Non-Miotic Improvement in Binocular Near Vision with a Topical Compound Formula for Presbyopia Correction

INTRODUCTION

The aim of this case series was to examine the association between unaided binocular visual acuity for near vision and pupil change after the instillation of a special topical formulation for presbyopia treatment.

METHODS

This was a case series consisting of consecutive participants with presbyopia aged 40-70 years who were tested for visual acuity and pupil diameter before and 2 h after instillation of a formulation of pilocarpine and phenylephrine drops (FOV Tears) for presbyopia. Participants underwent subjective refraction, photopic and scotopic pupil diameter measurement and unaided monocular and binocular visual acuity testing by logMAR for distance and near vision both pre- and post-instillation of eye drops.

RESULTS

The study enrolled 363 subjects (n = 176 women, 48%) with a mean (± standard deviation) age of 50.4 ± 5.8 years. Mean spherical equivalent (SE) changed significantly (- 0.17 Diopters) after instillation of the FOV Tears formulation (p < 0.001). Post-instillation of eye drops, the scotopic pupil diameter decreased by 0.97 ± 0.98 mm, and the near visual acuity by logMAR improved significantly by nearly two lines (p < 0.01). In the linear regression analyses, age (p < 0.001) and SE pre-drop instillation (p < 0.001) were associated with unaided binocular visual acuity. The changes in photopic pupil diameter and the scotopic pupil diameter were not associated with unaided binocular visual acuity.

CONCLUSIONS

The use of the pilocarpine and phenylephrine formulation (FOV Tears) improved binocular visual acuity for near vision in presbyopic patients, and the effect was independent of pupil change.

Causes of corneal transplant failure: a multicentric study

PURPOSE

To identify the causes of failure of the different surgical corneal graft techniques: penetrating keratoplasty (PK), deep anterior lamellar keratoplasty (DALK), Descemet stripping automated endothelial keratoplasty (DSAEK) and Descemet membrane endothelial keratoplasty (DMEK).

METHODS

This multicentric retrospective study enrolled a consecutive cohort of patients who had undergone any type of keratoplasty between 2001 and 2016. The clinical data were obtained from the patient's medical records, following ethical guidelines, permissions and data protection. The main outcome measured in the study was the cause of graft failure, defined as any irreversible loss of graft transparency capable of compromising vision. The main causes of graft failure were classified as follows: (A) primary graft failure (PGF), (B) immunological rejection, (C) non-rejection (which includes endothelial decompensation without rejection, IOP elevation/glaucoma, diseases of the ocular surface, recurrence of the primary disease, wound dehiscence/hypotonia and trauma, among others) and (D) specific causes of lamellar keratoplasty failure. A descriptive study of the obtained data was carried out. The distribution of the causes of failure was evaluated according to the type of corneal transplant.

RESULTS

Our research included a cohort of 571 keratoplasty failures, of which 509 met the inclusion criteria. The analysis of the causes of the PK failure showed that immunological allograft rejection represented the main cause, with 28.2% of the failures, followed by surface diseases (17.8%) and endothelial decompensation without rejection (17.3%). For the PK re-grafts group, the main cause of failure was immunological allograft rejection (34.0%), followed by diseases of the ocular surface (18.5%). For the DALK group, the failures mainly occurred due to surface diseases such as limbal stem cell insufficiency, infectious keratitis, keratolysis or persistent epithelial defect (37.8%). However, the main reason for failure in the DSAEK group was endothelial decompensation without rejection (31.9%) while primary graft failure was the main cause of failure in the DMEK group (64.1%).

CONCLUSION

The main reason for failure in PK was immunological allograft rejection, both in primary and secondary transplants. The leading causes for failure were diseases of the ocular surface in the DALK population, endothelial decompensation without rejection in DSAEK and primary graft failure in DMEK.

Pharmacological Therapy for Presbyopia in Patients with Previous Corneal Refractive Surgery: A Pilot Study

Purpose

To perform a pilot evaluation of a novel pharmacological therapy for presbyopia in patients with previous corneal refractive surgery.

Methods

This interventional study included 130 presbyopic patients. The patients were divided into three groups: (1) LASIK group, which included patients with previous LASIK for myopia or hyperopia; (2) previous presbyopia surgery group, including patients with previous monovision or PresbyLASIK (PresbyMAX, SCHWIND eye-tech-solutions GmbH, Kleinostheim, Germany); and (3) control group, which included presbyopes without any corneal refractive procedure. The main reason for dividing them into groups is that we hypothesized that the previous presbyopia surgery group may have better outcomes as the patients already have an increased depth of field. The uncorrected near and distance visual acuity was measured before and 2 hours after the binocular instillation of the eye drop (FOV tears), as well as the objective scatter index (OSI), and pupil diameter in photopic and scotopic conditions. Side effects were reported as well.

Results

There was a statistically significant improvement in the uncorrected near vision in all groups (p = 0.001). Ninety-one percent of the patients included in this study gained at least one line in near vision. All patients in the previous presbyopia surgery group gained at least one line in near vision. Six patients (13.9%) in the LASIK group and five (7.6%) in the control group did not gain any lines of near vision. There was no significant difference in the OSI, there was a significant change in pupil size in scotopic conditions in all groups (p = 0.001), and 5.3% of the patients reported having a headache as a side effect of the therapy.

Conclusions

Topical treatment with this pharmacological therapy offers a potential for near vision improvement in patients with previous corneal refractive surgery, especially in those with previous presbyopia surgery.

