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Background Hemodynamic changes have been observed in patients with Graves’ disease. The aim of our study was to evaluate choroidal vascular change using the choroidal vascularity index (CVI) in patients with thyroid-associated ophthalmopathy (TAO). Methods In this cross-sectional observational study, 40 patients affected by TAO were recruited. Forty healthy individuals, matched for age and sex, served as controls. Foveal enhanced-depth imaging optical coherence tomography scans were obtained from all participants. Images were binarized using the ImageJ software and luminal area (LA) and total choroidal area (TCA) were measured. CVI was calculated as the proportion of LA to TCA. The relation between CVI or subfoveal choroidal thickness (SFCT) and clinical activity score, exophthalmometric value, diplopia status, gender, and age was evaluated. Results CVI was significantly higher in patients with TAO (P = 0.004). No significant difference was observed in SFCT (P = 0.200) and TCA (P = 0.153) comparing TAO patients and healthy controls. LA was significantly higher in TAO group (P = 0.045). On multiple regression analysis, CVI was associated with TCA (P = 0.043). No association was found between SFCT or CVI and TCA, clinical activity score, exophthalmometric value, Inami value, diplopia status, gender or age (P > 0.05). Conclusions This is the first study that has demonstrated an increase in CVI in eyes with TAO compared with healthy controls and has assessed its association with clinical features.

Purpose To estimate the frequency of epiretinal membrane (ERM) in eyes with primary open-angle glaucoma (POAG) treated with Ex-Press shunt implant. Secondarily, we aimed to assess the role of concomitant cataract surgery and the impact of the ERM on central foveal thickness and macular volume. Methods In this prospective, consecutive, case-control study, we enrolled 54 patients affected by PAOG and scheduled for Ex-Press device implant with or without contemporary phacoemulsification. Contralateral eyes affected by POAG and receiving anti-glaucomatous eyedrops constituted the control group. Complete ophthalmologic evaluation and spectral-domain optical coherence tomography (OCT) were performed before and 1, 3 and 6 months after surgery. Results Twenty-six eyes received the Ex-Press implant alone, and 28 eyes underwent the combined procedure. Six months postoperatively, we observed 18 (33%) cases of ERM: 15 (28%) of cellophane macular reflex (CMR) and 3 (6%) of pre-macular fibrosis (PMF). In the control group, 9 (17%) eyes developed an ERM: 8 (15%) were CMR, and 1 (2%) was PMF. The frequency of ERM statistically differs between treated and contralateral eyes (P = 0.032, χ2 test). The ERM frequency did not statically differ between eyes subjected to simple or combined surgery (P = 0.846, χ2 test). Mean central foveal thickness and mean macular volume did not significantly differ between groups. Conclusion The Ex-Press glaucoma shunt may increase the risk of ERM onset regardless of the concomitant cataract surgery; however, most cases were cellophane macular reflex with limited functional and anatomical impact.

Background/aims To evaluate 1-year success rates and safety profile of Preserflo™ Microshunt in glaucoma patients. Methods Retrospective multicentre cohort study of 100 consecutive eyes (91 patients) from four tertiary-referral glaucoma centres. Four intraocular pressure (IOP) criteria were defined: A: IOP ≤ 21 mmHg+IOP reduction ≥20% from baseline; B: IOP ≤ 18 mmHg+IOP reduction ≥20%; C: IOP ≤ 15 mmHg+IOP reduction ≥25%; D: IOP≤12 mmHg+IOP reduction ≥30%. Success was defined as qualified or complete based on whether reached with or without medication. Primary outcome was success according to the above criteria. Secondary outcomes included: IOP, best-corrected visual acuity (BCVA), medication use, complications, postoperative interventions, and failure-associated factors. Results Qualified and complete success rates (95% CI) at 12 months were 74%(66–83%) and 58%(49–69%) for criterion A, 72%(63–82%) and 57%(48–68%) for B, 52%(43–63%) and 47%(38–58%) for C, 29%(21–40%) and 26%(19–36%) for D. Overall median (interquartile range (IQR)) preoperative IOP decreased from 21.5(19–28) mmHg to 13(11–16) mmHg at 12 months. BCVA was not significantly different up to 12 months (p = 0.79). Preoperative median (IQR) number of medications decreased from 3 (2–3) to 0 (0–1) at 12 months. Twelve eyes underwent needling, five surgical revision and one device removal due to corneal oedema. There were no hypotony-related complications. Non-Caucasian ethnicity was the only risk factor consistently associated with increased failure. Conclusions Preserflo™ Microshunt is a viable surgical option in glaucoma patients, with reasonable short-term success rates, decreased medications use, excellent safety profile, smooth postoperative care, and rapid learning curve. Success rates for the most stringent IOP cutoffs were modest, indicating that it may not be the optimal surgery when very low target IOP is required.

