCM only at 6 months. IVCM is an effective tool to monitor treatments in MGD.

Primary small gauge pars plana vitrectomy and silicone oil endotamponade for endophthalmitis after cataract surgery: Clinical and OCT findings

BACKGROUND

Retrospective analysis of morphological and functional outcomes after pars-plana vitrectomy and Silicone-Oil (SO) endotamponade in acute postoperative endophthalmitis (APOE).

METHODS

Minimum follow-up was 6 months. Every included patient received best-corrected visual acuity (BCVA) assessment, pre-operatively and at last follow-up. Spectralis OCT was used to investigate disorganization of inner (DRIL) and outer (DROL) retinal layers at 1, 3, 6 months and at last follow-up. OCT-A was performed to assess foveal avascular zone (FAZ) and vascular perfusion density (VPD) at 6 months and at last follow-up.

RESULTS

Seventeen eyes were recruited. Postoperative findings: BCVA ≥ 20/40 (in 14 eyes); epiretinal membranes (13); hyperreflective epiretinal material soon after surgery in (6) SO-filled eyes; inner retinal layers atrophy (5); macular edema (2); DROL (4) with persistent EZ disruption at final visit (2); no significant difference between study and fellow eyes in central macular thickness, FAZ and VPD; VPD decreased in all cases with prominent disorganization of retinal architecture.

CONCLUSION

OCT changes after APOE can be persistent or completely/partially self-resolving and seems related to the outward progression path of the infection/inflammation from the vitreous cavity to the inner and outer retina, rather than to the surgery.

Choroidal vasculature analysis in MEK inhibitor-associated retinopathy

PURPOSE

To evaluate choroidal vascularity index (CVI) in patients developing mitogen-activated protein kinase kinase (MEK) inhibitor-associated retinopathy (MEKAR).

METHODS

In this prospective observational study, extensive ophthalmic examination was performed, including enhanced-depth-imaging-optical coherence tomography (EDI-OCT). EDI-OCT scans of patients receiving Cobimetinib, taken at baseline and at MEKAR manifestation, were considered for choroid analysis. Choroidal thickness (CT) was measured on high-resolution b-scans passing through the fovea at three different locations. Same scans were therefore imported for binarization into a previously reported software and CVI was calculated as the ratio of luminal area (LA) to total choroid area (TCA).

RESULTS

When compared to baseline, eyes with MEKAR (14 eyes) did not show significative CT variation in subfoveal region (p = 0,57), 750-µm-nasal to the fovea (p = 0,08) and 750-µm-temporal to the fovea (p = 0,07). Similarly, there were no statistically significant differences for TCA (p = 0.54), LA (p = 0.85), stromal area (SA) (p = 0.13), LA/SA (p = 0.34) and CVI (p = 0.47). Best-corrected visual acuity was significantly reduced at fluid accumulation when compared to baseline values (p = 0.03), with complete recovery after fluid resolution (p = 0.73).

CONCLUSION

Multiple parameters reflecting the status of the choroid seemed not influenced by Cobimetinib administration. Retinal pigment epithelium toxic disfunction likely represents the crucial step in MEKAR pathogenesis.

New trends in intravitreal anti-VEGF therapy for ROP

Retinopathy of Prematurity (ROP) affects premature newborns, and it can cause childhood blindness and visual impairment if untreated. The understanding of the pathogenetic role of Vascular Endothelial Growth Factor (VEGF) has led to development of therapeutic strategies such as intravitreal anti-VEGF drugs. We reported drug efficacy and ROP recurrence rates, extrapolated from the reviewed studies. Association of Pegabtanib and laser photocoagulation confers efficacy in the regression of ROP stage 3 plus in zone I / II in 89.7% of treated eyes, reducing the recurrence rate to 14.6% compared to 50% of laser therapy alone. Irrespective of the dose, Ranibizumab demonstrated average efficacy greater than 75% on regression of active disease with the highest rates of the dose of 0.1 mg (92.5%). The recurrence, on the other hand, is the highest among this new anti-VEGF agents and is around an average of 41.5%, which records the highest values in the case of Aggressive Posterior Rop (APROP). Aflibercept at a dose of 1 mg demonstrated average efficacy of about 81.9% of treated infants, analyzing significantly fewer studies than Ranibizumab. The recurrence rate stands at an average of 28.9%, especially in the later forms of ROP. Using a dose of 0.25 mg of Conbercept, the disease regression rate is currently on average 83%, with an average recurrence rate of 15.24%, the peak of which was observed in cases of ROP in zone I. Further studies are needed to prove safety at long term, because,at the moment, only short-term data are available.