Study and characterization of morphogeometric parameters to assist diagnosis of keratoconus

Background

In case of significant imperfections on the cornea, data acquisition is difficult and a significant level of missing data could require the interpolation of important areas of the cornea, resulting in a very ambiguous model. The development of methods to define in vivo customised geometric properties of the cornea based only on real raw data is extremely useful to diagnose and assess the progression of diseases directly related to the corneal architecture. The present work tries to improve the prognostic of corneal ectasia creating a 3D customised model of the cornea and analysing different geometric variables from this model to determine which variables or combination of them could be defined as an indicator of susceptibility to develop keratoconus.

Methods

A corneal geometric reconstruction was performed using zonal functions and retrospective Scheimpflug tomography data from 187 eyes of 187 patients. Morphology of healthy and keratoconic corneas was characterized by means of geometric variables. The performance of these variables as predictors of a new geometric marker was assessed and their correlations were analysed.

Results

The more representative variable to classify the corneal anomalies related to keratoconus was posterior apex deviation (area under receiver operating characteristic curve > 0.899; p < 0.0001). However, the strongest correlations in both healthy and pathological corneas were provided by the metrics directly related to the thickness, as deviations of the anterior/posterior minimum thickness points.

Conclusions

The presented morphogeometric approach based on the analysis and custom geometric modelling of the cornea demonstrates to be useful for the characterization and diagnosis of keratoconus disease, stating that geometrical deformation is an effective marker of the ectatic disease’s progression.

Significant hyperopic shift in a patient with extreme myopia following severe hypotonia caused by glaucoma filtering surgery

INTRODUCTION:

To report the case of a high hyperopic refractive shift associated with significant shortening of the ocular axial length following glaucoma filtering surgery.

METHODS:

Case report. Patient's records were consulted retrospectively.

RESULTS:

A 57-year-old woman, highly myopic, with a history of bilateral intraocular refractive surgery in 1998 (phakic lens ZB5M) and bilensectomy in 2011 (phakic intraocular lens extraction plus cataract surgery with pseudophakic intraocular lens implantation), presented with consistently high intraocular pressure. Despite the treatment with different topical antiglaucomatous medications and good compliance, her intraocular pressure values remained consistently above 20 mmHg. In 2016, the patient was submitted for glaucoma filtering surgery and the mini shunt Ex-Press was implanted in both the eyes (3 months between surgeries). On the first postoperative day, the eyes were hypotonic (intraocular pressure of 5 mmHg) and bilateral macular edema was observed. Three days later, the intraocular pressure in both the eyes reached values higher than 6 mmHg (between 6 and 14 mmHg). Five months after the surgery the macular edema resolved and a significant shortening of the axial length and an important hyperopic refractive shift was observed. When comparing the preoperative and postoperative (18 months) measurements, the variation of the axial length was 2.49 mm in the right eye and 2.19 mm in the left eye; the patient refraction (spherical equivalent) shifted 2.50 diopters in the right eye and 1.75 diopters in the left eye.

CONCLUSION:

To the best of our knowledge, we report herein the first documented case of an axial length change of this magnitude after glaucoma filtering surgery.

Posterior keratoconus-clinical aspects and anterior segment optical coherence tomography findings: A case report

PURPOSE:

To describe a case of Posterior Keratoconus (keratoconus posticus); its clinical condition, corneal, refractive response to intracorneal ring implantation (MyoRing), anterior segment optical coherence tomography findings; and micro incisional cataract surgery outcome.

METHODS:

Case report.

RESULTS:

The case was studied with high resolution anterior segment optical coherence tomography (OCT), epithelium OCT, corneal topography, and aberrometry. A MyoRing was implanted and after the development of cataract, microincisional cataract surgery was performed. A large hyperopic shift was observed following the ring implantation. Calculation of the intraocular lens showed poor predictability.

CONCLUSIONS:

Posterior keratoconus is a rare corneal congenital disorder characterized by a posterior corneal elevation. Surprisingly, on the total corneal aberrometry, the coma is within normal levels; in the anterior and posterior corneal aberrometry, all the low order and high order aberrations are outside of normal parameters. The epithelial thickness is normal on the contrary to anterior keratoconus. Micro incisional cataract surgery can be safely performed in these eyes, although a refractive surprise is expected due to errors in the intraocular lens calculation.

Postoperative Efficacy, Predictability, Safety, and Visual Quality of Laser Corneal Refractive Surgery: A Network Meta-analysis

PURPOSE

To compare the postoperative efficacy, predictability, safety, and visual quality of all major forms of laser corneal refractive surgeries for correcting myopia.

DESIGN

Systematic review and network meta-analysis.

METHODS

Search of MEDLINE, EMBASE, Cochrane Library, and the US trial registry was conducted up to November 2015. Randomized controlled trials (RCT) reporting in accordance with the eligibility criteria were included in this review. We performed a Bayesian random-effects network meta-analysis.

RESULTS

Forty-eight RCTs were identified. For efficacy (uncorrected visual acuity [UCVA]), there were no statistically significant differences between any pair of treatments analyzed. The SUCRA (surface under the cumulative ranking curve) ranking (from best to worst) was femtosecond-based laser in situ keratomileusis (FS-LASIK), LASIK, small-incision lenticule extraction, femtosecond lenticule extraction (FLEx), photorefractive keratectomy (PRK), laser epithelial keratomileusis (LASEK), epipolis (Epi)-LASIK, transepithelial PRK (T-PRK). For predictability (refractive spherical equivalent [SE]), a statistically significant difference was found when FS-LASIK was compared with LASIK (odds ratio [OR] 2.29, 95% credible interval [CrI] 1.20-4.14), PRK (OR 2.16, 95% CrI 1.15-4.03), LASEK (OR 2.09, 95% CrI 1.08-4.55), and Epi-LASIK (OR 2.74, 95% CrI 1.11-6.20). The SUCRA ranking (from best to worst) was FS-LASIK, T-PRK, LASEK, PRK, LASIK, Epi-LASIK. There were no statistically significant differences in the safety (best spectacle-corrected visual acuity) comparisons. For both postoperative higher-order aberrations (HOAs) and contrast sensitivity (CS), there were no statistically significant differences between any pair of treatments analyzed. The SUCRA ranking results show that some corneal surface ablation techniques (PRK and LASEK) rank highest.