Francesco Oddone,1 Vincenzo Scorcia,2 Michele Iester,3 Dario Sisto,4 Stefano De Cilla,5 Paolo Bettin,6 Carlo Cagini,7 Michele Figus,8 Giorgio Marchini,9 Luca Rossetti,10 Gemma Rossi,11 Tommaso Salgarello,12,13 Gian Luca Scuderi,14 Giovanni Staurenghi15 On behalf of the VISIONARY Study Group (Italy)1Glaucoma Unit, IRCSS-Fondazione Bietti, Roma, Italy; 2Department of Ophthalmology, University Magna Græcia of Catanzaro, Catanzaro, Italy; 3Eye Clinic of Genoa, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genova, Genova, Italy; 4Ophthalmology Department, University of Bari, Bari, Italy; 5Department of Health Sciences, Eye Clinic, University of Piemonte Orientale, Novara, Italy; 6Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milano, Italy; 7Department of Medicine and Surgery, Ophthalmology Section, University of Perugia, Perugia, Italy; 8Ophthalmology, Department of Surgery, Medicine, Molecular and Emergency, University of Pisa, Pisa, Italy; 9Ophthalmology Unit, Department of Neurosciences, Biomedicine and Movement, University of Verona, Verona, Italy; 10Eye Clinic, San Paolo Hospital, University of Milan, Milano, Italy; 11University Eye Clinic, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy; 12Ophthalmology Unit, Department of Ageing, Neurosciences, Head-Neck and Orthopaedics Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; 13Institute of Ophthalmology, Università Cattolica del Sacro Cuore, Roma, Italy; 14NESMOS Department, Ophthalmology Unit, St. Andrea Hospital, Università di Roma La Sapienza, Roma, Italy; 15Eye Clinic, Department of Biomedical and Clinical Sciences Luigi Sacco, University of Milan, Milano, ItalyCorrespondence: Francesco Oddone, Glaucoma Unit, IRCSS-Fondazione Bietti, Roma, Italy, Tel + 39 06 85356727, Email oddonef@gmail.comIntroduction: The VISIONARY study examined the intraocular pressure (IOP)-lowering efficacy and tolerability of the preservative-free fixed-dose combination of tafluprost (0.0015%) and timolol (0.5%) (PF tafluprost/timolol FC) in a real-world setting. The country-level data reported herein comprise the largest and first observational study of PF tafluprost/timolol FC therapy in Italy.Methods: An observational, multicenter, prospective study included adult Italian patients with open-angle glaucoma (OAG) or ocular hypertension (OHT) demonstrating insufficient response or poor tolerability with topical prostaglandin analogue (PGA) or beta-blocker monotherapy. Treatment was switched to PF tafluprost/timolol FC therapy at baseline. Primary endpoint was the absolute mean IOP change from baseline at Month 6. Exploratory and safety endpoints included change in IOP at Weeks 4 and 12, ocular signs, symptom severity and reporting of adverse events (AEs).Results: Overall, 160 OAG/OHT patients were included. Mean ± standard deviation IOP was reduced from 19.6 ± 3.6 mmHg at baseline to 14.5 ± 2.6 mmHg at Month 6 (reduction of 5.1 ± 3.7 mmHg; 24.1%; p < 0.0001). IOP reduction was also statistically significant at Week 4 (23.1%; p < 0.0001) and Week 12 (24.7%; p < 0.0001). Based on data cutoff values for mean IOP change of ≥ 20%, ≥ 25%, ≥ 30% and ≥ 35%, respective Month 6 responder rates were 68.1%, 48.7%, 36.2% and 26.9%. Most ocular signs and symptoms were significantly reduced in severity from baseline at Month 6. Two non-serious and mild AEs were reported during the study period, among which, one AE was treatment-related (eyelash growth). &#x2003Conclusion: Italian OAG and OHT patients demonstrated a significant IOP reduction from baseline at Week 4 that was maintained over a 6-month period following a switch from topical PGA or beta-blocker monotherapy to PF tafluprost/timolol FC therapy. Severity of most ocular signs and symptoms was significantly reduced during the study period, and PF tafluprost/timolol FC was generally well tolerated.Keywords: fixed-dose combination therapy, intraocular pressure, ocular hypertension, PF tafluprost/timolol FC, preservative-free topical medication, primary open-angle glaucoma

