The suprachoroidal space in patients affected by retinitis pigmentosa

BACKGROUND AND OBJECTIVE

The Suprachoroidal Space (SCS) is a theoretical structure which can be demonstrated between the inner border of the sclera and the outer boundary of the choroid. SCS is being studied for its potential uses as a route for drug delivery and innovative surgical techniques for the treatment of many retinal diseases. Retinitis pigmentosa (RP) is a group of inherited eye disorders characterized by a gradual loss of photoreceptors, resulting in vision impairment, which typically presents as night blindness and progressive visual field loss. The purpose of the study is to define the morphology of outer choroidal margins by means of SS-OCT in RP.

MATERIAL AND METHOD

This is a retrospective observational study designed to evaluate the presence of SCS in RP. We performed Swept Source optical coherence tomography (SS-OCT) in a group of 55 patients affected by RP (26 males and 29 females, 110 eyes) with a mean age of 51.8 ± 13.7 years. In the control group, we included 28 healthy subjects (6 males and 22 females, 56 eyes) with a mean age of 48,8 ± 16,6 years.

RESULTS

OCT scans allowed the outer choroidal margin and inner scleral margin to be delineated with certainty in all 110 eyes. In the RP group SCS was detected in 47 of 110 eyes (42,7%), in the control group SCS was detected in 11 eyes (19,6%). Subjects with SCS visible (RP group) had reduced retinal thickness (168.4 µm) compared to those with not visible SCL (211.2 µm, P = .007).

CONCLUSIONS

SS-OCT can be successfully applied to assess the presence of SCS in RP and the high rate of SCS found in the RP patients is encouraging when considering future innovative therapies.

P83 PERCUTANEOUS INTERVENTION FOR AORTIC COARCTATION IN YOUNG ADULTS: A CASE SERIES

Introduction

Aortic coarctation is one of the most frequent misdiagnosed congenital heart diseases and the most commonly missed foetal congenital heart disease. In adulthood the treatment of this pathology is primarily percutaneous.

Case Presentation

We present a case series of two young patients. The formers was a 37–years–old male with recent onset of heart failure symptoms due to misdiagnosed congenital aortic coarctation. The latter was a 39–years–old woman with exertional dyspnoea and a previous operated bicuspid aortic valve; in this case the intervention for the aortic defect was made in a second time, in order to avoid a huge demolishing surgical procedure. The execution of a diagnostic multimodality imaging allowed to detect the aortic coarctation, which received indication to percutaneous correction of the aortic defect after the multidisciplinary “Heart Team” discussion (image 2 and 3). In the cath–lab, the use of novel digital techniques, integrating the angiographic images with previously acquired angio–CT, allowed a safe stent delivery with minimum amount of contrast injection (image 1).

Conclusion

Percutaneous treatment of aortic coarctation in young adult is safe and effective. Fusion imaging tools could be very useful to optimize procedural results and sparing contrast dye, suggesting their possible implementation in different percutaneous procedures.

Telemedicine: first steps in a north-eastern Italian region during first year of pandemic

Background

Covid-19 pandemic imposed searching for innovative solutions to ensure safety access to outpatient services. In March 2020 first cases were reported in Friuli Venezia Giulia (FVG) region, in Italy; in April 2020 FVG included teleconsultation in the healthcare offer. This study evaluated in-presence medical consultations (IPCs) delivered in FVG before and after first cases reported in region and correlation between IPCs, teleconsultations and new admissions to Covid-19 wards during pandemic.

Methods

IPCs were analysed dividing in pre (February 1st, 2019-February 29th, 2020) and post (March 1st, 2020-March 31st, 2021) Covid-19 emergency period and comparing mean months values with t-test. IPCs and teleconsultations delivered during emergency (March 1st, 2020-March 31st, 2021) were divided in months and correlated with new admissions to Covid-19 wards in the same period with Pearson test.

Results

IPCs delivered in pre-Covid-19 period compared with post were 1,105,823 vs 973,350 (-12%), peaking in October (98,980 vs 86,821; -12.3%) and minimum in April (82,061 vs 61,523; -25.1%). Pre-Covid-19 mean IPCs were significantly different compared to post (85,063 vs 74,873; p=.003). Focusing on emergency period, IPCs were negatively related to teleconsultations (973,350 vs 2140; r=-.43; p=.13). The negative correlation found between new admissions to Covid-19 wards (9154) and IPCs was weak and not significant (r=-.12; p=.69), while a positive and significant correlation was found between teleconsultations and new admissions to Covid-19 wards (r=.59; p=.03).

Conclusions

Results showed a significant reduction of post-Covid-19 IPCs compared to pre and a significant correlation between teleconsultations and new admissions to Covid-19 wards in FVG during first year of Covid-19 emergency. Contagion containment measures and fear probably influenced access to outpatient services while teleconsultation should be considered as an alternative to face-to-face during pandemic period.

Key messages

A reduction of in-presence medical consultations was found in a north-eastern Italian region during first year of pandemic.

Teleconsultation could be a valid solution in case of increasing Covid-19 hospitalizations.

Evaluation of myocardial reperfusion in patients undergoing cangrelor supported primary PCI for STEMI

Background

Optimal myocardial reperfusion is the main goal of pharmaco-invasive treatment in STEMI patients. Cangrelor is a new intravenous P2Y12 inhibitor, mainly used in intra-procedural PCI setting of STEMI patients. Intracoronary cangrelor bolus application results in high local drug concentrations and may be more effective than a standard intravenous bolus.

Aim

This study aims to investigate the potential benefits of intracoronary versus intravenous cangrelor bolus in STEMI patients undergoing to primary PCI (p-PCI).

Materials and methods

Overall, 71 consecutive STEMI patients undergoing p-PCI were treated with intracoronary (n=37) or intravenous (n=34) bolus cangrelor administration with subsequent 2-hour intravenous infusion. The primary end point was ST-elevation reduction (STR) ≥50% at 30 minutes and at 24 hours after p-PCI. Secondary end points were STR ≥70% at 30 min after p-PC, TIMI frame count, and the QT dispersion (QTd). Moreover, stent thrombosis, bleeding events according to BARC classification, and 30-day mortality have been evaluated as safety explorative end points.

Results

STEMI patients treated with intravenous Cangrelor bolus had a higher rate of STR ≥50% either at 30 minutes (72% vs. 45%; p=0.033) or at 24 hours after p-PCI (87.1% vs. 63.6%; p=0.030) as compared to patients treated with intracoronary Cangrelor bolus; similarly, STR ≥70% at 30 minutes was more frequent in the intravenous bolus group as compared to intracoronary one (67% vs. 29% p=0.02). Furthermore, multivariable analysis demonstrated that intravenous Cangrelor bolus administration was an independent predictor of STR ≥50% (OR 3.586; 95% CI 1.134 to 11.335; p=0.030). No differences according to the TIMI frame count and the QTd were found. No stent thrombosis were observed at 30 days. The incidence of mortality and bleeding events (BARC 3–5) were comparable among study groups (30 days-death: 2.9% vs 5.4%, p=0.606; BARC 3–5 bleedings: 17.6% vs 13.5% p=0.630).