CONCLUSIONS

This network meta-analysis shows that there were no statistically significant differences in either visual outcomes (efficacy and safety) or visual quality (HOAs and CS). FS-LASIK behaved better in predictability than any other type of surgeries.

Evaluation of the efficacy and safety of a standardised intracameral combination of mydriatics and anaesthetics for cataract surgery

Background/aims

To compare the efficacy and safety of intracameral (IC) administration at the beginning of cataract surgery, of Mydrane, a standardised ophthalmic combination of tropicamide 0.02%, phenylephrine 0.31% and lidocaine 1%, to a standard topical regimen.

Methods

In this international phase III, prospective, randomised study, the selected eye of 555 patients undergoing phacoemulsification with intraocular lens (IOL) implantation received 200 μL of Mydrane (Mydrane group) just after the first incision or a topical regimen of one drop each of tropicamide 0.5% and phenylephrine 10% repeated three times (reference group). The primary efficacy variable was achievement of capsulorhexis without additional mydriatics. The non-inferiority of Mydrane to the topical regimen was tested. The main outcome measures were pupil size, patient perception of ocular discomfort and safety.

Results

Capsulorhexis without additional mydriatics was performed in 98.9% of patients and 94.7% in the Mydrane and reference groups, respectively. Both groups achieved adequate mydriasis (>7 mm) during capsulorhexis, phacoemulsification and IOL insertion. IOL insertion was classified as ‘routine’ in a statistically greater number of eyes in the Mydrane group compared with the reference group (p=0.047). Patients in the Mydrane group reported statistically greater comfort than the reference group before IOL insertion (p=0.034). Safety data were similar between groups.

Conclusions

Mydrane is an effective and safe alternative to standard eye drops for initiating and maintaining intraoperative mydriasis and analgesia. Patients who received IC Mydrane were significantly more comfortable before IOL insertion than the reference group. Surgeons found IOL insertion less technically challenging with IC Mydrane.

Trial registration number

NCT02101359; Results.

Mesothelial cells: a cellular surrogate for tissue engineering of corneal endothelium

PURPOSE

To evaluate whether mouse adipose tissue mesothelial cells (ATMCs) share morphologic and biochemical characteristics with mouse corneal endothelial cells (CECs) and to evaluate their capacity to adhere to the decellularized basal membrane of human anterior lens capsules (HALCs) as a potential tissue-engineered surrogate for corneal endothelium replacement.

METHODS

Adipose tissue mesothelial cells were isolated from the visceral adipose tissue of adult mice, and their expression of several corneal endothelium markers was determined with quantitative RT-PCR, immunofluorescence, and Western blotting. Adipose tissue mesothelial cells were cultured in a mesothelial retaining phenotype medium (MRPM) and further seeded and cultured on top of the decellularized basal membrane of HALCs. ATMC-HALC composites were evaluated by optical microscopy, immunofluorescence, and transmission electron microscopy.

RESULTS

Mesothelial retaining phenotype medium-cultured ATMCs express the corneal endothelium markers COL4A2, COL8A2, SLC4A4, CAR2, sodium- and potassium-dependent adenosine triphosphatase (Na(+)/K(+)-ATPase), β-catenin, zona occludens-1, and N-cadherin in a pattern similar to that in mouse CECs. Furthermore, ATMCs displayed strong adhesion capacity onto the basal membrane of HALCs and formed a confluent monolayer within 72 hours of culture in MRPM. Ultrastructural morphologic and marker characteristics displayed by ATMC monolayer on HALCs clearly indicated that ATMCs retained their original phenotype of squamous epithelial-like cells.

CONCLUSIONS

Corneal endothelial cells and ATMCs share morphologic (structural) and marker (functional) similarities [corrected]. The ATMCs adhered and formed structures mimicking focal adhesion complexes with the HALC basal membrane. Monolayer structure and achieved density of ATMCs support the proposal to use adult human mesothelial cells (MCs) as a possible surrogate for damaged corneal endothelium.

Laboratory diagnosis of endophthalmitis: comparison of microbiology and molecular methods in the European Society of Cataract & Refractive Surgeons multicenter study and susceptibility testing

PURPOSE

To investigate and compare the use of molecular biology with the use of traditional Gram stain and organism culture for the laboratory diagnosis of postoperative endophthalmitis.

SETTING

Twenty-four ophthalmology units together with 9 microbiology laboratories and 2 European reference molecular biology laboratories.

METHODS

A prospective randomized partially masked multicenter cataract surgery study recruited 16 603 patients. This resulted in 29 cases of presumed postoperative endophthalmitis. Gram stain and culture were performed in the local laboratory according to agreed protocols. Samples of aqueous and/or vitreous were transported to the first referenced molecular biology laboratory (Regensburg, Germany) for polymerase chain reaction (PCR) testing, and an extracted aliquot of DNA was then referred to the second laboratory (Alicante, Spain) for PCR.