Non-infectious uveitis burden on quality of life and work impairment assessed through different psychometric questionnaires

BACKGROUND

The purpose of this study was to evaluate the association between a novel psychometric 12-item questionnaire (U-qest) and other validated questionnaires to assess quality of life and work impairment in patients with non-infectious uveitis.

METHODS

Data were collected at baseline and 3 months postbaseline using U-qest and two other validated questionnaires: The National Eye Institute 25-Item Visual Function Questionnaire (VFQ-25) and the 12-Item Short-Form Health Survey (SF-12).

RESULTS

A total of 136 patients (52.2% female) aged 47.9 ± 14.8 years (mean ± SD) were enrolled in 14 uveitis referral centres. U-qest correlated moderately with VFQ-25 and SF-12 at baseline and at 3 months. Both U-qest and VFQ-25 scores improved as disease improved; however, U-qest also detected improvement in patients for whom VFQ-25 scores did not improve. Disease activity was shown to significantly affect activity impairment. Patients and physicians expressed positive perceptions regarding the use and benefit of this instrument. U-qest showed very good reliability in terms of internal consistency (Cronbach's alpha = 0.91).

CONCLUSIONS

U-qest can be considered a useful tool to assess the burden of uveitis on quality of life.

New Insights On Ocular Sarcoidosis: An Optical Coherence Tomography Angiography Study

Purpose: To report optical coherence tomography angiography (OCT-A) findings in eyes with ocular sarcoidosis (OS) and to compare these findings with those of fluorescein angiography (FA). Methods: Observational, cross-sectional, case-control study. Patients presenting with OS involving the posterior segment were evaluated using FA, structural-OCT and OCT-A. OCT-angiograms of the superficial (SCP) and deep (DCP) capillary plexuses and choriocapillaris (CC) were qualitatively and quantitatively analyzed. Results: OCT-A seemed more sensitive than FA in detecting perifoveal capillary arcade disruptions, areas of hypoperfusion/non-perfusion and capillary abnormalities (p<0.05). Capillary hypoperfusion was more frequently detected in the DCP than in SCP, conversely capillary abnormalities were more often observed at the level of the SCP. Capillary vessel density values were significantly lower in eyes with OS than in healthy controls both at the level of DCP and CC (p<0.05). Conclusion: The depth-resolved nature of OCT-A allowed new insights on OS-induced microvascular and perfusion impairments.

Confocal scanning laser microscopy in patients with postoperative endophthalmitis

PURPOSE

To investigate alterations of corneal layers in eyes treated for acute postoperative endophthalmitis.

METHODS

In this retrospective, nonrandomized comparative study, eyes treated with 25 gauge pars plana vitrectomy (PPV) for acute post-cataract endophthalmitis (group A) were compared to eyes receiving uneventful cataract surgery (group B) and uneventful 25 gauge PPV for epiretinal membrane (group C). After a minimum follow-up of 8 months from last surgical procedure, laser scanning in vivo confocal microscopy (IVCM) was performed.

RESULTS

Twelve eyes for each group were recruited. Comparing study eyes with control eyes of group B and C, no statistical difference was found in corneal epithelial cell density (p = n.s.), in density of nerve fibers (p = n.s.), mean grade of nerve reflectivity (p = n.s.), mean grade of nerve tortuosity (p = n.s.), mean grade of anterior keratocyte activation (p = n.s.), and corneal endothelium cell density (p = n.s.), whereas a statistically higher mean grade of posterior keratocyte activation was found in group A (p < 0.01). Epithelial and endothelial corneal morphologies were graded as regular in all groups. Langerhans cells and corneal dendritic-shaped hyper-reflective endothelial deposits were found in group A. Both findings were absent in group B and C, and the difference was statistically significant (p < 0.01).

CONCLUSIONS

IVCM was a useful tool in the detection of microscopic chronic corneal abnormalities caused by postoperative endophthalmitis. These findings confirmed the presence of a subclinical chronic corneal inflammation localized to the posterior stroma that should be related to the infectious process. Future studies might clarify pathological processes in the acute phase of postoperative endophthalmitis.