Conclusion

Intravenous coronary bolus administration of cangrelor in primary PCI is superior to intracoronary treatment with respect to extent of microvascular obstruction, and perfusion.

Funding Acknowledgement

Type of funding sources: None.

Spondylodiscitis and endocarditis, the strange couple

Background

The association between spondylodiscitis and infective endocarditis (IE) was first reported in 1965 but only a few data are available in the literature about this clinical picture. Early diagnosis of infective endocarditis as the source of spondylodiscitis is often difficult. The aim of this study was to evaluate the proportion of spondylodiscitis in patients with IE and to determine its clinical features.

Methods

We retrospectively analyzed 355 consecutive patients (127 women) admitted to our department with definite diagnosis of IE. Mean age was 65 years (SD 15.3). IE occurred on native valves in 223 patients (63%) and it involved the aortic valve in 191 cases (54%), mitral valve in 138 cases (39%) and tricuspid valve in 26 (7%). Spondylodiscitis occurred in 24 patients (7%). The diagnosis of spondylodiscitis was made on the basis of typical clinical and radiologic signs. Long-term follow-up was obtained by structured telephone interviews. Average duration of follow-up was three years. Primary endpoint was to establish clinical features of patients with IE complicated by spondylodiscitis.

Results

At univariable analysis spondylodiscitis was associated with male sex (p=0.043), diabetes (p=0.049), drug abuse (p=0.017) and enterococcus infection (p=0.043). At multivariable analysis diabetes (p=0.014) and drug abuse (p=0.006) were independently correlated with the presence of spondylodiscitis. Other clinical features were not associated with the presence of spondylodiscitis (age, BMI, chronic renal failure, paravalvular extension of infection, vegetation length, EuroScore 2, PCR and procalcitonin levels, type of valve infected). Mortality was similar between patients with and without spondylodiscitis.

Conclusions

The association of spondylodiscitis and infectious endocarditis should always be suspected, expecially in patients with a high risk profile. Hence, patients with spondylodiscitis should be submitted to echocardiography, mainly when the infective organism is an Enterococcus. Conversely, patients with IE should undergo screening for methasthatic infection.

Funding Acknowledgement

Type of funding source: None

Gorlin's Syndrome. Case Report

Gorlin's syndrome (GS) is a hereditary dominant autosomal disease linked to a gene which has a strong discerning and an extremely variable expressiveness. It is an ecto-mesodermic polydysplasia generally characterized by multiple nevoid basal-cell carcinomas, palmo-plantar pits, cysts of cutis and long bones, intracranial ectopic calcification; less frequently it is accompanied by tumors of other organs such as the ovaries, and by brain, neurological and ocular defects. Chalazions and squinting are the most typical ocular complications. We describe a patient with GS detected at an ophthalmology consultancy during which by chance we found multiple peripheral retinal breaks with a partial retinal detachment and retinoschisis.

Retinal Pigment Epithelium Tear following Toxemia of Pregnancy

A 28-year-old woman with toxemia during the 34th week of pregnancy complained of visual loss in one eye. Two weeks after abruptio placentae and delivery a retinal pigment epithelium (RPE) tear which presumably followed a RPE detachment (PED) was found in the macular region of the right eye. Visual acuity was 0.8 at the time of diagnosis but was 1.0 in both eyes one year after the delivery. Some authors have described peculiar choroidal lesions associated with central serous chorioretinopathy (CSC) in pregnancy and ischemic exudative choroidal lesions during severe toxemia. However, the findings we describe are highly unusual, indicating that the mechanisms of choroidal and RPE pathology are still poorly understood. We also demonstrate that a pathological tear following toxemia of pregnancy is compatible with good acuity in spite of the anatomical damage.

Intravitreal Bevacizumab Therapy for Choroidal Neovascularization Secondary to Age-Related Macular Degeneration: 6-Month Results of an Open-Label Uncontrolled Clinical Study

Purpose

To investigate the 6-month safety and clinical outcomes of intravitreal injections of bevacizumab administered to treat choroidal neovascularization secondary to age-related macular degeneration.

Methods

Twenty-seven patients underwent 1.25 mg intravitreal injections of bevacizumab at baseline. A similar intravitreal injection was administered to all eyes at 1 and 2 month follow-up visits. At baseline and at each follow-up visit (1, 2, 3, and 6 months), patients underwent best-corrected visual acuity (BCVA) measurement, fluorescein angiography, indocyanine green angiography, and optical coherence tomography. Laboratory testing, visual field analyses, and endothelial cell counts were performed at baseline and third and sixth months.

Results

At 3 months, the mean BCVA remained substantially stable at 20/100. Mean central retinal thickness (CRT) decreased from 373 to 279 μm (p<0.01). Mean lesion greatest linear dimension (GLD) decreased from 4087 to 3782 microns (p<0.01). At 6 months, mean BCVA slightly decreased from 20/100−1 to 20/125−3 (not significant, p=0.40). Mean CRT was still inferior to baseline (305 μm, p<0.01). Mean lesion GLD was 4186 μm, not different from baseline values (p=0.59), but superior to 3-month mean GLD (p<0.01). Significant visual field defects or endothelial cell losses were not detected at 3 and 6 months. Laboratory testing did not reveal any clinically significant deviations compared to baseline values.

Conclusions

Intravitreal therapy using bevacizumab over 6 months showed stabilization of visual acuity and choroidal neovascularization activity; the safety data were convincing. (Eur J Ophthalmol 2007; 17: 230–7)

Infliximab for the Treatment of Posterior Uveitis with Retinal Neovascularization in Behçet Disease

Purpose

To report a case of posterior uveitis with retinal neovascularization in a patient with Behçet disease treated with infliximab.

Methods

A 50-year-old man with a history of recurrent relapses of ocular inflammation despite immunosuppressive therapy developed retinal neovascularization near the optic disk. The patient was treated with infliximab and followed up for 12 months.

Results

Retinal neovascularization regressed 8 months after the first anti–tumor necrosis factor (TNF) treatment and with six infusions of infliximab. The ocular inflammation resolved almost completely.

Conclusions

The result suggests that anti-TNF therapy may be effective in the treatment of retinal neovascularization caused by panuveitis in Behçet disease.

Temporal integration of soil N2O fluxes: validation of IPNOA station automatic chamber prototype

The assessment of nitrous oxide (N₂O) fluxes from agricultural soil surfaces still poses a major challenge to the scientific community. The evaluations of integrated soil fluxes of N₂O are difficult owing to their lower emissions when compared with CO₂. These emissions are also sporadic as environmental conditions act as a limiting factor. A station prototype was developed to integrate annual N₂O and CO₂ emissions using an automatic chamber technique and infrared spectrometers within the LIFE project (IPNOA: LIFE11 ENV/IT/00032). It was installed from June 2014 to October 2015 in an experimental maize field in Tuscany. The detection limits for the fluxes were evaluated up to 1.6 ng N-N₂O m² s^-1 and 0.3 μg C-CO₂ m² s^-1. A cross-comparison carried out in September 2015 with the "mobile IPNOA prototype"; a high-sensibility transportable instrument already validated provided evidence of very similar values and highlighted flux assessment limitations according to the gas analyzers used. The permanent monitoring device showed that temporal distribution of N₂O fluxes can be very large and discontinuous over short periods of less than 10 days and that N₂O fluxes were below the detection limit of the instrumentation during approximately 70% of the measurement time. The N₂O emission factors were estimated to 1.9% in 2014 and 1.7% in 2015, within the range of IPCC assessments.

