Examination of Subbasal Nerve Plexus and Central Corneal Stromal Microstructure in Subjects With Congenital Aniridia, Using in Vivo Confocal Laser Scanning Microscopy

PURPOSE

During life up to 70% of aniridia subjects develop aniridia-associated keratopathy (AAK). AAK is characterized by limbal stem cell insufficiency, impaired corneal epithelial cell differentiation and abnormal cell adhesion, which leads to centripetal spreading vascularization, conjunctivalization, and thickening of the cornea. Our aim was to examine the subbasal nerve plexus and central corneal stromal microstructure in subjects with congenital aniridia, using in vivo confocal laser scanning microscopy CLSM.

METHODS

31 eyes of 18 patients (55.6% males, mean age: 25.22 ± 16.35 years) with congenital aniridia and 46 eyes of 29 healthy subjects (41.4% males, mean age 30 ± 14.82 years) were examined using the Rostock Cornea Module of Heidelberg Retina Tomograph-III. At the subbasal nerve plexus, corneal nerve fiber density (CNFD), corneal nerve fiber length (CNFL), corneal total branch density (CTBD), and corneal nerve fiber width (CNFW) were analyzed using ACCMetrics software. Keratocyte density in the anterior, middle and posterior stroma was assessed manually.

RESULTS

The CNFD (2.02 ± 4.08 vs 13.99 ± 6.34/mm2), CNFL (5.78 ± 2.68 vs 10.56 ± 2.82 mm/mm2) and CTBD (15.08 ± 15.62 vs 27.44 ± 15.05/mm2) were significantly lower in congenital aniridia subjects than in controls (p < 0.001 for all). CNFW was significantly higher in aniridia subjects than in controls (0.03 ± 0.004 vs 0.02 ± 0.003 mm/mm2) (p = 0.003). Keratocyte density was significantly lower in all stromal layers of aniridia subjects than in controls (p < 0.001 for all). Stromal alterations included confluent keratocytes, keratocytes with long extensions and hyperreflective dots between keratocytes in aniridia.

CONCLUSIONS

Decrease in CNFD, CNFL, and CTBD, as well as increase in CNFW well refer to the congenital aniridia-associated neuropathy. The decreased keratocyte density and the stromal alterations may be related to an increased cell death in congenital aniridia, nevertheless, stromal changes in different stages of AAK have to be further analyzed in detail.

[Congenital aniridia patients' experience on their visual impairment in Hungary.]

INTRODUCTION

Aniridia is a rare congenital panocular disease associated with varying degrees of visual acuity impairment.

OBJECTIVE

To assess the experiences of congenital aniridia patients in Hungary, with visual impairment using a questionnaire developed by the ANIRIDIA-NET.

PATIENTS AND METHOD

Patients completed the Hungarian version of the 20-item ANIRIDIA-NET questionnaire with our assistance. The questionnaire covered demographic data, the most common complaints caused by the disease, the difficulties caused by low vision in different life situations and the frequency of low vision aids used in daily life.

RESULTS

33 subjects (17 female [51.51%] and 16 male [48.48%]), 16 (48.5%) children and 17 (51.5%) adults completed the questionnaire, with an age of 25.69 ± 17.49 years (5-59 years). Daily photosensitivity was reported by 27 (81.8%), dry eyes by 5 (15.2%), tearing by 4 (12.1%), fluctuating vision by 3 (9.1%), and eye pain by 2 (6.1%) subjects. The majority of respondents said that personal communication with schoolmates (16 [48.5%]) or colleagues at work (11 [33.3%]) never caused difficulties because of their visual impairment. 29 people (87.9%) never needed help with daily routines at home, 24 (72.7%) with getting to school/work and 17 (51.5%) with various activities. 29 people (87.8%) never used low vision aids for communication, 23 (69.7%) for travelling, 20 (60.6%) for participating in social activities, 18 (54.5%) for studying/work.

CONCLUSION

Although aniridia is associated with reduced visual acuity, the majority of people with congenital aniridia, especially in childhood, manage to cope with personal communication and various life situations without difficulty, despite their eye complaints. Low vision aids can be an important aid for them as they grow into adulthood and as they age. Orv Hetil. 2023; 164(34): 1342-1349.