Purpose: To examine retinal displacement after vitrectomy with internal limiting membrane peeling for epiretinal membrane treatment, and to determine the correlation between the extent of displacement and the ganglion cell layer thickness changes. Methods: Thirty-nine consecutive patients were evaluated. Optical coherence tomography was performed preoperatively, and 2 and 6 months postoperatively. The distance between the fovea, the vessel intersection in the superior nasal, superior temporal, inferior nasal, and inferior temporal macular regions, and the optic disk were measured. Ganglion cell layer thickness was recorded. Results: The distance from the optic disk to the fovea and the superior nasal and inferior nasal vessel intersections significantly reduced at 2 and 6 months. Ganglion cell layer thickness significantly decreased in all the subfields (except nasal) at 6 months. A significant negative correlation was found between the change in the ganglion cell layer thickness and the movement of the fovea toward the optic disk. The ganglion cell layer thickness changes significantly correlated with retinal displacement. Conclusion: Retinal displacement toward the optic disk was detected after vitrectomy with internal limiting membrane peeling in eyes with epiretinal membrane. Ganglion cell layer thickness significantly reduced in all the subfields (except nasal). The extent of the displacement and the ganglion cell layer thickness changes showed significant negative correlation.

Purpose: We aimed to develop indicators based on electronic administrative data to compare treatment intensity at a hospital level in Tuscany, Italy. Methods: Data from 3 university hospitals (UHs), 11 local hospitals (LHs) and 2 private hospitals were analysed. Patients newly treated with an intravitreal injection were followed up for 365 days. Indicator #1 concerned hospitals with >80% of injections linked to a drug and patients with all injections linked to a drug. Indicator #2 included patients who received ⩾3 injections during the first 90 days, regardless of injection-drug linkage. Results: Indicator #1 was computed on four hospitals and included 3210 patients (48.3%). The average number of injections was 3.24 in the largest UH1. Compared to the latter, indicator #1 was significantly lower in UH2 and UH3 (−0.47 and −0.58, respectively; p Conclusion: The two indicators proved to have the potential for supporting clinicians and policy makers in promoting the appropriate treatment intensity with intravitreal anti-vascular endothelial growth factor drugs.

The new XEN63 implant is a minimally invasive glaucoma surgery device with limited experience in real life. This retrospective study included open-angle glaucoma patients who underwent XEN63 implant, either alone or in combination with cataract surgery. Primary endpoints were the intraocular pressure (IOP) at month 3 and the incidence of serious adverse events. Twenty-three eyes of 23 patients were included. Mean age was 67.8 ± 15.3 years and 15 (65.2%) were women. Mean IOP was significantly lowered from 27.0 ± 7.8 mmHg at baseline to 12.2 ± 3.4 mmHg at month 3 (p &lt, 0.0001). Mean IOP lowering was 40.8 ± 23.5%, with 14 (60.9%) and 16 (69.6%) eyes achieving an IOP lowering ≥30% and ≥20% without hypotensive medication, respectively. The number of hypotensive medications (NHM) was significantly reduced from 2.27 ± 0.94 drugs at baseline to 0.09 ± 0.42 drugs at month 3, p &lt, 0.0001. Four (17.4%) eyes had hypotony (IOP ≤ 6 mmHg) at postoperative day one, which was successfully resolved without sequelae. Four (17.4%) eyes had choroidal detachment (3 at day 7 and 1 at day 15), which was successfully resolved with medical treatment, at the month 1 visit. Three (13.0%) eyes required needling (mean time for needling 35.6 ± 9.7 days). XEN63 significantly lowered IOP and reduced the NHM, with a good short-term safety profile.