Allergological in vitro and in vivo evaluation of patients with hypersensitivity reactions to infliximab

BACKGROUND

The administration of biological agents is potentially affected by IgE-mediated infusion reactions.

OBJECTIVE

The aim of the study was to evaluate the utility of skin testing in patients who have experienced infliximab (IFX)-related reactions.

METHODS

Thirty patients with previous immediate hypersensitivity reaction to IFX, 20 disease-matched non exposed subjects, 15 IFX-treated disease-matched tolerant patients and 15 IFX non-responder patients were enrolled. Non-isotype-specific and IgE anti-drug antibodies (ADAs) were measured by a double-capture ELISA kit and ImmunoCAP assay, respectively. Prick and intra-dermal tests were carried out with the commercial IFX preparation serially diluted.

RESULTS

Skin testing, performed in 23 of 30 reactive patients, resulted positive in 7 of them (30.4%), whereas no positivity was found in other groups of patients. The majority of reactive patients displayed non-isotype-specific ADAs (23/30, 76.6%) and the presence of anti-IFX IgE antibodies was detected in 6 of them (26%). All 6 IgE-positive reactive patients showed skin testing positivity. One reactive ADAs-positive patient who resulted skin test positive, with no detectable serum IFX-specific IgE ADAs, was also found. Skin testing positivity was associated with severe and early reactions (within the 3rd dose). No unexpected adverse reactions to skin testing were recorded.

CONCLUSIONS AND CLINICAL RELEVANCE

This study shows that about 30% of reactive patients display skin testing positivity. They usually develop severe reactions, mainly during the first administrations of IFX. The specificity and the safety of skin testing procedure for this biological agent are also confirmed.

Descriptive epidemiology of malignant mucosal and uveal melanomas and adnexal skin carcinomas in Europe

This work provides descriptive epidemiological data of malignant mucosal and uveal melanomas and adnexal skin carcinomas in Europe as defined as in the RARECARE project. We analysed 8669 incident cases registered in the period 1995-2002 by 76 population-based cancer registries (CRs), and followed up for vital status to 31st December 2003. Age-standardised incidence to the European standard population was obtained restricting the analysis to 8416 cancer cases collected by 64 not specialised CRs or with information available only for some anatomical sites. Period survival rates at 2000-2002 were estimated on 45 CRs data. Twenty-two CRs which covered the period 1988-2002 were analysed to obtain the 15-year prevalence (1st January 2003 as reference date). Complete prevalence was calculated by using the completeness index method which estimates surviving cases diagnosed prior to 1988 ('unobserved' prevalence). The expected number of new cases per year and of prevalent cases in Europe was then obtained multiplying the crude incidence and complete prevalence rates to the European population at 2008. We estimated 5204 new cases per year (10.5 per million) to occur in Europe, of which 48.7% were melanomas of uvea, 24.8% melanomas of mucosa and 26.5% adnexal carcinomas of the skin. Five-year relative survival was 40.6% and 68.9% for mucosal and uveal melanomas, respectively. Adnexal skin carcinomas showed a good prognosis with a survival of 87.7% 5 years after diagnosis. Northern Europe, United Kingdom (UK) and Ireland showed the highest 5-year survival rate for uveal melanomas (72.6% and 73.4%), while Southern Europe showed the lowest rate (63.7%). More than 50,000 persons with a past diagnosis of one of these rare cancers were estimated to be alive at 2008 in Europe, most of them (58.8%, n=29,676) being patients with uveal melanoma. Due to the good prognosis and high incidence of uveal melanomas, these malignancies are highly represented among the long-term survivors of the studied rare cancer types. Therefore, maximising quality of life is particularly important in treatment of uveal melanoma. As regards mucosal melanomas, the centralisation of treatment to a select number of specialist centres as well as the establishment of expert pathology panels should be promoted. The geographical differences in incidence and survival should be further investigated analysing the centre of treatment, the stage at diagnosis and the treatment.

Light panretinal photocoagulation (LPRP) versus classic panretinal photocoagulation (CPRP) in proliferative diabetic retinopathy

PURPOSE

We misled to verify whether a panretinal photocoagulation (PRP) performed using low levels of ARGON laser energy (light PRP) has the same efficacy as a PRP performed in a conventional fashion using argon green wavelengths (classic PRP) in eyes with high-risk proliferative diabetic retinopathy (HRPDR). Furthermore, we misled to compare the session number performed and the side effects produced by the two techniques.

METHODS

Sixty-five eyes with HRPDR of 50 consecutive patients were enrolled in a prospective randomized controlled trial. In eyes selected for light PRP, a very light biomicroscopic effect on the retina was obtained for each spot. In eyes assigned to classic PRP, each spot produced a white-yellow biomicroscopic effect. Mean follow-up was 22.4 months +/- 9.7 in the light PRP and 21.6 months +/- 9.3 in the classic PRP group (p = 0.727).

RESULTS

The initial mean logMAR visual acuity (VA) in the light PRP group was 0.12 +/- 0.13 and in the classic PRP group 0.14 +/- 0.15 (p = 0.493). The final mean VA in the former was 0.18 +/- 0.25, and in the latter 0.27 +/- 0.30 (p = 0.231). Median power was 235mW (100-540mW) for light and 420mW (200-950mW) for classic PRP (p < 0.001). Regression of HRPDR at the end of the follow-up was obtained in 30/31 eyes (97%) treated with classic PRP and in 31/34 eyes (91%) treated with light PRP (p = 0.615). The total mean session number was 7.4 +/- 2.4 for light and 9.9 +/- 2.2 for the classic PRP group (p < 0.001). Complications were more frequent in the classic PRP group.

CONCLUSIONS

The efficacy of Light PRP is similar to that of classic Light PRP in eyes with HRPDR. Light PRP is associated with fewer complications and allows the reduction of the number of treatment sessions.

[High-intensity focused ultrasound and prostate cancer: technology, state of the art and future]

BACKGROUND. The potential applications of the high-intensity focused ultrasound (HIFU) as a minimally invasive therapy of the localized prostate cancer explain the growing interest of the urologic community towards this technique. HIFU has been assessed for its role in the treatment of localized prostate cancer in patients who otherwise would not have benefited from surgery, and in local recurrences after radiation failure. Methods. Relevant information on HIFU treatment was identified through a literature search of published studies. RESULTS. High biochemical efficacy, excellent tumor local control and favorable mid- and long-term oncological data with a low morbidity rate have been shown in many series of patients. CONCLUSIONS. Although HIFU is a recent and emerging technology, it has been well studied and developed to a point that HIFU will undoubtedly be an effective alternative to radiation therapy.

High-intensity focused ultrasound and prostate cancer: technology, state of the art and future

Background.