RESULTS

Of the 29 who presented with presumed postoperative endophthalmitis, 20 were classified as proven infective endophthalmitis with positive Gram stain, culture, or PCR. Fourteen patients were culture-positive; all but 1 of these was also positive by PCR. Six patients were positive by PCR but negative by Gram stain or culture. Nine patients were negative by both microbiology and PCR testing.

CONCLUSIONS

Use of molecular biology technique increased the laboratory rate of identifying the pathogen by 20%, confirming the technique is very useful for the endophthalmitis specimen. Samples of both aqueous and vitreous should be collected and stored at -20 degrees C for PCR at the time of the diagnostic taps.

[Limbal transplantation: multicenter retrospective case series analysis]

PURPOSE

To report the results of limbal transplantation (LT) in patients with limbal stem cell deficiency (LSCD) in the context of ocular surface diseases.

MATERIALS AND METHODS

A multicenter (5 centers) retrospective case series analysis of patients who underwent LT between 1996 and 2004 was performed. Data were collected by the same researcher using a customized database. Success was defined by the absence of a persistent corneal epithelial defect, on-going inflammation or recurrence of a pterygium.

RESULTS

Data from 72 LT performed in 61 patients (65 eyes) with a mean follow-up of 20.8 months (SD 23.5; range, 3-115) were analyzed. There were 33 males and 28 females with a mean age of 55.8 years (SD: 15.6; range, 20-89). Fifty-eight (80.6%) LT were autografts (40 pterygia, 12 alkali burns, 3 iatrogenic cases, 2 viral infections, 1 neoplasia case) and 14 (19.4%) were allografts from cadaveric donors (7 immune-based disorders, 6 alkali burns, 1 iatrogenic case); all patients receiving allografts also received systemic immunosuppression. Of the total number of LT, 48 (66.7%) were successful. This proportion increased to 81.0% (47/58) when autografts were used. However, only 7.1% (1/14) of all allografts were successful. The success rate was higher (80.0%) when performed for a pterygium and lower when done for immune-based inflammation (14.3%).

CONCLUSION

Autograft tissue for LT is always preferable to allografts to surgically treat LSCD, as clinical success is significantly higher, and systemic immunosuppression is avoided. As expected, immune-based disorders are the most difficult cases to treat. LT has been shown to be an excellent option for recurrent pterygium, although prospective studies need to be performed to further corroborate these results.

[Optic neuritis after meningococcal vaccination]

CASE REPORT

We report the case of a 13 year-old male with bilateral optic neuritis after meningococcal C vaccination. He was treated with intravenous corticosteroids, but only showed visual recovery in one eye. A significant limitation of his sharp vision remained in his other eye.

DISCUSSION

There have been no previously reported cases of optic neuritis after meningococcal C vaccination and for this reason we have reported this case. It is not possible, however, to exclude some other factor in the etiology of the optic neuritis, but the temporal relationship between the neuritis and the vaccination suggests this was the cause.

Hyperopic LASIK With Esiris/Schwind Technology

PURPOSE

To investigate the refractive and visual outcomes of hyperopic LASIK using Esiris/Schwind technology.

METHODS

This retrospective non-comparative observational study included 106 eyes (65 patients) operated with the Esiris/Schwind laser for hyperopia. Eyes were divided into two groups: group 1, < or = +3.99 diopters (D) and group 2, > or = +4.0 D (up to +7.0 D). Visual outcome for distance and near uncorrected (UCVA) and best spectacle-corrected visual acuities (BSCVA) (decimal values), cycloplegic refraction, keratometry (K), pachymetry, and complications were evaluated.

RESULTS

In group 1, mean UCVA was 0.4 +/- 0.1 preoperatively and 0.8 +/- 0.2 6 months postoperatively. Mean BSCVA was 0.9 +/- 0.1 preoperatively and 0.9 +/- 0.1 6 months postoperatively. Safety index was 1.1 and efficacy index was 0.97. Mean spherical equivalent refraction was +2.33 +/- 0.9 D preoperatively and +0.3 +/- 0.3 D 6 months postoperatively. Mean K reading was 43.7 +/- 1.1 D preoperatively and 45.0 +/- 1.6 D 6 months postoperatively. In group 2, mean UCVA was 0.3 +/- 0.1 preoperatively and 0.8 +/- 0.2 6 months postoperatively. Mean BSCVA was 0.9 +/- 0.1 preoperatively and 0.9 +/- 0.1 6 months postoperatively. Safety index was 0.98 and efficacy index was 0.92. Mean spherical equivalent refraction was +5.1 +/- 0.9 D preoperatively and +0.4 +/- 0.5 D 6 months postoperatively. Mean K reading was 43.1 +/- 1.6 D preoperatively and 46.0 +/- 1.4 D 6 months postoperatively. Forty-six (90.2%) of 51 eyes in group 1 and 47 (85.5%) of 55 eyes in group 2 were within +/- 0.5 D of emmetropia. At 6-month follow-up, 40 (78%) of 51 eyes in group 1 had UCVA of 20/20 compared to 41 (75%) of 51 eyes in group 2. One (2%) of 51 eyes in group 1 and 4 (7.3%) of 55 eyes in group 2 lost < or = 2 lines of BSCVA. No eye lost >2 lines of BSCVA.

CONCLUSIONS

Hyperopic LASIK with Esiris/Schwind technology is effective and safe in the correction of hyperopia up to + 7.0 D. Although a slight statistical significance was found for low hyperopia, visual and refractive results obtained in high hyperopia were encouraging.

Interface Corneal Edema Secondary to Steroid-induced Elevation of Intraocular Pressure Simulating Diffuse Lamellar Keratitis

PURPOSE

To describe interface corneal edema secondary to steroid-induced elevation of intraocular pressure (IOP) following LASIK.