[Staging of aniridia-associated keratopathy]

INTRODUCTION

Congenital aniridia is a rare panocular disease that affects almost all eye structures leading in most patients to reduced visual acuity. Ophthalmological signs include aniridia-associated keratopathy, secondary glaucoma, cataract, macular and optic nerve head hypoplasia, nystagmus. Although the term aniridia-associated keratopathy has long been used in the literature, various staging proposals have been described.

OBJECTIVE

To analyze aniridia-associated keratopathy stages, using available literature classifications, in patients with aniridia in Hungary.

PATIENTS AND METHODS

We examined 65 eyes of 33 patients with congenital aniridia (age: 25.69 ± 17.49 [5-59] years, 17 females [51.51%]). We recorded the corneal status by slit-lamp examination and classified the corneal abnormalities according to the Mackman, Mayer, López-García and Lagali staging.

RESULTS

According to Mackman's classification, 8 eyes (12.3%) were in stage 0, 0 eye in stage 1A, 38 eyes (58.46%) in stage 1B and 19 eyes (29.23%) in stage 2. According to Mayer, stage I included 8 eyes (12.3%), stage II 38 eyes (58.46%), stage III 5 eyes (7.7%), stage IV 7 eyes (10.77%) and stage V 7 eyes (10.77%). In López-García's classification, 8 eyes (12.3%) could not be grouped, 20 eyes (30.77%) were in stage 1, 18 eyes (27.7%) in stage 2 and 19 eyes (29.3%) in stage 3. Lagali's classification included 8 eyes (12.3%) in stage 0, 20 eyes (30.77%) in stage 1, 18 eyes (27.7%) in stage 2, 5 eyes (7.7%) in stage 3 and 14 eyes (21.54%) in stage 4.

CONCLUSION

We recommend using Lagali's staging scheme for aniridia-associated keratoptahy due to its ease of use, detailed progression assessment, and treatment planning. In stage 1 according to Lagali, blood vessels cross the limbus by up to 1 mm, in stage 2 the central 2-3 mm of the corneal area is spared of blood vessels. When the blood vessels reach the center of the cornea, it is stage 3, followed by opaque, uneven corneal pannus in stage 4. Orv Hetil. 2023; 164(27): 1063-1069.

[Congenital aniridia - Hungarian data of a spectrum disease]

INTRODUCTION

Congenital aniridia is a rare disease, characterised by the complete or partial absence of the iris, but lesions may be present in all structures of the eye.

OBJECTIVE

To determine the prevalence of ocular diseases in congenital aniridia by analyzing patients from a Hungarian centre.

PATIENTS AND METHODS

Patients at the Department of Ophthalmology of Semmelweis University, examined between October 2005 and May 2022, have been included. After taking the patients' medical history, a detailed ophthalmological examination has been performed.

RESULTS

Of the 82 patients in the database, 33 (age 25.69 ± 17.49 [5-59] years, 17 females [51.51%]) presented for examination and 65 eyes were examined. Nystagmus was found in 45 eyes of 23 patients (69.23%), and the patients' uncorrected distance visual acuity was 0.14 ± 0.128 (0.9 logMAR; 0.63-0.005). The aniridia-associated keratopathy was Grade 0 in 8 eyes (12.3%), Grade 1 in 10 eyes (15.38%), Grade 2 in 16 eyes (24.62%), Grade 3 in 4 eyes (6.15%) and Grade 4 in 25 eyes (38.46%). 30 eyes (46.15%) of 15 patients had secondary glaucoma, 6 eyes (9.2%) of 3 patients were glaucoma suspect. 8 eyes (12.3%) had a clear lens, 44 eyes (67.69%) had cataract, of which 22 (33.84%) were anterior cortical polar cataracts. 13 eyes (20%) were pseudophakic (PCL) and 7 eyes (10.77%) had lens dislocation or zonular insufficiency. Macular hypoplasia was found in 6 eyes of 3 patients (4.6%) and optic nerve head malformation in 2 eyes of 1 patient (3.03%).