The potential applications of the high-intensity focused ultrasound (HIFU) as a minimally invasive therapy of the localized prostate cancer explain the growing interest of the urologic community towards this technique. HIFU has been assessed for its role in the treatment of localized prostate cancer in patients who otherwise would not have benefited from surgery, and in local recurrences after radiation failure.

Methods.

Relevant information on HIFU treatment was identified through a literature search of published studies.

Results.

High biochemical efficacy, excellent tumor local control and favorable mid- and long-term oncological data with a low morbidity rate have been shown in many series of patients.

Conclusions.

Although HIFU is a recent and emerging technology, it has been well studied and developed to a point that HIFU will undoubtedly be an effective alternative to radiation therapy.

Laser photocoagulation for neovascular age-related macular degeneration

BACKGROUND

Laser photocoagulation was the first treatment introduced to try to halt the progression of neovascular age-related macular degeneration (AMD), in which newly formed vessels or choroidal neovascularisation (CNV) grow under the macula leading to the occurrence of a scotoma or blind spot in the central visual field.

OBJECTIVES

The aim of this review was to examine the effects of laser photocoagulation for neovascular AMD.

SEARCH STRATEGY

We searched the CENTRAL, MEDLINE, EMBASE, LILACS, NRR and ZETOC in March 2007.

SELECTION CRITERIA

We included randomised trials of laser photocoagulation in people with CNV due to AMD.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data. The risk ratio (RR) of severe visual loss (loss of six or more lines of visual acuity) was estimated at three months and two years after treatment.

MAIN RESULTS

Fifteen trials were included in the review (2064 participants). Three types of photocoagulation were used in the trials: direct photocoagulation of the entire CNV (11 trials), perifoveal photocoagulation (one trial) and grid photocoagulation (three trials). In 12 trials the control group was observation only. One trial compared photocoagulation to submacular surgery and two trials compared different lasers. Data on the progression of visual loss could be extracted from five of the eight trials of direct photocoagulation of the CNV versus observation. The treatment effect was in the direction of harm in all studies at three months follow up (RR 1.41, 95% confidence intervals (CI) 1.08 to 1.82). After two years the treatment effect was in the direction of benefit (RR 0.67, 95% CI 0.53 to 0.83). These studies were clinically heterogeneous with participants having CNV lesions in different locations and different baseline visual acuities. There was little evidence of statistical heterogeneity at three months but substantial statistical heterogeneity at two years. However, all treatment effects in the individual trials were in the direction of benefit. One study comparing perifoveal photocoagulation or observation of subfoveal CNV found benefits that were statistically significant only at two years (RR 0.36, 95% CI 0.18 to 0.72). Other comparisons did not demonstrate differences.

AUTHORS' CONCLUSIONS

In the medium to long term laser photocoagulation of CNV slows the progression of visual loss in people with neovascular AMD. However, it is associated with an increased risk of visual loss immediately after treatment and this period may be longer in people with subfoveal AMD. With the advent of modern pharmacological therapies, and concern for the impact of iatrogenic scotoma in subfoveal CNV, laser photocoagulation of subfoveal CNV is not recommended. No studies have compared photocoagulation with modern pharmacological agents for AMD for non-subfoveal CNV.

Quality of vision: A consensus building initiative for a new ophthalmologic concept

PURPOSE

Many studies have addressed the quantification of visual acuity, and the conventional method of measuring it has so far demonstrated serious limitations. Vision testing requires new methods that can more precisely express the quality of vision as perceived by the patient.

METHODS

This study employed the Delphi method of consensus building. Concepts associated with quality of vision (QoV) were identified by a board of experts and proposed to participating specialists in two subsequent questionnaires. Upon receipt of the completed questionnaires, the replies were classified to determine the building blocks of a consensus.

RESULTS

By analyzing the replies to the two questionnaires, the authors determined the key elements of QoV on which a consensus was found among the respondents.

CONCLUSIONS

A consensus was reached on the opinion that the quantification of visual acuity by traditional means is inadequate for investigating QoV. Although visual acuity is still a basic element for testing, the experts believe that contrast sensitivity, reading speed, and microperimetry are additional parameters necessary for quantifying QoV. The use of a psychometric questionnaire on visual function could allow a better interpretation of visual impairment.

Reading aids for adults with low vision

BACKGROUND

The purpose of low vision rehabilitation is to allow people to resume or to continue to perform daily living tasks, reading being one of the most important. This is achieved by providing appropriate optical devices and special training in the use of residual vision and low vision aids, which range from simple optical magnifiers to high power video magnifiers.

OBJECTIVES

The objective of this review was to assess the effects of reading aids for adults with low vision.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group Trials Register) in The Cochrane Library, MEDLINE, EMBASE, SIGLE, LILACS, IndMed to July 2006 and the reference lists of relevant articles. We used the Science Citation Index to find articles that cited the included studies and contacted investigators and manufacturers of low vision aids. We handsearched the British Journal of Visual Impairment from 1983 to 1999 and the Journal of Visual Impairment and Blindness from 1976 to 1991.

SELECTION CRITERIA

This review included randomised and quasi-randomised trials in which any device or aid used for reading had been compared to another device or aid in people aged 16 or over with low vision as defined by the study investigators.

DATA COLLECTION AND ANALYSIS

Each author independently assessed trial quality and extracted data.

MAIN RESULTS

Eight small studies with a cross-over design (221 people overall) and one three parallel-arm study (243 participants) were included in the review. The cross-over studies evaluated various types of aids. The quality of the studies was unclear in most cases, especially concerning carry-over or period effects. In one study on 20 participants head-mounted electronic devices (four types) were worse than optical devices. We could not find any differences in comparisons among electronic devices when pooling 23 participants of two small studies. One study on 10 people found that overlay coloured filters were no better than a clear filter. A parallel-arm study including 243 patients with age-related macular degeneration found that custom or standard prism spectacles are not different from conventional near spectacles, but the estimated difference was not precise.

AUTHORS' CONCLUSIONS

Further research is needed on the comparison of different types of low vision aids. It will be also necessary to delineate patient's characteristics that predict performance with costly electronic devices as well as their sustained use in the long term compared to simpler and cheaper optical devices.

Evolving European guidance on the medical management of neovascular age related macular degeneration

BACKGROUND

Until recently, only two options were available for the treatment of choroidal neovascularisation (CNV) associated with age related macular degeneration (AMD)-thermal laser photocoagulation and photodynamic therapy with verteporfin (PDT-V). However, new treatments for CNV are in development, and data from phase III clinical trials of some of these pharmacological interventions are now available. In light of these new data, expert guidance is required to enable retina specialists with expertise in the management of AMD to select and use the most appropriate therapies for the treatment of neovascular AMD.

METHODS

Consensus from a round table of European retina specialists was obtained based on best available scientific data. Data rated at evidence levels 1 and 2 were evaluated for laser photocoagulation, PDT-V, pegaptanib sodium, and ranibizumab. Other treatments discussed are anecortave acetate, triamcinolone acetonide, bevacizumab, rostaporfin (SnET2), squalamine, and transpupillary thermotherapy.