METHODS

Retrospective observational case series. Diffuse interface edema secondary to steroid-induced elevation of IOP was observed after LASIK simulating diffuse lamellar keratitis (DLK) in 13 eyes. Mean patient age was 31.4 +/- 5.3 years. Patients were divided into two groups according to provisional misdiagnosis: DLK group (group 1) comprised 11 eyes and infection group (group 2) comprised 2 eyes (microbial keratitis). Mean follow-up was 8.1 +/- 0.5 weeks.

RESULTS

In the DLK group, typical diffuse haze was confined to the interface and extended to the visual axis, impairing vision in all eyes. Provisional diagnosis was late-onset DLK and topical steroids were started. Repeat examination showed elevated IOP as measured at the corneal center and periphery using applanation tonometry (mean 19.1 mmHg and 39.5 mmHg, respectively), causing interface edema with evident interface fluid pockets. Steroids were stopped and topical anti-glaucoma therapy was started. The interface edema decreased and at the end of follow-up the corneal transparency was restored and IOP dropped to normal values. The infection group demonstrated a microbial keratitis-like reaction and underwent flap lifting and interface wound debridement and biopsy with administration of fortified antibiotics and steroids. After elevated IOP was detected, steroids and antibiotics were stopped and topical anti-glaucoma therapy was started, resulting in the resolution of the interface edema.

CONCLUSIONS

Interface fluid syndrome secondary to steroid-induced elevation of IOP might develop in steroid responders after LASIK with a misleading clinical picture simulating DLK or infectious keratitis. Management includes stopping topical steroids and starting topical antiglaucoma therapy.

Advances in microincision cataract surgery intraocular lenses

PURPOSE OF REVIEW

This review provides an update of recent advances in understanding the quality and functional significance of contrast sensitivity for the clinician regarding cataract, intraocular lenses and refractive surgery that goes beyond the measurement of visual acuity.

RECENT FINDINGS

New American National Standards Institute standards for contrast sensitivity based on linear sine-wave gratings are discussed that promise rapid advances of understanding and quantifying visual quality and function by unifying clinical results reported using contrast sensitivity. Increased sensitivity of linear sine-wave gratings over proposed bull's-eye radial gratings is discussed. Digital-image-processing software uses contrast sensitivity data to process images to help understand the quality of what the patient sees. Contrast sensitivity measurement is compared with wavefront aberrometry. Contrast sensitivity measures the total visual system quality in terms of contrast, whereas wavefront aberrometry measures the optical quality in terms of spatial distortion. Both measurements are needed to more fully understand the quality of vision.

SUMMARY

Recent advances provide the clinician with an awareness of why the new contrast-sensitivity standards are based on linear sine-wave gratings and how image-processing software can be used to better understand the quality of functional vision of the patient.

Mutation screening of USH3 gene (clarin-1) in Spanish patients with Usher syndrome: low prevalence and phenotypic variability

Usher syndrome type III is an autosomal recessive disorder clinically characterized by the association of retinitis pigmentosa (RP), variable presence of vestibular dysfunction and progressive hearing loss, being the progression of the hearing impairment the critical parameter classically used to distinguish this form from Usher syndrome type I and Usher syndrome type II. Usher syndrome type III clinical subtype is the rarest form of Usher syndrome in Spain, accounting only for 6% of all Usher syndrome Spanish cases. The gene responsible for Usher syndrome type III is named clarin-1 and it is thought to be involved in hair cell and photoreceptor cell synapses. Here, we report a screening for mutations in clarin-1 gene among our series of Usher syndrome Spanish patients. Clarin-1 has been found to be responsible for the disease in only two families: the first one is a previously reported family homozygous for Y63X mutation and the second one, described here, is homozygous for C40G. This accounts for 1.7% of Usher syndrome Spanish families. It is noticeable that, whereas C40G family is clinically compatible with Usher syndrome type III due to the progression of the hearing loss, Y63X family could be diagnosed as Usher syndrome type I because the hearing impairment is profound and stable. Thus, we consider that the progression of hearing loss is not the definitive key parameter to distinguish Usher syndrome type III from Usher syndrome type I and Usher syndrome type II.

Outcomes of Microincision Cataract Surgery versus Coaxial Phacoemulsification

PURPOSE

To compare outcomes of microincision cataract surgery (MICS) with coaxial phacoemulsification.

DESIGN

Prospective randomized consecutive case series.

PARTICIPANTS

One hundred eyes of 50 patients with nuclear or corticonuclear cataract (grades 2+ to 4) with Lens Opacities Classification System III.

METHODS

One hundred eyes (50 patients) were randomly operated through clear corneal incisions using 2 techniques: coaxial phacoemulsification (50 eyes) and microincision cataract surgery (50 eyes).

MAIN OUTCOME MEASURES

Mean phacoemulsification time, total phacoemulsification percent, effective phacoemulsification time (EPT) (calculated by multiplying total phacoemulsification time in seconds by the average power percent used), intraoperative total balanced salt solution (BSS) volume, visual outcome, vectorial astigmatic changes, corneal thickness, endothelial cell count, and anterior chamber flare and cells preoperatively and at 1 day, 1 month, and 3 months.