CONCLUSION

The ocular signs of congenital aniridia are aniridia-associated keratopathy, secondary glaucoma, cataract, macular and optic nerve head hypoplasia. Systematic collaboration of different ophthalmological specialties is required for the management and care of all these ocular abnormalities. Orv Hetil. 2023; 164(4): 148-155.

[The impact of district nurses in screening visual impairments]

INTRODUCTION

The children's physical and mental health is determinative for the whole society. Parents, teachers, district nurses, and doctors share the duty to ensure their uninterrupted visual development. District nurses compose key elements in connecting families and health care providers, since they have the chance to detect any visual anomalies, and to refer the children to a pediatrician, ophthalmologist, or a neurologist. Their team work yields advantages to the whole community as beyond preserving good vision, children get a real chance of right physical and mental development.

OBJECTIVE

Our aim was to recollect district nurses' areas of activity and to collect data about their present status in visual screening programs. Furthermore, to assess their screening methods and circumstances, and to reshape their continuous learning programs linked to the universities.

METHOD

Questionnaires were sent online anonymously to district nurses in practice, in order to collect data referring to their focuses during the visual screening methods. Administration of online parental tutorials was assessed, and measures of professional support in nurses' education was debated.

RESULTS

Visual screening among infants looks for potential strabismus, and among school-age children looks for potential refractive errors. Vision tests and stereo tests are usually available as screening tools, but pen lights are underused. Only a few nurses suggest online tutorials to enhance patient education, but nurses are highly motivated in postgraduate courses about vision screening.

CONCLUSION

Our results reflect good adherence to the screening protocols but there is some uncertainty in some fields. In harmony with the results, adequate technical and educational support and specific training were compiled for postgraduate district nurses. Coaching and training in visual screening (in the form of seminars or e-learning) should be available in spring 2023. Orv Hetil. 2023; 164(3): 88-95.

Axenfeld–Rieger syndrome: ophthalmological and dental diagnostic and therapeutic options

Összefoglaló. Az Axenfeld-Rieger-szindróma ritka betegség. A közlemény bemutatja a klinikai megjelenési formáit, a diagnosztikus és terápiás lehetőségeket. A szemgolyó elülső szegmentumát érintő fejlődési rendellenességek vizsgálata a hagyományos biomikroszkópos vizsgálat mellett digitális kamerával is történhet, mely a csarnokzugi képleteket nagy nagyításban, éles képet mutatva tudja megjeleníteni. Az elülső szegmentum leképezését segítő optikaikoherencia-tomográfia és ultrahang-biomikroszkópia a fejlődési rendellenességnek és a csarnokvíz-elvezető sönt tubusának vizsgálatára, megjelenítésére is alkalmas. A szemnyomást a gyermek kooperációjának függvényében többféle módon mérhetjük. A szabálytalan alakú, sokszor csak résnyi pupilla, valamint a szemnyomás-emelkedés miatt szemészeti beavatkozás lehet szükséges. A korai pupillaképzés az amblyopia megelőzését, az antiglaucomás műtétek (trabeculectomia, hosszú tubusú sönt implantációja) pedig a látási funkciók megőrzését szolgálják. A szemészeti műtéteket akár már néhány hónapos korban szükséges elvégezni altatásban. A maxillahypoplasia és a fogászati fejlődési anomáliák miatt kétirányú panoráma-röntgenfelvétel szükséges. Többlépcsős fogászati konzervatív és restoratív kezelés hozhat eredményt. A diagnózis felállítása és a kezelés is multidiszciplináris megközelítést igényel. Gyermekgyógyász, genetikus, kardiológus, fogász-szájsebész és gyermekszemész együttes munkája biztosíthat megfelelő eredményt. Orv Hetil. 2021; 162(5): 192-199. Summary. Axenfeld-Rieger syndrome is a rare disease. Our paper presents its clinical manifestations, diagnostic and therapeutic options. Due to maxillary hypoplasia and dental developmental anomalies, bidirectional panoramic radiography is required. Multi-stage dental conservative and restorative treatment can provide better results. In addition to traditional biomicroscopic examination, developmental abnormalities affecting the anterior segment of the eye can also be examined with a digital camera, which can display the angle of the anterior chamber at high magnification, with a sharp image. Anterior segment optical coherence tomography and ultrasound biomicroscopy are also suitable for the examination and display of developmental abnormalities and drainage shunt tubes. Intraocular pressure can be measured in several ways depending on the child's cooperation. Due to the irregular shape of the pupil, often with only a slit aperture, and an increase in intraocular pressure, ophthalmic intervention may be required. The pupilloplasty is important preventing amblyopia prevention and early glaucoma surgery (trabeculectomy, shunt implantation) helps to preserve visual function. Eye surgeries need to be performed under anaesthesia, sometimes at few months of age. Both diagnosis and treatment require a multidisciplinary approach. The joint work of a paediatrician, geneticist, cardiologist, dental-oral surgeon and paediatric ophthalmologist may provide a satisfactory result. Orv Hetil. 2021; 162(5): 192-199.