Visual pathway involvement in multiple sclerosis: Look straight in the eyes

Visual symptoms are a common clinical manifestation of multiple sclerosis (MS) and are frequently due to acute optic neuritis (ON). However, the entire visual pathway can be involved throughout the disease course. We describe the case of a young MS patient who experienced visual symptoms that were eventually found to be caused by retinal periphlebitis, an inflammatory process of the anterior visual pathway, which is common during MS, but rarely symptomatic. This case reinforces the concept that in all MS patients complaining visual symptoms, a complete work-up should be performed in order to rule out possible ON mimicries.

Tear Film Stability in Sjögren Syndrome Patients Treated with Hyaluronic Acid Versus Crosslinked Hyaluronic Acid-Based Eye Drops

PURPOSE

To compare the stability of the tear film after instillation of eye drops containing hyaluronic acid (HA) or crosslinked hyaluronic acid (CLHA)-based in patients with Sjögren syndrome-related dry eye (SSDE).

METHODS

Forty subjects were included in this study and were divided into 2 groups: the first group (control group) consisted of 20 healthy volunteers; the second group (study group) constituted of 20 suffering from SSDE; before and 5, 30, and 60 min after instillation of eye drops the surface regularity index (SRI) and surface asymmetry index (SAI) were registered.

RESULTS

Comparing HA and CLHA, in the control group, SAI show statistically significant difference in the time 0 and in time 5, whereas there is no a statistically significant difference after 30 and 60 min from instillation. For SRI there is no statistically significant difference at any time. In SSDE group there is no statistically significant difference in the time 0 and 5, whereas there is a statistically significant difference after 60 min for SAI, and after 30 and 60 min for SRI from instillation. Both SRI and SAI in dry eyes were significantly greater than in control eyes (P < 0.05).

CONCLUSION

Our study showed a better efficacy of CLHA compared with HA in maintaining the stability of the tear film in a patient suffering from SSDE.

Transient therapeutic effect of vitrectomy in primary intraocular lymphoma

This photo essay shows the transient therapeutic effect of pars plana vitrectomy (PPV) in a patient affected by primary intraocular lymphoma (PIOL). PPV is crucial for the diagnosis of PIOL, but it may also play a role in the therapeutic approach.

Repeatability and reproducibility of retinal thickness measurements in diabetic patients with spectral domain optical coherence tomography

BACKGROUND

To determine the repeatability and reproducibility of optical coherence tomography (OCT) Spectralis retinal thickness measurements in diabetic patients with clinically significant macular edema (CSME).

METHODS

Twelve eyes of 12 volunteers (without macular pathology - control group) and 21 eyes of 21 diabetic patients with CSME were included in the study. Reproducibility, repeatability, intraclass correlation coefficients (ICCs) and intrasession correlation coefficients were tested with 20 × 15 degree raster scans consisting of 19 high-resolution line scans that were repeated three times by two experienced examiners.

RESULTS

In the control group, examining all regions, coefficient of repeatability was less than 1.1%, while coefficient of reproducibility was less than 2.2%. In diabetic patients, examining all regions, coefficient of repeatability was less than 2.6%, while coefficient of reproducibility was less than 2.4%. ICCs were, respectively, greater than or equal to 0.98 in the control group and 0.99 in diabetic patients. Intrasession coefficients of variation were less than 0.4% in the control group and less than 0.5% in diabetic patients.

CONCLUSION

Retinal thickness measurements are repeatable and reproducible with OCT Spectralis in both the control group and diabetic patients. The results indicate that a change in central subfield thickness exceeding 12 µm and 3% in the diabetic patients is likely to be real.

Rituximab treatment for persistent scleritis associated with rheumatoid arthritis

PURPOSE

To report a clinical case of a patient with severe scleritis associated with rheumatoid arthritis (RA) refractive to conventional treatment that was treated effectively with rituximab.

METHODS AND RESULTS

A 55-year-old man with RA, on etanercept and oral methotrexate, was referred with diagnosis of acute stromal keratitis, anterior uveitis, and anterior nodular scleritis in his right eye. Cyclophosphamide induced complete regression of acute stromal keratitis and anterior uveitis, but scleritis was still active and persistent. After two 1000-mg infusions of rituximab, scleritis regressed completely and is still in remission 9 months after the second rituximab infusion, without any concomitant use of oral steroids.