Purpose. To assess the visual and refractive outcome of immediate intraoperative vitrectomy and intrascleral intraocular lens implantation using a “standardized” sutureless Yamane technique during cataract luxation in the vitreous chamber as a complication of phacoemulsification. Design. A prospective, interventional, consecutive case series. Materials and Methods. Twelve patients underwent vitrectomy and intrascleral intraocular lens fixation using a standardized Yamane technique as the primary procedure during complicated phacoemulsification. Patients were evaluated preoperatively and 6 months postoperatively for best-corrected distance visual acuity, correspondence to the preoperative refractive target in the spherical equivalent, endothelial cell count, and complications. Results. Mean preoperative best-corrected visual acuity was 1.16 ± 0.3 logarithm of the minimum angle of resolution (logMAR), the endothelial cell count was 1910.5 ± 297.64, and target refraction at baseline was −0.197 ± 0.087. Postoperatively, best-corrected visual acuity was significantly improved; the mean value was 0.05 logMAR ± 0.06. Mean baseline target refraction in the spherical equivalent was −0.20 ± −0.09 (range: −0.08 to −0.37), and mean final refraction was −0.44 ± −0.14 (range: −0.25 to −0.75) with no significant difference p = 0.87 . No complication was registered intra- and postoperatively. Conclusion. Standardization of the Yamane technique seemed a valuable option for patients who had complicated phacoemulsification to achieve a predictable refractive outcome. Synopsis. The predictable refractive outcome could be achieved with the immediate standardized Yamane technique in patients with intraoperative cataract luxation in the vitreous chamber during phacoemulsification.

The purpose of this study was to evaluate the efficacy and safety of combined phacoemulsification and Ex-PRESS implant with everting suture in primary angle-closure glaucoma (PACG) and to examine predictive factors of failure. Twenty-three eyes of 18 patients were enrolled. Data about time of removal of releasable sutures and traction of the everting suture and about changes in intraocular pressure (IOP) were collected, as well as comprehensive ophthalmic examinations. Success was defined by the following criteria: IOP ≤ 18 mmHg (criterion 1), IOP ≤ 15 mmHg (criterion 2), and IOP ≤ 12 mmHg (criterion 3). Success was categorized as complete or qualified, depending on whether it was reached without or with drugs, respectively. Success rate was assessed with Kaplan–Meier survival analysis with a Cox proportional hazard model to adjust for potential confounders. The lowering of IOP and the reduction of medications were statistically significant at every follow-up visit compared with the baseline (p &lt, 0.05). The complete success rates were 87%, 70%, and 17% accordingly to criterion 1, 2, and 3, the qualified success rates were 93%, 70%, and 20%, respectively. Most of the complications resolved spontaneously and conservatively. In conclusion, combined phacoemulsification and Ex-PRESS Minishunt implant with everting suture is a safe and effective surgery, even in PACG, lowering IOP and number of medications.

Purpose The purpose of this paper is to present a new surgical technique to remove vitreous cortex remnants. Methods Non-consecutive retrospective interventional case series. Results When the posterior vitreous is split, its outermost layer may remain attached to the retina, developing vitreoschisis-induced vitreous cortex remnants (VCR). Their role in macular pathology etiopathogenesis has been well documented; however, recently, it has been proposed that VCR also play a crucial role in proliferative vitreoretinopathy and consequent retinal redetachment. The prevalence of VCR is underestimated because triamcinolone acetonide is not routinely used for vitreous staining. Vitreous cortex remnants (VCR) removal is challenging, and several surgical techniques have been proposed. However, they require sclerotomy enlargement, material that may not be readily available, and manual fashioning. Alternatively, a diamond-dusted membrane scraper (DDMS), already widely used in macular pathology treatment, can follow the contour of the retina, as it is a silicone tube, and remove VCR with its abrasive tip. A DDMS may also be introduced in the vitreous cavity through a standard trocar. Finally, the use of a DDMS provides predictable feedback, making the learning curve short. In this case series, 34 eyes affected by primary rhegmatogenous retinal detachment were enrolled. The retinal redetachment rate was 2.9% at six months of follow-up, below the average literature value of 21%. No adverse events were reported. Conclusion A DDMS can be suitable for use in VCR removal, although further studies are warranted to understand the indications and extent of this surgical technique for improving the management of rhegmatogenous retinal detachment.

