Use of intraoperative fourier-domain anterior segment optical coherence tomography during descemet stripping endothelial keratoplasty

To evaluate the intraoperative use of handheld Fourier-domain optical coherence tomography (OCT) during Descemet stripping automated endothelial keratoplasty (DSAEK) to assess the donor-host interface.

[Safety of treatment with tacrolimus ointment for anterior segment inflammatory diseases]

BACKGROUND: The off-label use of topical tacrolimus (Protopic) for inflammatory external eye diseases is gaining popularity. However, there are no reports on the safety profile of this new treatment option. PATIENTS AND METHODS: We treated six patients with different inflammatory eye diseases with topical tacrolimus (Protopic 0.03 %) as off-label use in addition to the conventional anti-inflammatory treatment. Patients were interviewed for side effects and serum drug concentrations were measured under steady state conditions one hour after topical application of tacrolimus ointment. RESULTS: Two patients reported a slight burning sensation immediately after application, in one patient we found a slight worsening of the dry eye problems. No patient abandoned the treatment due to side effects. Serum drug concentrations remained below the analytical threshold in all cases (< 1.5 ng/ml). CONCLUSIONS: Tacrolimus for the topical treatment of anterior segment inflammatory eye diseases is well tolerated without detectable systemic drug resorption.

Bimanual anterior segment revision surgery for anterior capsule contraction syndrome associated with anterior flexion of intraocular lens haptics

PURPOSE To report the incidence of anterior capsule contraction syndrome (ACCS) and to present a novel minimally invasive bimanual technique for anterior segment revision surgery associated with ACCS with anterior flexion of the intraocular lens haptics. METHODS A consecutive cohort of 268 eyes of 161 patients undergoing phacoemulsification and implantation of the same type of hydrophilic acrylic aspheric intraocular lens cohort were analysed and a novel technique of minimally invasive bimanual technique for anterior segment revision surgery is described. RESULTS We identified four eyes (1.5%) of three patients with advanced ACCS. Successful restoration of a clear visual axis with minimal induction of astigmatism and rapid visual rehabilitation was achieved in all four cases. CONCLUSION This technique is a safe and minimally invasive alternative to laser or vitrector-cut capsulotomy to restore a clear visual axis. In cases of advanced ACCS, it offers the option for haptic reposition or amputation.

Prophylactic use of bevacizumab to avoid anterior segment neovascularization following proton therapy for uveal melanoma.

PURPOSE To investigate whether the prophylactic use of bevacizumab reduces the rate of rubeosis after proton therapy for uveal melanoma and improves the possibility to treat ischemic, reapplicated retina with laser photocoagulation. DESIGN Comparative retrospective case series. METHODS Uveal melanoma patients with ischemic retinal detachment and treated with proton therapy were included in this institutional study. Twenty-four eyes received prophylactic intravitreal bevacizumab injections and were compared with a control group of 44 eyes without bevacizumab treatment. Bevacizumab injections were performed at the time of tantalum clip insertion and were repeated every 2 months during 6 months, and every 3 months thereafter. Ultra-widefield angiography allowed determination of the extent of retinal ischemia, which was treated with laser photocoagulation after retinal reapplication. Main outcome measures were the time to rubeosis, the time to retinal reattachment, and the time to laser photocoagulation of ischemic retina. RESULTS Baseline characteristics were balanced between the groups, except for thicker tumors and larger retinal detachments in the bevacizumab group, potentially to the disadvantage of the study group. Nevertheless, bevacizumab prophylaxis significantly reduced the rate of iris rubeosis from 36% to 4% (log-rank test P = .02) and tended to shorten the time to retinal reapplication until laser photocoagulation of the nonperfusion areas could be performed. CONCLUSIONS Prophylactic intravitreal bevacizumab in patients treated with proton therapy for uveal melanoma with ischemic retinal detachment prevented anterior segment neovascularization, until laser photocoagulation to the reapplied retina could be performed.

Imaging of the Sclera in Patients with Scleritis and Episcleritis using Anterior Segment Optical Coherence Tomography

PURPOSE To evaluate the sclera and episclera in patients with scleritis and episcleritis using anterior segment optical coherence tomography (AS-OCT). METHODS Cross-sectional prospective case series of 11 consecutive patients with episcleral or scleral inflammatory disease located anterior to the equator. The thickness of the ocular wall (sclera and the episclera) was measured using AS-OCT and compared to the contralateral healthy eye. RESULTS Eleven patients with a mean age of 49.5 years presented with symptomatic scleritis or episcleritis. The mean thickness of the ocular wall in the affected eye was 982 ± 56 μm compared to 790 ± 23 μm (p < 0.05) in the fellow eye. Enhanced-depth AS-OCT showed that the thickening occurred mainly in the episcleral layer in both scleritis and episcleritis. CONCLUSION Enhanced-depth AS-OCT may be a useful tool for imaging scleritis or episcleritis and may serve to monitor therapeutic success in these patients.