Comparison of the current and a new RTVue OCT software version for detection of ganglion cell complex changes due to cataract surgery

The purpose was to compare the current (6.3) and a novel software version (6.12) of the RTVue-100 optical coherence tomograph (RTVue OCT) for ganglion cell complex (GCC) and retinal nerve fibre layer thickness (RNFLT) changes after phacoemulsification in healthy cataract eyes, and to investigate whether version 6.12, in which image segmentation is improved, provides benefits over version 6.3 for RNFLT and GCC imaging via mild cataract. One eye of 22 consecutive healthy cataract patients were imaged before and 1 month after uncomplicated cataract surgery using RTVue-100 OCT software version 6.3. The images were analysed with both software versions. Signal strength index increased significantly after surgery for both RNFLT and the GCC measurements (p ≤ 0.0015). No difference was seen for any RNFLT parameter between the software versions and time points (p ≥ 0.0140). The GCC values did not differ between the versions either before or after surgery (p ≥ 0.4471), but all increased significantly after surgery with software version 6.12 (p < 0.0001). Neither focal loss volume (FLV) nor global loss volume (GLV) differed between the software versions before and after surgery, respectively, but GLV decreased (improved) significantly after surgery (p = 0.010 and <0.001 for versions 6.3 and 6.12, respectively). Cataract surgery induced similar changes with both software versions, but version 6.12 identified the increase of GCC thickness and the decrease of GLV better than the current version. Although no significant difference between software versions was seen before surgery, our results suggest that version 6.12 may be more precise in measuring GCC parameters than the currently available version.

Complement activation in the aqueous humor of pseudophakic bullous keratopathy patients

BACKGROUND/AIMS

According to some studies, inflammation is a potential etiological factor in pseudophakic bullous keratopathy (PBK). Our aim was to obtain information on the activation of the complement system in the aqueous humor in this disorder.

METHODS

Aqueous humor samples were collected during keratoplasty of 12 PBK patients, as well as during phacoemulsification surgery of 18 control patients. The concentrations of the protein-protein complexes generated during complement activation (C1rC1sC1inh and C3bBbP) through the classical and alternative pathways, respectively, as well as of the C3 cleavage product C3a, were measured with ELISA methods. The correlation among the complement factors and between the duration of the edema, the stage of the disease, and the level of the complement activation products was examined.

RESULTS

The concentration of C1rC1sC1inh, C3bBbP complex and C3a was significantly higher in the PBK group (p < 0.001) compared to the control group. In PBK patients, a correlation was found between the levels of the C1rC1sC1inh complex and C3a only.

CONCLUSION

Our new findings indicate that in PBK the complement system is activated - via the classical pathway - in the aqueous humor. The activated complement may play a role in increased endothelial cell loss.

Increased tear osmolarity in patients with severe cases of conjunctivochalasis

PURPOSE

To evaluate and compare tear osmolarity in different grades of conjunctivochalasis.

PATIENTS AND METHODS

Forty subjects divided into four groups based on grading of conjunctivochalasis by lid-paralell conjunctival fold (LIPCOF) test and tear osmolarity evaluated by TearLab osmometer. Schirmer test, tear film break up time (BUT) and vital staining were also performed.

RESULTS

Patients with mild and moderate conjunctivochalasis showed similar tear osmolarity to normal subjects. A significant increase (P < 0.008) of osmolarity was found in patients with severe conjunctivochalasis. A significant increase of osmolarity was found in patients with abnormal BUT (P = 0.018) and in patients with positive lissamine-green staining (P = 0.023). No association could be elicited when results of osmolarity were compared to those of Schirmer test or when compared those of fluorescein staining to osmolarity, respectively.