RESULTS

Statistically significant differences were found between MICS and coaxial phacoemulsification regarding mean incision size, mean total phacoemulsification percent, and EPT. There were no significant differences between the techniques regarding the mean percent of endothelial cell loss, anterior chamber cell count and flare, mean phacoemulsification time, pachymetric measures or total BSS volume utilized, or visual outcome. The vectorial astigmatic changes in the MICS group showed a change of < or =0.25 diopters (D) in 35% of the eyes, 0.25 to 0.5 D in 50% of the eyes, and 0.5 to 1.0 D in 15% of the eyes. These changes were induced by the surgery. Vectorial astigmatic changes of >1 D were not observed. In the coaxial phacoemulsification group, vectorial astigmatic changes of <0.25 D were not observed either. Changes of 0.25 to 0.5 D were seen in 20% of the eyes, and changes of 0.5 to 1.0 D were seen in 30%. Fifty percent of the eyes showed changes of >1.0 D. Mean vectorial astigmatic changes were 0.36+/-0.23 D in the MICS group and 1.2+/-0.74 D in the coaxial phacoemulsification group (P<0.001).

CONCLUSIONS

Microincision cataract surgery significantly lowered mean phacoemulsification time, mean total phacoemulsification percent, mean EPT, and surgically induced astigmatism when compared with coaxial phacoemulsification.

Diffuse Lamellar Keratitis 6 Months After Uneventful Laser in situ Keratomileusis

PURPOSE

Diffuse lamellar keratitis after laser in situ keratomileusis (LASIK) typically occurs between 1 and 7 days after the procedure, and its etiologic factor(s) remain unknown.

METHODS

We describe a case of diffuse lamellar keratitis 6 months after uneventful LASIK in a 25-year-old woman.

RESULTS

Slit-lamp microscopy showed a diffuse infiltrate confined to the interface, extending to the visual axis, with no other relevant findings. Late on-set diffuse lamellar keratitis was our provisional diagnosis and treatment with topical corticosteroids was instituted, with rapid response and improvement of the clinical signs and symptoms.

CONCLUSIONS

This case supports the theory that a previously inert inciting agent could cause a delayed toxic or inflammatory response of the cornea several months after surgery.

Toric phakic intraocular lens: European multicenter study

OBJECTIVE

To evaluate safety, efficacy, predictability, stability, complications, and patient satisfaction after implantation of Artisan toric phakic intraocular lenses (TPIOLs) for the correction of myopia or hyperopia with astigmatism.

DESIGN

Prospective, nonrandomized, comparative (self-controlled) multicenter trial.

PARTICIPANTS

Seventy eyes of 53 patients (mean, 35 years; range, 22-59 years) with preoperative spherical equivalent between +6.50 and -21.25 diopters (D) and cylinder between 1.50 and 7.25 D.

METHODS

Seventy eyes underwent implantation of a TPIOL with an optical zone of 5.0 mm (Artisan, Ophtec, Groningen, The Netherlands). The dioptric power of the intraocular lens was calculated by considering refraction, keratometry, and anterior chamber depth. The follow-up was 6 months in all cases. Lenses were available in powers ranging from +12.0 D to -23.5 D (spherical equivalent) in 0.5-D increments, with additional cylinder from 1.0 D to 7.0 D, also in 0.5-D increments.

MAIN OUTCOME MEASURES

The main parameters assessed were best spectacle-corrected visual acuity (BSCVA), uncorrected visual acuity (UCVA), refraction, endothelial cell count (ECC), intraocular pressure, slit-lamp biomicroscopy, indirect ophthalmoscopy, subjective complaints, and patient satisfaction.

RESULTS

Eyes were divided into group A, myopia (n = 48), with an average preoperative spherical equivalent of -8.90 +/- 4.52 D, and group B, hyperopia (n = 22), with an average preoperative spherical equivalent of +3.25 +/- 1.98 D. No eyes in either group experienced a loss in BSCVA, and 46 eyes gained 1 or more lines of their preoperative BSCVA. In 62 eyes (88.6%), UCVA was 20/40 or better. There was a significant reduction in spherical errors and astigmatism in all cases after surgery. All eyes of both groups were within +/-1.00 D of target refraction, and 51 eyes (72.9%) were within +/-0.50 D of target refraction. There was a 4.5% mean total loss of ECC during the first 6 months. No serious complications were observed. Overall patient satisfaction was very high.

CONCLUSIONS

Six-month clinical trial results demonstrate that implantation of the Artisan TPIOL safely, predictably, and effectively reduced or eliminated high ametropia and astigmatism with one procedure. The refractive effect was stable at 6 months after surgery.

Intracorneal rings to correct corneal ectasia after laser in situ keratomileusis

PURPOSE

To evaluate the potential of using intrastromal corneal ring technology (Intacs, KeraVision) to correct posterior ectasia after laser in situ keratomileusis (LASIK) for myopia.

SETTING

Department of Cornea and Refractive Surgery, Instituto Oftalmológico de Alicante, and Miguel Hernández University School of Medicine, Alicante, Spain.

METHODS

In this prospective noncomparative intervention case series, Intacs segments were implanted in 3 eyes that developed posterior ectasia after myopic LASIK with clear central corneas. Posterior ectasia and corneal thickness were tested using the Orbscan II Slit Scanning Corneal Topography/Pachymetry System (Orbtek Inc.). Segment thickness varied based on corneal topography analysis and refraction. The mean follow-up was 8.3 months (range 7 to 11 months).

RESULTS

The cases showed marked improvement after Intacs segment implantation. Postoperatively, there was a reduction in the magnitude of the posterior and anterior corneal surface steepening or ectasia and an increase in the topographical regularity index. In addition, the significantly enlarged optical zones resulted in a favorable visual outcome. In 2 eyes, the uncorrected visual acuity (UCVA) was 20/40 postoperatively. In the third eye, there was a residual refractive error; the UCVA was 20/50 and the best spectacle-corrected visual acuity, 20/40.