Ocular pulse amplitude in healthy subjects as measured by dynamic contour tonometry

OBJECTIVES: To test whether dynamic contour tonometry yields ocular pulse amplitude (OPA) measurements that are independent of corneal thickness and curvature, and to assess variables of observer agreement. METHODS: In a multivariate cluster analysis on 223 eyes, the relationship between central corneal thickness, corneal curvature, axial length, anterior chamber depth, intraocular pressure, sex, age, and OPA measurements was assessed. Intraobserver and interobserver variabilities were calculated from repeated measurements obtained from 8 volunteers by 4 observers. RESULTS: The OPA readings were not affected by central corneal thickness (P = .08), corneal curvature (P = .47), anterior chamber depth (P = .80), age (P = .60), or sex (P = .73). There was a positive correlation between OPA and intraocular pressure (0.12 mm Hg/1 mm Hg of intraocular pressure; P<.001) and a negative correlation between OPA and axial length (0.27 mm Hg/1 mm of length; P<.001). Intraobserver and interobserver variabilities were 0.08 and 0.02 mm Hg, respectively, and the intraclass correlation coefficient was 0.89. CONCLUSIONS: The OPA readings obtained with dynamic contour tonometry in healthy subjects are not influenced by the structure of the anterior segment of the eye but are affected by intraocular pressure and axial length. We found a high amount of agreement within and between observers.

Scleral thinning after repeated intravitreal injections of antivascular endothelial growth factor agents in the same quadrant

PURPOSE We assessed the effects of intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy on scleral architecture using spectral domain anterior segment optical coherence tomography (OCT). METHODS A total of 35 eyes of 35 patients treated with at least 30 intravitreal injections in one eye in the inferotemporal quadrant with ranibizumab or aflibercept and 10 or less intravitreal injections in the fellow eye attending the intravitreal injection clinic were included. Enhanced depth imaging anterior segment OCT was used to measure scleral thickness. For each eye the sclera was measured in four quadrants at 3 mm from the limbus. In addition axial eye length was measured in all subjects using partial coherence interferometry. RESULTS The mean number of intravitreal injections was 42 (range, 30-73) and 1.6 (range, 0-9) in the fellow eyes. In the study eyes with more than 30 injections the average scleral thickness in the inferotemporal quadrant was 568.4 μm (SD ± 66 μm) and 590.6 μm (SD ± 75 μm) in the fellow eyes with 10 or less injections (P = 0.003). The mean average scleral thickness in the other three quadrants (inferonasal, superotemporal, and superonasal) was 536.6 μm in the study eyes (SD ± 100 μm) and 545.2 μm (SD ± 109 μm) in the fellow eyes (P = 0.22). There was a borderline association of the total number of injections with scleral thickness change in the inferotemporal quadrant (r = 0.3, P = 0.052). CONCLUSIONS Intravitreal injections may lead to scleral changes when applied repeatedly in the same quadrant. Thus, alternating the injection site should be considered in patients requiring multiple intravitreal injections.

Metrics of the normal anterior sclera: imaging with optical coherence tomography

BACKGROUND To investigate anterior scleral thickness in a cohort of healthy subjects using enhanced depth imaging anterior segment optical coherence tomography. METHODS Observational case series. The mean scleral thickness in the inferonasal, inferotemporal, superotemporal, and superonasal quadrant was measured 2 mm from the scleral spur on optical coherence tomography in healthy volunteers. RESULTS Fifty-three eyes of 53 Caucasian patients (25 male and 28 female) with an average age of 48.6 years (range: 18 to 92 years) were analysed. The mean scleral thickness was 571 μm (SD 84 μm) in the inferonasal quadrant, 511 μm (SD 80 μm) in the inferotemporal quadrant, 475 (SD 81 μm) in the superotemporal, and 463 (SD 64 μm) in the superonasal quadrant. The mean scleral thickness was significantly different between quadrants (p < 0.0001, repeated measures one-way ANOVA). The association between average scleral thickness and age was statistically significant (p < 0.0001, Pearson r = 0.704). CONCLUSIONS Enhanced depth imaging optical coherence tomography revealed the detailed anatomy of the anterior sclera and enabled non-invasive measurements of scleral thickness in a non-contact approach. The anterior scleral thickness varies significantly between quadrants, resembling the spiral of Tillaux. An association of increasing scleral thickness with age was found.