Graves’ orbitopathy (GO) is the most common extrathyroidal manifestation of Graves’ disease (GD). Several studies support the involvement of TSH receptor autoantibodies (TRAbs) in the pathogenesis of GO, and a correlation between GO features and TRAbs has been reported, but not confirmed by all studies. Thus, we conducted a cross-sectional investigation to determine whether there is a correlation between TRAbs and the clinical features of GO in an initial phase of the eye disease. Ninety consecutive patients with untreated GO (67 women and 23 men, age 48.9 ± 12.6 years) were included. Patients who had received treatments other than anti-thyroid drugs for hyperthyroidism or lubricants for GO were excluded. All patients underwent an endocrinological and ophthalmological evaluation, the latter including exophthalmometry, measurement of eyelid width, clinical activity score (CAS), visual acuity, assessment of diplopia, and NOSPECS score. TRAb levels were measured by a third-generation competitive immunoassay. There was a statistically significant, direct correlation between serum TRAb levels and CAS by linear regression analysis (R = 0.278, P = 0.007). The correlation was confirmed by a multiple regression analysis (R = 0.285; P = 0.006) including age and FT3 levels, which also correlated with CAS. There were no relationships between TRAbs and exophthalmometry, eyelid aperture, degree of diplopia, visual acuity, and NOSPECS score. The levels of TRAb in subjects with a recent-onset, untreated GO are directly correlated with the clinical activity of the disease, confirming a possible role of these antibodies in the pathogenesis of GO.

Introduction: To report a case of ocular dirofilariasis in Central Italy (Pisa, Tuscany) and review the previous cases of ocular dirofilariasis reported in Italy. Case description: A 67-year-old man complained about recurrent ocular redness and discomfort previously treated as conjunctivitis. The slit-lamp examination showed a round, translucent cystic swelling under the bulbar conjunctiva of the right eye, near the lateral canthus. Inside this lesion was observed the presence of a motile worm. A surgical procedure was immediately performed, excising a thin, segmented, greyish worm identified as Dirofilaria repens. After the excision, no recurrence of the symptomatology was recorded. Conclusion: Ocular dirofilariasis can lead to misdiagnosis due to its rare ocular manifestations and it is considered an emergent zoonosis in European countries. In Italy from 2001 to January 2018, seven new cases were reported in the literature. In our opinion, it is critical to record all the new cases to assess the epidemiological situation and increase the awareness of this rare infection.

Clinical efficacy of intravitreal anti-VEGF drugs has been widely demonstrated in several angiogenesis-driven eye diseases including diabetic macular edema and the neovascular form of age-related macular degeneration. Pegaptanib, ranibizumab, and aflibercept have been approved for use in the eye, whereas bevacizumab is widely used by ophthalmologists to treat patients “off-label”. These drugs are active in the nanomolar to picomolar range; however, caution is required when establishing the rank order of affinity and potency due to in vitro inter-experimental variation. Despite the small doses used for eye diseases and the intravitreal route of administration may limit systemic side effects, these drugs can penetrate into blood circulation and alter systemic VEGF with unknown clinical consequences, particularly in vulnerable groups of patients. Clinical pharmacokinetics of ocular anti-VEGF agents should therefore be taken into account when choosing the right drug for the individual patient. The gaps in current understanding that leave open important questions are as follows: (i) uncertainty about which drug should be given first, (ii) how long these drugs can be used safely, and (iii) the choice of the best pharmacological strategy after first-line treatment failure. The current review article, based on the information published in peer-reviewed published papers relevant to anti-VEGF treatments and available on the PubMed database, describes in detail the clinical pharmacology of this class of drugs to provide a sound pharmacological basis for their proper use in ophthalmology clinical practice.

Background: The purpose of this prospective study was to evaluate the efficacy and safety of the Ultrasound Cyclo Plasty (UCP) procedure using high-intensity focused ultrasound in surgery-naïve open-angle glaucoma patients. Methods: prospective, non-randomized, single-arm, multicenter clinical trial. Sixty-six eyes with primary open-angle glaucoma, intraocular pressure (IOP) ≥21 mmHg and with no history of filtering surgery were enrolled. Patients were treated by UCP with a therapy probe comprising six piezoelectric transducers, consecutively activated for 8 s each. Complete ophthalmic examination was performed before the procedure, 1 day after the procedure, and 1, 3, 6, 12, 18 and 24 months after the procedure. Primary outcomes were complete success (defined as IOP lowering from baseline ≥20% without additional glaucoma medications) and vision-threatening complications. Secondary outcomes were the presence of complications and the reduction of the number of medications used. Results: IOP was significantly reduced after one procedure (p &lt, 0.05), from a mean pre-operative value of 24.3 ± 2.9 mmHg (n = 2.3 hypotensive medications) to a mean value of 15.9 ± 3.6 mmHg (n = 2.2 hypotensive medications) at 2 years (mean IOP lowering of 33%). Surgical success was achieved in 74% of eyes. Notwithstanding side effects such as transient anterior chamber inflammation, refractive error changes, transient hypotony and macular edema, no major intra or post-operative complications such as phthisis, induced cataract, neovascularization or significant vision loss were observed. Conclusions: Ultrasound Cyclo Plasty is a valuable, effective and well-tolerated procedure to lower IOP in patients with open-angle glaucoma without previous filtering surgery.