CONCLUSION

Rituximab may be a treatment alternative in severe scleritis that is refractive to conventional therapy. Considering its safety profile, further studies are needed to refine its mechanism of action, optimal indications, and dosing in ocular inflammation.

Somatostatin for Uveitic Cystoid Macular Edema (CME)

PURPOSE

To report the favorable response of bilateral recalcitrant uveitic cystoid macular edema (CME) to treatment with a somatostatin analog.

METHODS

Medical ophthalmic history and the results of ophthalmic examinations were recorded. Fluorescein angiography (FA) studies were reviewed.

RESULTS

A 52-year-old white female with intermediate uveitis developed bilateral recalcitrant CME. Treatment with subcutaneous injections of the somatostatin analog octreotide resulted in partial resolution of the CME and improvement of visual acuity.

CONCLUSIONS

Somatostatin may play a role in the treatment of CME secondary to uveitis.

Retinal Astrocytic Hamartoma with Associated Macular Edema: Report of Spontaneous Resolution of Macular Edema as a Result of Increasing Hamartoma Calcification

The purpose of this article is to report a case of retinal astrocytic hamartoma with an associated macular edema and the spontaneous resolution of the latter due to an increase in hamartoma calcification over a seven-year follow-up period. Clinical examination, red-free and colour fundus photographs, fluorescein angiography, and optical coherence tomography were performed during a seven-year follow-up. We conclude that retinal astrocytic hamartomas may be associated with cystoid macular edema. In some cases, the CME may resolve due to an increase in tumor calcification. Whether the progressive calcification of the retinal mass represents an overall positive prognostic factor is still unknown and further histologic studies are certainly required.

A pilot study on ocular safety of intravitreal infliximab in a rabbit model

PURPOSE

To determine whether infliximab may be used safely as an intraocular drug, the ocular safety of intravitreal infliximab in rabbits was studied by clinical examination, electroretinography (ERG), and histology in rabbits.

METHODS

Twelve New Zealand albino rabbits were selected for this study. Different infliximab doses, namely 1.0 mg, 1.7 mg, and 3.3 mg in 0.1 mL, were injected intravitreally into one eye each of three rabbits. As a control, the vehicle solution was injected into the fellow eye of each animal. Eye clinical examination and ERG recordings were made before and 2, 6, and 12 weeks after injection. Eventually, the rabbits were humanely killed, and the retinas were examined by light microscopy. In addition, the elimination half-life of the drug in the vitreous was assessed.

RESULTS

Slit lamp biomicroscopy, indirect funduscopy, and ERG evidenced no significant differences between control and infliximab-injected eyes in this rabbit model, at any of the tested doses. Histologic examination revealed no retinal abnormality in the rabbits injected with 1 mg and 1.7 mg intravitreal infliximab. In two of three eyes injected with 3.3 mg infliximab, significant edema of the nerve fibers was detected compared with the control group. The half-life of the drug was estimated to be 8.5 days.

CONCLUSIONS

These results indicate that infliximab may be a safe intravitreal drug in the rabbit model at a dose of up to 1.7 mg. If proven safe and efficacious in further studies, intravitreal injection of infliximab could be considered an alternative to systemic administration in selected patients.

Limbal anaesthesia versus topical anaesthesia for clear corneal phacoemulsification

PURPOSE

To compare the safety and clinical efficacy provided by limbal anaesthesia with topical anaesthesia in cataract surgery.

METHODS

A total of 117 consecutive patients undergoing routine cataract surgery were randomly assigned to receive limbal or topical anaesthesia. Limbal anaesthesia was administered with a cellulose ophthalmic sponge soaked in preservative-free lidocaine hydrochloride 4% applied to the temporal perilimbal area for 45 seconds immediately before surgery. For topical anaesthesia lidocaine 4% was instilled in each patient at 10-min intervals four times before surgery. We studied phaco time, perioperative pain, visual outcome and intraoperative complications. The level of intraoperative pain was scored on a scale of 1-10, where 1 = no pain and 10 = severe pain.