Evaluation of scleral and corneal thickness in keratoconus patients

PURPOSE To determine whether the scleral stroma is affected as much as the corneal stroma in keratoconus. SETTING University Eye Clinic, Bern, Switzerland. DESIGN Comparative case-control study. METHODS Eyes with keratoconus (keratoconus group) and eyes of age-, sex-, and axial length-matched controls (control group) were analyzed. Corneal videokeratometry and pachymetry were performed using a Scheimpflug tomographer (Pentacam). For measurements of the peripheral cornea and the anterior sclera, a spectral-domain anterior segment optical coherence tomography device (Spectralis) was used. RESULTS The study group comprised 51 eyes and the control group, 50 eyes. The mean central corneal thickness in the keratoconus group was statistically significantly lower than in the control group (447.8 μm ± 57.8 [SD] versus 550.5 ± 35.5 μm) (P < .0001). No significant difference in the mean anterior scleral thickness was found between the keratoconus group and the control group (479.1 ± 43.7 μm versus 474.2 ± 43.0 μm) (P =.57). CONCLUSION Although corneal thinning was observed in keratoconus patients, the anterior scleral stroma thickness in these patients seemed to be similar to that in healthy control eyes.

Retinal Complications after Damaging the Vitreolenticular Barrier

This article gives an overview of the vitreal anatomy and its changes in ageing, which have a significant impact on the two main retinal complications after damage of the vitreolenticular barrier, namely retinal detachment and cystoid macular edema. The possible reasons and pathomechanisms for this entity of retinal diseases in the context of anterior segment interaction are highlighted, and a summary of references is provided showing the epidemiology and consequences of such interventions.

Funduscopy in adult zebrafish and its application to isolate mutant strains with ocular defects

Funduscopy is one of the most commonly used diagnostic tools in the ophthalmic practice, allowing for a ready assessment of pathological changes in the retinal vasculature and the outer retina. This non-invasive technique has so far been rarely used in animal model for ophthalmic diseases, albeit its potential as a screening assay in genetic screens. The zebrafish (Danio rerio) is well suited for such genetic screens for ocular alterations. Therefore we developed funduscopy in adult zebrafish and employed it as a screening tool to find alterations in the anterior segment and the fundus of the eye of genetically modified adult animals.A stereomicroscope with coaxial reflected light illumination was used to obtain fundus color images of the zebrafish. In order to find lens and retinal alterations, a pilot screen of 299 families of the F3 generation of ENU-treated adult zebrafish was carried out.Images of the fundus of the eye and the anterior segment can be rapidly obtained and be used to identify alterations in genetically modified animals. A number of putative mutants with cataracts, defects in the cornea, eye pigmentation, ocular vessels and retina were identified. This easily implemented method can also be used to obtain fundus images from rodent retinas.In summary, we present funduscopy as a valuable tool to analyse ocular abnormalities in adult zebrafish and other small animal models. A proof of principle screen identified a number of putative mutants, making funduscopy based screens in zebrafish feasible.

Intravitreal bevacizumab (Avastin) in the treatment of neovascular glaucoma

PURPOSE: To describe a case series of neovascular glaucoma (NVG) caused by central retinal vein occlusion (CRVO) that was treated with intravitreal bevacizumab (IVB; Avastin). DESIGN: Retrospective interventional case series. METHODS: Six consecutive patients with NVG and a refractory, symptomatic elevation of intraocular pressure (IOP) and pronounced anterior segment congestion received IVB (1.25 mg/0.05 ml). Diode laser cyclophotocoagulation was carried out only if pressure was controlled insufficiently by topical medication. Follow-up examinations occurred at four to 16 weeks. RESULTS: IVB resulted in a marked regression of anterior segment neovascularization and relief of symptoms within 48 hours. IOP decreased substantially in three eyes; in the other three eyes, adjuvant cyclophotocoagulation was necessary. No side effects were observed. Panretinal photocoagulation (PRP) was performed as soon as feasible, five to 12 weeks after IVB treatment. CONCLUSION: IVB leads to a rapid regression of iris and angle neovascularization and should be investigated more thoroughly as an adjunct in the management of NVG.