RESULTS

PDT-V is currently recommended for subfoveal lesions with predominantly classic CNV, or with occult with no classic CNV with evidence of recent disease progression and a lesion size <or=4 Macular Photocoagulation Study (MPS) disc areas (DA). The new classes of anti-angiogenic agents-namely, pegaptanib sodium and ranibizumab (the latter when peer reviewed phase III data become available) are recommended for subfoveal lesions with any proportion of classic CNV or occult with no classic CNV. For juxtafoveal classic CNV, PDT-V or anti-angiogenic therapy should be considered if the new vessels are so close to the fovea that laser photocoagulation would almost certainly extend under the centre of the foveal avascular zone. For all other well demarcated juxtafoveal lesions and for extrafoveal classic lesions, laser photocoagulation remains the standard treatment. Therapy should be undertaken within 1 week of the fluorescein angiogram on which the clinical decision to treat is based. At each follow up, fluorescein angiography should be performed and best corrected visual acuity measured as a minimum requirement.

CONCLUSIONS

These recommendations provide evidence based guidance for the choice and use of non-surgical therapies for the management of neovascular AMD. Revisions of the recommendations may be required as new data become available.

Orientation and mobility training for adults with low vision

BACKGROUND

Orientation and mobility (O&M) training is provided to people who are visually impaired to help them maintain travel independence. It teaches them new orientation and mobility skills to compensate for reduced visual information.

OBJECTIVES

The objective of this review was to assess the effects of (O&M) training, with or without associated devices, for adults with low vision.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group Trials Register) in The Cochrane Library, MEDLINE, SIGLE, EMBASE, National Research Register, Zetoc, LILACS, and the reference lists of articles. Updated searches were in 2006.

SELECTION CRITERIA

We planned to include randomised or quasi-randomised trials comparing (O&M) training with no training in adults with low vision.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the search results for eligibility, evaluated study quality and extracted the data.

MAIN RESULTS

Two small studies satisfied the inclusion criteria. They were consecutive phases of development of the same training curriculum and assessment tool. The intervention was administered by a volunteer on the basis of written and oral instruction. In both studies the randomisation technique was inadequate, being based on alternation, and masking was not achieved. Training had no effect in the first study while it was found to be beneficial in the second. Reasons for this may have been: the high scores obtained in the first study, suggestive of little need for training and small room for further improvement (a ceiling effect), and the refinement of the curriculum allowing better tailoring to patients' specific needs and characteristics, in the second study.

AUTHORS' CONCLUSIONS

The review found two small trials with similar methods, comparing (O&M) training to physical exercise, which were unable to demonstrate a difference. Therefore, there is little evidence on which type of orientation and mobility training is better for people with low vision who have specific characteristics and needs. Orientation and mobility instructors and scientists should plan randomised controlled studies to compare the effectiveness of different types of (O&M) training. A consensus is needed on the adoption of standard measurement instruments of mobility performance which are proved to be reliable and sensitive to the diverse mobility needs of people with low vision. For this purpose, questionnaires and performance-based tests may represent different tools that explore people with low vision's subjective experience or their objective functioning, respectively.

Clear corneal incision of 2.75 mm for cataract surgery induces little change of astigmatism in eyes with low preoperative corneal cylinder

PURPOSE

To assess the early astigmatic effect induced by 2.75 mm clear cornea incisions with different locations for cataract surgery.

METHODS

A total of 146 eyes of different patients were studied prospectively. Cataract surgery was performed by three surgeons, two using a temporal approach and one using a superior approach. For both approaches, the site of the 2.75 mm incision was allowed to vary slightly according to the characteristics of the eye and orbit. Computerized videokeratography was used to measure corneal astigmatism before surgery and after 1, 4, and 12 weeks. Corneal astigmatism was recorded as cylinder and axis and it was then converted to 2 power vector. Model based prediction and comparisons were made for the most commonly used corneal incision sites: 12 (both eyes), 2 (left eye), and 8 (right eye) o'clock meridian.

RESULTS

After 3 months the differences in corneal astigmatism (JCC 0 ) between the incisions performed at 12 and 2 o'clock were not statistically significant (-0.08, 95% CI: -0.19, -0.02); the differences in JCC 0 between incisions at 12 and 8 o'clock were -0.17 (95% CI: -0.30, -0.05; p<0.01). After 3 months the change in JCC 0 for the patients with 0.5 D with-the-rule preoperatively were -0.32 (95% CI: -0.44, 0.21; p<0.01) for incisions at 12; -0.24 (95% CI: -0.36, 0.13; p<0.01) for incisions at 2; and -0.15 (95% CI: -0.27, -0.03; p<0.05) for incisions at 8. After 3 months the changes of JCC 0 for the patients with -0.5 D against-the-rule pre-operatively were 0.10 (95% CI: 0.04, 0.23) for incision at 12; 0.18 (95% CI: 0.04, 0.32; p<0.05) for incisions at 2; and 0.27 (95% CI: 0.14, 0.40; p<0.01) for incisions at 8 o'clock. The oblique astigmatic vector (JCC 45 ) was very modest in this sample before surgery and underwent minimal and nonsignificant change after it.

CONCLUSIONS

This study has shown that a 2.75 mm clear corneal incision causes a small change of corneal cylinder regardless of incision site.

Fluorescein angiography and indocyanine green angiography for identifying occult choroidal neovascularization in age-related macular degeneration

PURPOSE

To assess whether fluorescein angiography (FA) alone without indocyanine green angiography (ICGA) can identify and localize occult choroidal neovascularization (CNV) in age-related macular degeneration (ARMD).

METHODS

Seventy-nine eyes of 77 consecutive patients with occult CNV were evaluated independently by two skilled physicians at first with FA alone and then with FA combined with ICGA by fundus camera.

RESULTS

The agreement between FA and ICGA was 73% and 68% for the two physicians (K=0.585 and 0.512, respectively). The first operator correctly identified 20/27 as plaque CNV; six had different sizes and locations. The second operator identified 25/30, with one mistaken for size and location. For focal CNV the first operator identified 34/39, and the second one 23/35.

CONCLUSIONS

Comparing the FA results with ICGA, CNV was correctly identified in about 60% of cases. Therefore, ICGA should be considered an indispensable diagnostic test to identify the presence, the type, and the location of occult CNV.

Laser photocoagulation for choroidal neovascularisation in pathologic myopia

BACKGROUND

Pathologic myopia is usually defined as the need for a spectacle correction of -6 diopters or higher. Choroidal neovascularisation (CNV) is the most commonly occurring cause of visual loss in people with pathologic myopia. In myopic macular degeneration the occurrence of newly formed vessels in the macula often leads to a fibrotic pigmented scar causing a blind spot in the centre of the visual field.

OBJECTIVES

The primary objective of this review was to examine the effects of laser photocoagulation for CNV associated with pathologic myopia. A secondary objective was to compare the effects of different photocoagulation techniques.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group Trials Register) on The Cochrane Library (Issue 2, 2005), MEDLINE (1966 to July 2005), EMBASE (1980 to July 2005, week 28), LILACS (July 2005) and the reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials comparing photocoagulation with observation or comparing different photocoagulation techniques in people with CNV associated with myopia of -6 diopters or higher.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the search results for eligibility.