CONCLUSIONS

Intacs intrastromal corneal rings used as a mechanical device may alter the biomechanical properties of the cornea for the correction of iatrogenic keratectasia and the associated residual myopia.

[Right ventricular outflow obstruction due to a giant pseudoaneurysm of the anterior descending coronary artery in a patient with Behçet's disease]

Giant pseudoaneurysms of coronary arteries in patients with Behçet's disease is a uncommon finding. It has been described exceptionally in the literature. We present a case of giant pseudoaneurysm of the left anterior descending coronary artery with obstruction of the right ventricular outflow in a patient with Behçet's disease. He improved after surgical resection and steroid treatment.

Corneal stromal changes induced by myopic LASIK

PURPOSE. Despite the rapidly growing popularity of laser in situ keratomileusis (LASIK) in correction of myopia, the tissue responses have not been thoroughly investigated. The aim was to characterize morphologic changes induced by myopic LASIK in human corneal stroma.

METHODS

Sixty-two myopic eyes were examined once at 3 days to 2 years after LASIK using in vivo confocal microscopy for measurement of flap thickness, keratocyte response zones, and objective grading of haze.

RESULTS

Confocal microscopy revealed corneal flap interface particles in 100% of eyes and microfolds at the Bowman's layer in 96.8%. The flaps were thinner (112 +/- 25 microm) than intended (160 microm). The keratocyte activation in the stromal bed was greatest on the third postoperative day. Patients with increased interface reflectivity due to abnormal extracellular matrix or activated keratocytes at > or = 1 month (n = 9) had significantly thinner flaps than patients with normal interface reflectivity (n = 18; 114 +/- 12 versus 132 +/- 22 microm, P = 0.027). After 6 months the mean density of the most anterior layer of flap keratocytes was decreased.

CONCLUSIONS

Keratocyte activation induced by LASIK was of short duration compared with that reported after photorefractive keratectomy. The flaps were thinner than expected, and microfolds and interface particles were common complications. The new findings such as increased interface reflectivity associated with thin flaps and the apparent loss of keratocytes in the most anterior flap 6 months to 2 years after surgery may have important clinical relevance.

Management of radial keratotomy overcorrections by corneal sutures

Refractive hyperopia is a significant complication after radial keratotomy (RK). In this study, we corrected it by suturing the radial incisions, using purse-string sutures, and using a combined technique. Thirteen patients (six original overcorrections, four overcorrections after reoperation, and three progressive hyperopes) were included, demonstrating that the techniques induced a wide range of central corneal steepness and therefore corrected variable amounts of hyperopia. However, only the combination of purse-string suture and radial incision suturing provided a stable result. One patient in the purse-string group and two in the radial group required a third combined surgery to achieve an acceptable result. In the combined group, all cases achieved an improvement in visual acuity. While all cases were within 1 diopter of emmetropia, in seven cases pre-RK visual acuity was equal to the best corrected visual acuity six months after surgery. Preoperative best corrected visual acuity was maintained in all cases. Suture removal at the sixth month postoperatively did not seem to influence the refractive result. Our results suggest that neither purse string nor radial suturing is enough to achieve the girdle effect to the cornea; they must be combined. A significant regression of the effect should be expected following the suture placement, mainly during the early postoperative period, until a stable result is achieved about six months later. A computer-assisted photokeratoscope image was taken preoperatively and postoperatively, showing that some irregular astigmatism should be expected as a result of the procedure.

New theoretical matrix formula for intraocular lens calculation using the optimal bending factor

By applying Gaussian optics we propose a new matrix formula model for intraocular lens (IOL) calculation that yields not only IOL optical power for a particular eye but also an evaluation of the bending factor of different IOL optical designs. This option improves IOL selection and results in the best possible optical image, a function dependent on the IOL's bending factor. This formula is a new approach to IOL calculation and may be useful in designing IOLs for abnormally hyperopic or myopic eyes. Optimal IOL power and design should both be considered in IOL calculation, which may improve the optical and clinical results of IOL implantation in the aphakic patient. The radius of the cornea is assumed to be spherical, and aspherical curves of the cornea may influence the optimal "bending" or shape factor of a lens.

[Clinical and angiographic course after coronary angioplasty. Analysis of predictor factors of restenosis]

In order to know the restenosis rate and its predictive factors and the short-term clinical outcome (6-12 months) after coronary angioplasty (PTCA), we prospectively followed 200 consecutive patients with 231 coronary stenoses successfully dilated (residual stenosis < 50%). Patients have been clinically and angiographically followed 6-9 months after the procedure. Forty-nine clinical, hemodynamic, angiographic and technical variables were analyzed. Restenosis (stenosis > or = 50% in late angiographic control) rate was 51.5%, and 61% of the study population was symptomless. Variables associated with restenosis in the univariate analysis were: pre-PTCA positive exercise test (p = 0.004); stenosis severity pre-PTCA (p = 0.04); eccentricity (p < 0.0001) and irregularity (p < 0.0001) of the pre-PTCA stenosis; total dilation time (p = 0.02) and post-PTCA dissection (p = 0.002). The multivariate analysis revealed the following variables as independent predictors of restenosis: presence of dissection after PTCA, eccentricity and irregularity of pre-PTCA stenosis, positive pre-PTCA stress test and duration of symptoms before the procedure. These data suggest that the probability of restenosis after PTCA is predominantly determined by the characteristics of the lesion being dilated and the degree of intimal injury produced during the procedure. These variables could define high and low risk populations and may modify PTCA indications and follow up strategies.