CONCLUSION

Hyperosmolarity of tear was reported as a fact of ocular surface inflammation. While in mild and moderate conjunctivochalasis tear osmolarity was similar to normal controls, increased osmolarity can refer to the presence of ocular surface inflammation in these patients with severe conjunctivochalasis.

Bacterial contamination in the anterior chamber after povidone–iodine application and the effect of the lens implantation device

PURPOSE

To assess the incidence of anterior chamber bacterial contamination during cataract surgery, and compare results of injector implantation and forceps implantation of foldable intraocular lenses (IOLs).

SETTING

Department of Ophthalmology and Institute of Medical Microbiology, Semmelweis University, Budapest, Hungary.

METHODS

This prospective randomized controlled clinical study comprised 97 eyes of 96 patients. Antibiotic eyedrops were not used; however, povidone-iodine 10% solution was used to prepare the eyebrow and eyelids and povidone-iodine 5% to disinfect the ocular surface. A Steri-Drape (3M) was used to surround the eye. Aqueous fluid samples were aspirated from the anterior chamber at the beginning and the end of surgery. The samples were cultured for 14 days under aerobic and anaerobic conditions simultaneously. Cataract surgery was performed using a sutureless, superotemporal, clear corneal phacoemulsification technique. The IOL was implanted with an injector (n = 47) or a forceps (n = 50), with the instrument randomly selected. The frequency of positive bacterial cultures with each implantation method was compared using the Fisher exact test.

RESULTS

Bacteria were found in the conjunctival samples in 21 eyes (21.65%) before povidone-iodine application and in 4 eyes (4.12%) after disinfection. The anterior chamber sample before surgery was culture positive for Staphylococcus epidermidis in 2 eyes and for Micrococcus luteus in 1 eye. After surgery, the culture was positive for S epidermidis in 1 eye (2.15%) in the injector group and 1 eye (2.00%) in the forceps group (P = .74). Neither sample came from an eye that had a positive culture preoperatively. There were no intraoperative complications.

CONCLUSIONS

In uneventful clear corneal phacoemulsification, meticulous technique can prevent antibiotic use during surgery. No difference in anterior chamber bacterial contamination was found between IOL implantation using an injector or a forceps.

Corneal topography parameters after superior clear corneal incision cataract surgery in arcus lipoides

PURPOSE

To compare changes in corneal topographic parameters after cataract surgery in eyes with different severities of arcus lipoides.

METHODS

Fourty eyes of 40 patients (23 women, 17 men, age 71.3+/-20.4 years, range 40 to 89 years) were studied prospectively in a consecutive, non-interventional, comparative series of cases. Eyes were classed in three groups (0 to 2) according to the assessed grade of arcus lipoides (none, <180 degrees, >180 degrees). Corneal topography (Tomey TMS-2) was performed preoperatively and at 1 and 10 days and 1 and 3 months following cataract surgery (superior 4.0 mm clear corneal incision, no suture). Keratometric astigmatism (Dcyl), surface regularity index (SRI), surface asymmetry index (SAI), and potential visual acuity (PVA) were evaluated for the different groups and time-points, using the Kruskal-Wallis, Wilcoxon, and Mann-Whitney statistical tests.

RESULTS

No significant preoperative difference was found in mean Dcyl, SRI, or PVA; preoperative SAI was lower in Group 1. Postoperatively Dcyl was increased at day 1 in Groups 1 and 2, and remained higher in Group 2 until month 1. At month 3 significant differences among Groups 0, 1, and 2 disappeared.

CONCLUSIONS

The 4.0 mm superior clear corneal incision is a safe method for cataract surgery in the presence of arcus lipoides. This procedure induces greater corneal astigmatism, surface irregularity, and lower PVA in the early postoperative period in cases with arcus lipoides than in normal corneas. Concerning final results, wound healing was not affected by greater severity of arcus lipoides, although stabilization of the corneal surface tended to be slower.

Unilateral Malassezia furfur blepharitis after perforating keratoplasty

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