MAIN RESULTS

Two studies were included that enrolled people with CNV located at 100 microns or more from the foveal centre. One study compared photocoagulation with observation. At the final examination, 16/35 participants randomised to photocoagulation versus 31/35 randomised to observation had visual acuity of 20/100 or worse after 6 to 48 months. The second study randomised 27 eyes (26 patients) to photocoagulation with three laser wavelengths (9 eyes per group). The number of eyes losing two or more lines was 2 (577 nm), 3 (590 nm) and 3 (620 nm) after 3 to 17 months. In both studies comparisons were made using outcomes assessed at the final examination. As the final examination took place at different follow-up times it was difficult to interpret the findings and it was impossible to extract data for further analyses.

AUTHORS' CONCLUSIONS

Despite its use over several years the effectiveness of laser photocoagulation for myopic CNV has not been established. Although there was a suggestion of short-term effectiveness in one small study on non-subfoveal CNV the results were potentially biased. Observational studies suggest that the enlargement of the atrophic laser scar after laser treatment of non-subfoveal CNV could be a potentially vision-threatening long-term complication, even in eyes free of CNV recurrence.

Infliximab for the treatment of posterior uveitis with retinal neovascularization in Behçet disease

PURPOSE

To report a case of posterior uveitis with retinal neovascularization in a patient with Behçet disease treated with infliximab.

METHODS

A 50-year-old man with a history of recurrent relapses of ocular inflammation despite immunosuppressive therapy developed retinal neovascularization near the optic disk. The patient was treated with infliximab and followed up for 12 months.

RESULTS

Retinal neovascularization regressed 8 months after the first anti-tumor necrosis factor (TNF) treatment and with six infusions of infliximab. The ocular inflammation resolved almost completely.

CONCLUSIONS

The result suggests that anti-TNF therapy may be effective in the treatment of retinal neovascularization caused by panuveitis in Behçet disease.

Transdermal electromotive administration of verapamil and dexamethasone for Peyronie's disease

OBJECTIVE

To evaluate the effects of the transdermal electromotive administration of verapamil and dexamethasone on plaque size, penile deviation, pain, erectile function and capacity for vaginal penetration in patients with Peyronie's disease.

PATIENTS AND METHODS

Forty-nine patients were treated four times weekly for six consecutive weeks. During each session the drug mixture was administered from a receptacle fixed to the skin overlying the plaques, using 2.4 mA pulsed current for 20 min. Plaque size and penile deviation were evaluated by dynamic penile duplex ultrasonography, X-ray and photographs; pain, erectile function and capacity for vaginal penetration were assessed using a questionnaire. Vital signs and side-effects were recorded. Differences before and after treatment were assessed.

RESULTS

The plaque disappeared in 8% of patients, with a measurable reduction in volume in 74% and no change in 18% (P < 0.001). Penile deviation resolved in 10% of the men, decreased in 74% and remained unchanged in 16% (P < 0.001). The plaque volume was halved in two-thirds of the men, to a mean (sd) of 515 (301) mm3, and the penile deviation halved in 45% of patients, to 24 (5) degrees; pain was completely eliminated in 88% (P < 0.001). Erectile function was completely restored in 42% of patients with initial erectile dysfunction and improved in 17% (P < 0.001); vaginal penetration improved in 73%. No toxicity was noted, except for a transient skin erythema at the site of the penile and dispersive electrodes.

CONCLUSION

The transdermal electromotive administration of verapamil and dexamethasone is clinically safe and appears to be an effective treatment in patients with Peyronie's disease.

Orientation and mobility training for adults with low vision

BACKGROUND

Orientation and mobility (O&M) training is provided to people who are visually impaired to help them maintain travel independence, teaching them new orientation and mobility skills to compensate for reduced visual information.

OBJECTIVES

The objective of this review was to assess the effects of orientation and mobility training, with or without associated devices, for adults with low vision.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials - CENTRAL (which contains the Cochrane Eyes and Vision Group trials register) (Issue 3 2002), MEDLINE (1966 to August 2002), EMBASE (1980 to September 2002) and LILACS (September 2002) and the reference lists of articles.

SELECTION CRITERIA

We planned to include randomised or quasi-randomised trials comparing orientation and mobility training with no training in adults with low vision.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the search results for eligibility.

MAIN RESULTS

No studies were found that satisfied the inclusion criteria.

REVIEWER'S CONCLUSIONS

We could not find any controlled trials on the effects of orientation and mobility training for adults with low vision. As a premise to future trials, orientation and mobility instructors and scientists should reach a consensus and develop valid measures of mobility performance which are both reliable and meaningful to people with low vision.

Retroperitoneal lipoma. Unusual presentation with detrusor instability

Retroperitoneal lipomas are a heterogeneous group of mesenchymal tumors. They are usually large and occur most frequently in the retroperitoneal, perineal and pelvic regions. Lipomas grow slowly surrounding the retroperitoneal and pelvic organs, with a displacement of bowel and vascular axis. A case of a 61-year-old male patient which referred urinary frequency, urgency and nocturia is presented. Urodynamics evidenced a detrusor instability in a low capacity bladder. CT scan demonstrated a bladder dome compression due to a huge retroperitoneal mass extending from the right hepatic lobe to the hypogastric region and the right thigh. Surgical complete resection was performed: histology demonstrated a lipoma with areas of well differentiated myxoid degeneration. After surgery the irritative urinary symptoms disappeared. This is the first case described in literature of detrusor instability due to bladder compression by retroperitoneal lipoma.

Bahren types III and IVa testicular vein anomalies as a reason for failure in left idiopathic varicocele retrograde sclerotherapy. Ontogenic discussion and clinical implications

Left testicular vein anatomy has received more attention due to the presence of competent or incompetent venous valves and bypassing anastomoses, which are involved in venographic diagnosis and embolisation of varicocele. The left gonadal vein develops, in both males and females, between the 5th and 7th intrauterine weeks, being derived from the distal or postrenal portion of the left subcardinal vein. The varicocele aetiologic hypothesis leads to ontogenetic disturbances in the development of the secondary venous system. Retrograde testicular venography shows the precise anatomy of the left pampiniform plexus, while anterograde testicular venography identifies the presence of the valve and possible continence. In the present case sclerotherapy could not be achieved due to testicular vein anomalies. Sclerotherapy versus surgical high ligature of the left testicular vein in cases of left idiopathic varicocele with testicular vein anomalies is discussed.

Clinical implications of left ovarian vein incomplete duplicity with embryonic intersubcardinal anastomosis-derived branches

During the dissection of a female human cadaver a case of a duplex ovarian vein was observed. It was unique in its upper course where it anastomosed with an inferior polar renal vein, which in turn was linked to an upper polar renal vein by means of a joining branch. It is hypothesised that this represent a persistent link between the left subcardinal vein and the left sacrocardinal vein, together with some branches of a venous net, which represent the embryological intersubcardinal anastomosis. The gonadal vein arises from the distal (or postrenal) left subcardinal vein portion; the left renal vein develops from the intersubcardinal anastomosis. The venous net derived from the intersubcardinal anastomosis may represent a bypass system in cases of left renal vein occlusion. Left gonadal vein duplicity may also play an important role in the anatomical basis of idiopathic left ovarian vein syndrome or left varicocele, and can lead to mistakes being made during venous sclerotherapy.