[Pleural effusion and constrictive pericarditis secondary to bromocriptine treatment]

The case of a 60 year old patient with Parkinson's disease is reported, who, following 2 years of treatment with bromocriptine, presented a left pleural effusion in which chronic constrictive pericarditis was demonstrated. Studies aimed at establishing the etiology were negative. Upon withdrawal of bromocriptine, the pleural effusion disappeared and the patient remained asymptomatic, with only pleural thickening persisting in the thoracic radiography. The appearance of polyserositis as an undesirable effect of the use of bromocriptine is discussed. The first case associated to chronic pericarditis is reported.

[Changes in the Q-Tc interval in the acute phase of cerebral ischemic infarction]

A clinical prospective study was carried out in 100 patients with stroke (S) (56 with lacunar infarctions [LI] and 44 with nonlacunar infarctions [NLI]) and in a control group without organic cerebral disease (n = 100) to compare the abnormalities in the Q-Tc interval of the electrocardiogram. An abnormal Q-Tc interval (greater than 0.44 sec) was found in 18% of S and in 8% of the control subjects (p less than 0.05). These abnormalities in S were more common at the onset of the disease (18%) than from 3 weeks after the development of focal signs (9%). An abnormal Q-Tc interval was found in 18% of NLI (8 of 44 cases) and in 18% of NLI (10 of 56 cases). Regarding the topography of the lesions, an abnormal Q-Tc interval was found in 20% (3 of 15 cases) of the brainstem infarctions; in 19% of the infarctions of basal ganglia (9 of 47 cases) and in 13% (4 of 30 cases) of hemispheral strokes. Our results show that the abnormalities of Q-Tc interval in strokes are not uncommon. They may be reversible and in some cases they are related with the topography of the cerebral lesion.

[Brain-heart interaction: a controlled prospective study of the electrocardiographic disorders in 100 consecutive patients with acute ischemic cerebrovascular pathology]

We carried out a prospective clinical study in 100 patients with cerebral infarctions (Cl) (56 lacunar and 44 nonlacunar infarctions) and in a control group (n = 100) without organic cerebrovascular disease to evaluate the electrocardiographic (ECG) abnormalities. 72% of the Cl and 38% of the control group had ECG abnormalities (p less than 0.0001). These abnormalities were significantly more common (p less than 0.001) at the beginning of the disease (72%) than three weeks after the development of focal neurological symptoms (54%). The major ECG findings were abnormal ventricular repolarization (changes in the ST segment and the T wave), prolonged Q-Tc interval, and U waves. Atrial fibrillation was significantly more common (p less than 0.03) in nonlacunar infarctions (18%) than in lacunar infarctions (2%) and in the control group (5%). Regarding the topography of the lesions, abnormalities of ECG were found in 80% of hemispheric infarctions, in 66% of the infarcts of basal ganglia, and in 73% of brainstem infarctions. In Cl, ECG abnormalities are common. They may be reversible, and some of them are usually correlated with the type of Cl and with the involved brain topography.

[Evaluation of small branch occlusion and myocardial damage related to angioplasty. Usefulness of determining serum CK-MB]

In 65 consecutive cases of PTCA we prospectively looked for the appearance of myocardial necrosis during PTCA and for the presence of occlusion of collateral branches arising from the inflation area. Premedication was oral in 44 and intramuscular in 21 cases. CK-MB was abnormally increased in 6 cases: 3 with total occlusion of the dilated artery, 1 with transient coronary occlusion, and 1 with occlusion of a collateral branch greater than 1 mm diameter; in the sixth case the increased CK-MB peak was attributed to repeated defibrillations. Only 1 collateral branch less than 1 mm was occluded during PTCA though myocardial necrosis was not detected. Only collateral branches arising from the dilated stenosis were affected (occlusion and/or appearance of new stenosis) by PTCA (4/24 vs 0/162; p less than 0.01). There were no significant differences in CK-MB peak between both types of premedication. Thus we conclude that: 1) in PTCA myocardial necrosis is only induced by occlusion of coronary arteries greater than 1 mm diameter; 2) only collateral branches arising from the dilated stenosis are at risk of occlusion; 3) estimation of CK-MB pre-PTCA and 8 hours post-PTCA are sufficient for detection of myocardial necrosis.

Ultrastructural study of a retinoma by intraocular fine-needle aspiration biopsy

The authors present the results of a transmission electron-microscopic study performed on a tissue sample obtained by an intraocular fine-needle aspiration biopsy in a case of retinoma. The ultrastructural study showed that the tumor was composed mainly of granular osmiophilic material which contained some tumor cells. These cells showed peculiar ultrastructural characteristics, which demonstrated their neural character, and appeared in different degenerative stages. Apparently, this is the first case in whom ultrastructural technique have been applied to study an intraocular tumor sample obtained by intraocular fine-needle aspiration biopsy, and the first case of retinoma studied by such a diagnostic approach.

Retinal manifestations of Mediterranean spotted fever

The authors studied the incidence, type and systemic relationship of the retinal findings observed by ophthalmoscopy in Mediterranean spotted fever (MSF) in a consecutive series of 34 cases. It is found that retinal vasculitis either arterial and/or, more frequently, venous is present in 55.9% of the cases. Branch vein retinal thrombosis appeared as complication of such small vessel vasculitis in 1 case. Although frequent, the retinal findings were asymptomatic in all cases but the retinal vein thrombosis one, and were not significatively related to or were predicted by other systemic parameters of severity of the disease. Because of its frequency, retinal vasculitis might be considered as an important clinical sign of MSF in endemic areas.