RESULTS

55 patients (91.6%) in the topical group and 54 patients (94.7%) in the limbal group tolerated the procedure well, giving pain scores of 1-3, with no statistical difference. No patients in either group required supplemental anaesthesia and no intraoperative complications were recorded. No eyes had epithelial defects at the end of surgery or at postoperative check-ups.

CONCLUSION

Limbal anaesthesia in cataract surgery is safe and the two anaesthesia techniques do not present differences in the degree of analgesia achieved.

Ocular Cicatricial Pemphigoid, Keratomycosis, and Intravenous Immunoglobulin Therapy

PURPOSE

To report the case of a patient developing fungal keratitis in the context of uncontrolled ocular cicatricial pemphigoid (OCP), which, despite intravenous immunoglobulin (IVIg) and other immunomodulatory therapy, progressed to end-stage pemphigoid, with corneal opacification, ankyloblepharon, and xerosis. Keratoprosthesis (KPro) restored functional vision for the patient.

METHODS

A 39-year-old man presented with uncontrolled CP and corneal ulcer in the left eye. Conjunctival biopsy diagnosed OCP; corneal scraping and biopsy diagnosed the cause of the corneal ulcer. OCP was treated with systemic steroids, immunosuppressive drugs, and IVIg. Visual rehabilitation was accomplished with Ahmed valve and a type II Dohlman KPro.

RESULTS

Immunohistology of the biopsied conjunctiva showed IgG at the epithelial basement membrane zone, confirming the clinical diagnosis of OCP. Microbiologic studies of the corneal biopsy specimen were negative for Acanthamoeba and herpes but positive for Aspergillus niger. The patient's keratomycosis resolved with topical antifungal therapy. Treatment with Dapsone, intravenous-pulse steroid, oral cyclophosphamide, and intravenous immunoglobulin (IVIg) failed to control the OCP, with resultant complete conjunctivization of the cornea. Keratoprosthesis improved the patient's visual acuity from hand movements to 20/20.

CONCLUSIONS

Patients with uncontrolled OCP are at increased risk of corneal infection. The difficulty in diagnosing keratomycosis and the relatively rare occurrence of OCP explain the uniqueness of our reported case. OCP may progress to "end-stage" disease despite therapy. Keratoprosthesis can restore vision in selected otherwise seemingly hopeless cases.

Bilateral chronic anterior uveitis & neuro-ophthalmologic manifestations in a patient with Churg-Strauss syndrome: an unusual ocular presentation

We describe a patient with Churg-Strauss syndrome (CSS) who developed bilateral chronic anterior uveitis and neuro-ophthalmologic manifestations 20 years after the onset of asthma and sinus disease. The patient was treated successfully with a combination of cyclophosphamide and prednisone, after other immunomodulatory strategies, aside from systemic prednisone, had failed.

Outcomes of early and late immunomodulatory treatment in patients with HLA-B27-associated chronic uveitis

PURPOSE

To evaluate the outcomes of early versus late immunomodulatory treatment (IMT) in patients with HLA-B27-associated chronic uveitis.

METHODS

Seventy-two patients (114 eyes) with HLA-B27-associated chronic uveitis received IMT at the Ocular Immunology & Uveitis Service of the Massachusetts Eye and Ear Infirmary and were evaluated retrospectively. Main outcome measures were visual acuity, control of inflammation, number of flare-ups and steroid-sparing effect.

RESULTS

The median time between diagnosis and start of IMT was 3.05 years. Accordingly, patients were divided into two groups: group A comprised those in whom initiation of IMT was within the first 3 years (36 patients), and in group B initiation of IMT was more than 3 years from the initial diagnosis (36 patients). Control of inflammation was achieved in 29 patients (80.5%) of the early-treated group and in 33 patients (91.6%) of the late-treated group. A steroid-sparing effect was achieved for 13 (81.25%) of the 16 and for 11 (73.33%) of the 15 patients who were on systemic steroid in the early- and late-treated groups respectively. The mean follow-up for the early-treated group was 2.14 years and for the late-treated group, 3.46 years.

CONCLUSIONS

Immunomodulatory therapy is an effective treatment for severe HLA-B27 uveitis that fails to respond to conventional steroid treatment, regardless of the timing of its initiation. However, introduction of IMT within 3 years of the disease onset prevents the adverse effects of steroids (cataract, glaucoma) and reduces the likelihood of repeated recurrences of the uveitis.