Intermittent catheterization with a prelubricated catheter in spinal cord injured patients: a prospective randomized crossover study

PURPOSE

We compared the safety and patient acceptance of a conventional Nélaton and a prelubricated nonhydrophilic catheter in 18 spinal cord injured patients on intermittent catheterization.

MATERIALS AND METHODS

In a prospective crossover study each catheter was used for 7 weeks and the initial course was randomized. Urinalysis and urine culture were performed at 2, 4 and 7 weeks. Urethral trauma was evaluated by urethral cell count on the surface of each catheter used on the last day of each study period. Patient satisfaction was assessed at the end of the study by a questionnaire using multiple visual analog scales.

RESULTS

Urinary tract infection was identified in 12 and 4 patients on a Nélaton and a prelubricated nonhydrophilic catheter (p = 0.03), while asymptomatic bacteruria was identified in 18 and 8 (p = 0.0244), respectively. The mean urethral cell count plus or minus standard deviation on the catheter surface was 6.7 +/- 2.8 x 10(4) and 15.1 +/- 8.9 x 10(4) for the prelubricated nonhydrophilic and the Néelaton catheter, respectively (p = 0.01). The prelubricated nonhydrophilic catheter resulted in a better mean satisfaction score than the Nélaton catheter (2.33 +/- 1.06 versus 4.72 +/- 2.13, p = 0.022). Urethral bleeding was reported in 2 patients during the study period while using the Nélaton catheter.

CONCLUSIONS

The prelubricated nonhydrophilic catheter is a safe, effective and comfortable option in spinal cord injured patients on intermittent self-catheterization.

Prostatic small cell carcinoma diagnosed by tru-cut needle biopsy: discussion of clinico-pathological findings

The small cell carcinoma is a neuroendocrine tumour characterised by an aggressive clinical course and a high mortality rate. It occurs most commonly in the lung. Small cell carcinomas originating in the genitourinary system have been diagnosed with increasing frequency in recent years, because of the use of immunohistochemistry. Prostatic small cell carcinomas present the same biological behavior and similar histological, immunohistochemical and ultrastructural features to small cell carcinomas of the lungs. We describe the clinico-pathological findings in a 65-year-old male patient with a diagnosis of prostatic small cell carcinoma, obtained by means of a tru-cut needle biopsy. We performed the immunohistochemical tests using neuron-specific enolase and chromogranin A antibodies, according to the literature. On the basis of our experience we stress the malignant features of small cell carcinoma and the difficulty in obtaining an early diagnosis and treatment because of the aggressive course of the lesion and the late symptomatology.

Carbon dioxide degassing by advective flow from Usu volcano, Japan

Magmatic carbon dioxide (CO2) degassing has been documented before the 31 March 2000 eruption of Usu volcano, Hokkaido, Japan. Six months before the eruption, an increase in CO2 flux was detected on the summit caldera, from 120 (September 1998) to 340 metric tons per day (September 1999), followed by a sudden decrease to 39 metric tons per day in June 2000, 3 months after the eruption. The change in CO2 flux and seismic observations suggests that before the eruption, advective processes controlled gas migration toward the surface. The decrease in flux after the eruption at the summit caldera could be due to a rapid release of CO2 during the eruption from ascending dacitic dikes spreading away from the magma chamber beneath the caldera.

[ICG angiography and retinal pigment epithelial decompensation (CRSC and epitheliopathy)]

PURPOSE

To evaluate the prognosis of chronic central serous chorioretinopathy (CSC) and to assess whether certain clinical and angiographic features are associated with increased risk of vision loss.

METHODS

All of the 51 patients with chronic CSC, who had received a baseline evaluation with fluorescein angiography (FA) and indocyanine green angiography (ICGA), during the last 5 years were retrospectively included in the study.

RESULTS

The mean age was 49 years (range: 28-77 years). Sixteen out of 102 eyes (15.7%) of 14 patients lost at least 3 lines (0.3logMAR) after a mean follow-up of 34.7 months (range: 12-72 months). Logistic regression showed that CSC onset more than 7 years before inclusion (odds ratio: 4.3, p=0.024) and having areas of confluent RPE atrophy with FA at baseline (at least 2 disc diameters, odds ratio: 4.9,p=0.020) were independently associated with vision loss. Choroidal neovascularization was observed during follow-up in 4 eyes of 3 patients.

CONCLUSION

Disease duration of more than 7 years and the presence of confluent RPE atrophy independently characterized CSC patients at higher risk for visual loss in our series.

Retroperitoneal laparoscopic access in children using a direct vision technique

PURPOSE

Retroperitoneal procedures were initiated in 1992 by balloon dissection of the retroperitoneum. More recently a new type of retroperitoneal access has been obtained by directly entering the retroperitoneum using the Visiport visual trocar. We present our initial experience with direct visual access to the retroperitoneum in the pediatric population.

MATERIALS AND METHODS

A total of 31 children underwent retroperitoneal laparoscopy, including renal biopsy in 22, varicocelectomy in 5, renal cyst ablation in 3 and pyelolithotomy for a staghorn stone in 1. Patients were placed in the full flank position. A maximum of 3 ports was used and the initial trocar was placed under direct vision. The laparoscope was then used to dissect bluntly a working space in the retroperitoneum.

RESULTS

All procedures were successful. Blood loss was minimal. Operative time was 4 hours for pyelolithotomy and less than 1 for the other procedures. Mean hospital stay was 1.5 days and all patients returned to normal activity at a mean of 6 days. Two minor complications developed. The peritoneum was inadvertently entered in 1 case, in which no further treatment was necessary and convalescence was uneventful and short. In another case severe arrhythmia developed, resulting in an aborted procedure.

CONCLUSIONS

This technique is simple, safe and does not require extensive laparoscopic experience.

[Ultrasonography of the upper urinary tract in patients with spinal cord injury]

A lesion of the upper urinary tract (UUT) is a possible outcome of the bladder dysfunction following a spinal cord injury (SCI). The most common findings are hydronephrosis, bladder-ureteral reflux and pyelonephritis. Aim of the study was to evaluate the prevalence of UUT abnormalities, evaluable by ultrasound (US), in a population of SCI patients; furthermore we correlated the presence of such abnormalities to clinical findings. We evaluated 115 consecutive patients who underwent US scan of UUT. Mean time between injury and our evaluation was 81.5 +/- 100.2 months. Lesion level was cervical (38/115), dorsal (59/115) and lumbar (18/115). Eight patients emptied their bladder spontaneously, 105 by means of intermittent catheterization, while 2 were wearing indwelling catheter. Seventy-four patients used anticholinergics drugs. It was evaluated the presence of: hydronephrosis, renal stones and chronic pyelonephritis using US. Afterward the presence of such alterations was correlated to sex and age of patients, time between injury and our evaluation, method of bladder emptying and use of anticholinergics drugs. In 25/115 patients (21.7%) were found abnormalities of UUT. A significative correlation was found between presence of UUT lesions and older age. In our series, prevalence of UUT abnormalities observed by means of US in SCI patients is 21.7%. This finding could be due to correct management and strict follow up of the patients.