Autofluorescence endoscopy in surveillance of Barrett's esophagus: a multicenter randomized trial on diagnostic efficacy

BACKGROUND AND STUDY AIMS: The reference surveillance method in patients with Barrett's esophagus is careful endoscopic observation, with targeted as well as random four-quadrant biopsies. Autofluorescence endoscopy (AFE) may make it easier to locate neoplasia. The aim of this study was to elucidate the diagnostic accuracy of surveillance with AFE-guided plus four-quadrant biopsies in comparison with the conventional approach. PATIENTS AND METHODS: A total of 187 of 200 consecutive Barrett's esophagus patients who were initially enrolled (73 % male, mean age 67 years, mean Barrett's segment length 4.6 cm), who underwent endoscopy for Barrett's esophagus in four study centers, were randomly assigned to undergo either AFE-targeted biopsy followed by four-quadrant biopsies or conventional endoscopic surveillance, also including four-quadrant biopsies (study phase 1). After exclusion of patients with early cancer or high-grade dysplasia, who underwent endoscopic or surgical treatment, as well as those who declined to participate in phase 2 of the study, 130 patients remained. These patients were examined again with the alternative method after a mean of 10 weeks, using the same methods described. The main study parameter was the detection of early cancer/adenocarcinoma or high-grade dysplasia (HGD), comparing both approaches in study phase 1; the secondary study aim in phase 2 was to assess the additional value of the AFE-guided approach after conventional surveillance, and vice versa. Test accuracy measures were derived from study phase 1. RESULTS: In study phase 1, the AFE and conventional approaches yielded adenocarcinoma/HGD rates of 12 % and 5.3 %, respectively, on a per-patient basis. With AFE, four previously unrecognized adenocarcinoma/HGD lesions were identified (4.3 % of the patients); with the conventional approach, one new lesion (1.1 %) was identified. Of the 19 adenocarcinoma/HGD lesions detected during AFE endoscopy in study phase 1, eight were visualized, while 11 were only detected using untargeted four-quadrant biopsies (sensitivity 42 %). Of the 766 biopsies classified at histology as being nonneoplastic, 58 appeared suspicious (specificity 92 %, positive predictive value 12 %, negative predictive value 98.5 %). In study phase 2, AFE detected two further lesions in addition to the initial alternative approach in 3.2 % of cases, in comparison with one lesion with conventional endoscopy (1.7 %). CONCLUSIONS: In this referral Barrett's esophagus population with a higher prevalence of neoplastic lesions, the AFE-guided approach improved the diagnostic yield for neoplasia in comparison with the conventional approach using four-quadrant biopsies. However, AFE alone was not suitable for replacing the standard four-quadrant biopsy protocol.

Myocardial bridging: depiction rate and morphology at CT coronary angiography--comparison with conventional coronary angiography

PURPOSE: To prospectively assess the depiction rate and morphologic features of myocardial bridging (MB) of coronary arteries with 64-section computed tomographic (CT) coronary angiography in comparison to conventional coronary angiography. MATERIALS AND METHODS: Patients were simultaneously enrolled in a prospective study comparing CT and conventional coronary angiography, for which ethics committee approval and informed consent were obtained. One hundred patients (38 women, 62 men; mean age, 63.8 years +/- 11.6 [standard deviation]) underwent 64-section CT and conventional coronary angiography. Fifty additional patients (19 women, 31 men; mean age, 59.2 years +/- 13.2) who underwent CT only were also included. CT images were analyzed for the direct signs length, depth, and degree of systolic compression, while conventional angiograms were analyzed for the indirect signs step down-step up phenomenon, milking effect, and systolic compression of the tunneled segment. Statistical analysis was performed with Pearson correlation analysis, the Wilcoxon two-sample test, and Fisher exact tests. RESULTS: MB was detected with CT in 26 (26%) of 100 patients and with conventional angiography in 12 patients (12%). Mean tunneled segment length and depth at CT (n = 150) were 24.3 mm +/- 10.0 and 2.6 mm +/- 0.8, respectively. Systolic compression in the 12 patients was 31.3% +/- 11.0 at CT and 28.2% +/- 10.5 at conventional angiography (r = 0.72, P < .001). With CT, a significant correlation was not found between systolic compression and length (r = 0.16, P = .25, n = 150) but was found with depth (r = 0.65, P < .01, n = 150) of the tunneled segment. In 14 patients in whom MB was found at CT but not at conventional angiography, length, depth, and systolic compression were significantly lower than in patients in whom both modalities depicted the anomaly (P < .001, P < .01, and P < .001, respectively). CONCLUSION: The depiction rate of MB is greater with 64-section CT coronary angiography than with conventional coronary angiography. The degree of systolic compression of MB significantly correlates with tunneled segment depth but not length.