Perilimbal topical anesthesia for clear corneal phacoemulsification

PURPOSE

To evaluate the efficacy of perilimbal topical anesthesia for clear corneal cataract surgery.

SETTING

Department of Ophthalmology, University of Udine, Udine, Italy.

METHODS

Seventy-five consecutive patients were studied for perioperative pain, visual outcome, and intraoperative complications. Topical anesthesia was administered with a cellulose sponge soaked in preservative-free lidocaine 2%. The perilimbal area was touched 360 degrees for 30 seconds with the sponge tip under the operating microscope just before surgery. No sedation or adjunctive anesthetic drops were given. Surgery was performed through a temporal corneal tunnel with the easy-chop technique. Pain was scored on a subjective scale from 0 (no pain) to 3 (severe pain). Visual acuity was measured 1 day and 1 week after surgery. Mean operating time was recorded.

RESULTS

Sixty-nine patients (92%) tolerated the procedure well, giving a pain score of 0 or 1. Six (8%) of the 40 patients who had a single stitch at the end of surgery scored 2. No patient reported pain during iris touch, intraocular lens implantation, or conjunctiva manipulation. No intraoperative complications were recorded. Mean operating time was 12.7 minutes +/- 3.7 (SD) (range 7 to 34 minutes). Mean preoperative visual acuity was 0.4 +/- 0.2 (range 0.01 to 0.80). Visual acuity of 0.5 or better was attained in 93.6% of eyes 1 day and in 96% 1 week postoperatively.

CONCLUSIONS

Perilimbal topical anesthesia was an effective and easy-to-administer anesthetic procedure for phacoemulsification, providing good perioperative pain tolerance by patients and rapid visual recovery.

Recurrent RPE microrips in a case of vascularised pigment epithelial detachment

Microrips of the RPE are an infrequent finding in vascularised pigment epithelial detachments (PEDs). Fluorescein angiography revealed that they are identical to the leaks seen in central serous chorioretinopathy (CSC); it has been hypothesised that both may be caused by hydrostatic forces generating a mechanical disruption of the RPE. We report a case of vascularised PED that was complicated by repeated subretinal haemorrhages and presented recurrent microrips of the RPE, which is a finding never described before according to our knowledge. In this case, a very high protein concentration in the subretinal space, due to prolonged bleeding from the neovascular membrane, might have damaged the RPE and reduced the choroidal suction, as believed for CSC. It might also have increased the intraluminal pressure in the PED, finally determining the passage of fluid through the microrips, which have been hypothesised to be RPE defects. These observations represent further speculation about the pathogenesis and the unique angiographic pattern of the leaks in CSC and of RPE microrips.

Is scleral fixation a safe procedure for intraocular lens implantation?

PURPOSE

No consensus currently exists on the optimal method for intraocular (IOL) implantation without capsular support. We evaluated the outcome and angiographic findings of eyes that underwent the implantation of scleral fixated IOLs.

METHODS

Iris and retinal fluorescein angiography were performed in 13 eyes that had received posterior chamber IOL implantation with scleral fixation. Follow-up examinations also assessed visual acuity (VA), intraocular pressure (IOP), IOL decentration and complications related to the procedure.

RESULTS

Mean visual acuity was 0.29 preoperatively and 0.71 postoperatively after a mean follow-up of 14.2 months. A best corrected visual acuity of 0.5 or better was obtained in 12 eyes. Iris fluorescein angiography did not show major vascular abnormalities. Retinal angiography showed 5 cases of macular edema. In 6 eyes light-induced retinal lesions occurred. Cellophane maculopathy was disclosed in 4 eyes. Macular edema was associated with photic injury in 4 cases and with cellophane maculopathy in 2 cases. Mean postoperative visual acuity was 0.6 in eyes with macular edema and 0.88 in eyes without (SD 0.18; range 0.5-1.0). Four of 5 eyes with macular edema had a postoperative visual acuity of 0.5 or better. There was no evidence of persistent IOP elevation or IOL decentration. No serious complications were recorded during surgery.

CONCLUSIONS

Transscleral fixation of posterior chamber IOLs provides adequate visual acuity in most patients. Macular edema was frequently associated with the procedure. Although this complication was a cause of low visual recovery after implantation, the majority of eyes with macular edema achieved a visual acuity of 0.5 or better. Light-induced retinal injury was a permanent complication.

Feasibility of telementoring between Baltimore (USA) and Rome (Italy): the first five cases

BACKGROUND AND PURPOSE

Telemedicine is the use of telecommunication technology to deliver healthcare. Telementoring has been developed to allow a surgeon at a remote site to offer guidance and assistance to a less-experienced surgeon. We report on our experience during laparoscopic urologic procedures with mentoring between Rome, Italy, and Baltimore, USA.

MATERIAL AND METHODS

Over a period of 3 months, two laparoscopic left spermatic vein ligations, one retroperitoneal renal biopsy, one laparoscopic nephrectomy, and one percutaneous access to the kidney were telementored. Transperitoneal laparoscopic cases were performed with the use of AESOP, a robotic for remote manipulation of the endoscopic camera. A second robot, PAKY, was used to perform radiologically guided needle orientation and insertion for percutaneous renal access. In addition to controlling the robotic devices, the system provided real-time video display for either the laparoscope or an externally mounted camera located in the operating room, full duplex audio, telestration over live video, and access to electrocautery for tissue cutting or hemostasis.

RESULTS

All procedures were accomplished with an uneventful postoperative course. One technical failure occurred because the robotic device was not properly positioned on the operating table. The round-trip delay of image transmission was less than 1 second.

CONCLUSION

International telementoring is a feasible technique that can enhance surgeon education and decrease the likelihood of complications attributable to inexperience with new operative techniques.

Successful management of retroperitoneal malignant fibrous histiocytoma involving both kidneys

We report a rare case of a retroperitoneal inflammatory variant of malignant fibrous histiocytoma (MFH) involving both kidneys. The best treatment for MFHs is surgery with radical excision of the tumor. In this case the need to save at least one kidney meant tumorectomy was incomplete. The patient underwent adjuvant chemotherapy and 4 years later survives in a fairly good condition.

Unilateral macular retinoschisis with stellate foveal appearance in two females with myopia

Stellate foveal retinoschisis is considered the hallmark of X-linked retinoschisis. We describe the finding of unilateral retinoschisis with stellate foveal appearance in 2 females with myopia who had no evidence of familial disease. Optical coherence tomography (OCT) and fluorescein angiography were obtained in both cases. Neither patient had a family history of low vision, night blindness, or retinal detachment. Visual acuity in the affected eyes was 20/50 and 20/25, respectively. Both fellow eyes had normal fundi, except for mild myopic changes. With OCT, widespread retinal splitting was detected at the posterior pole in the affected eyes, whereas the fellow eyes were normal. In one case, OCT showed that foveal retinoschisis represented the macular involvement of a flat inferior retinoschisis, although this was not clinically apparent. Macular retinoschisis with stellate foveal appearance may rarely be associated with pathologic myopia. OCT was useful to establish the true extension of these macular changes.