The supraciliary space is a physiological route for aqueous humor outflow located anteriorly between the outer surface of the ciliary body and the internal surface of the sclera. Posteriorly, the suprachoroidal space is located between the choroid and the internal surface of the sclera. These spaces have been targeted as suitable and helpful pathways for glaucoma treatment, alternatives to the traditional subconjunctival space. The subconjunctival surgical pathway is affected by several limitations such as poor cosmesis, a lifetime risk for endophthalmitis, and an unpredictable wound healing response. Because of these limitations, the supraciliary space has gained growing interest as a possible target for new glaucoma drainage devices such as: Gold Micro Shunt (SOLX Inc.; Waltham, MA, USA), iStent Supra (Glaukos Corporation, Laguna Hills, CA, USA), CyPass Micro-Stent (Transcend Medical Inc., Menlo Park, CA, USA), Aquashunt (OPKO health Inc., Miami, FL, USA), STARflo (iSTAR Medical, Isnes, Belgium), and Esnoper-Clip implant (AJL Ophthalmics, Álava, Spain). We review the current literature concerning the supraciliary space to evaluate its safety and efficacy as a suitable pathway for glaucoma surgical treatment.

The purpose of this study was to evaluate whether the eye tracking system (ETS) improved the reproducibility of a single circle peripapillary retinal nerve fiber layer (RNFL) measurement acquired with spectral-domain optical coherence tomography (OCT).The sample comprised 205 individuals divided into 2 groups according to intraocular pressure and visual field outcomes. A total of 100 healthy individuals and 105 patients with open-angle glaucoma underwent imaging of the optic nerve head with OCT 3 times during the same session and 2 additional times in subsequent sessions (30 days apart). Intraclass correlation coefficient (ICC), coefficient of variation, and test-retest variability were calculated for the RNFL thickness acquired with and without the ETS enabled, and compared.The glaucoma group mainly comprised patients with moderate glaucoma (mean deviation of standard automated perimetry, -6.73±6.2 dB). The RNFL thicknesses did not differ between acquisitions with or without the ETS activated and disabled. All ICCs were0.9 in the control and glaucoma groups with or without the ETS activated. The best parameter in the intersession analysis (with ETS activated) was global RNFL thickness (ICC, 0.95; coefficient of variation, 2.7%; and test-retest variability, 2.87 μm). The reproducibility and repeatability of RNFL measurements did not differ significantly between acquisitions with or without the ETS in either group.The reproducibility of peripapillary RNFL thicknesses acquired with OCT was excellent. The variability between OCT measurements did not decrease with the ETS activated.

The purpose of this paper is to provide a meaningful literature review about the epidemiology, pathogenesis, imaging and treatment of pachychoroid neovasculopathy (PNV). A computerized search from inception up to December 2019 of the online electronic database PubMed was performed using the following search string: “pachychoroid neovasculopathy”. The reference list in each article was scanned for additional relevant publications. PNV is a type-1 choroidal neovascularization, overlying focal areas of choroidal thickening and dilated choroidal vessels. It can develop in patients affected by pachychoroid pigment epitheliopathy or chronic central serous chorioretinopathy. The absence of drusen, the presence of pachydrusen, younger age of onset and choroidal thickening distinguish it from neovascular age-related macular degeneration (AMD). PNV incidence and prevalence data are lacking. Its pathophysiology is not fully understood, but angiogenic mechanisms involved in neovascular AMD may be different from those in PNV. Due to optical coherence tomography (OCT) improvements, PNV can be diagnosed more easily than before. In particular, PNV shows a shallow pigment epithelium detachment with an undulating retinal pigment epithelium over a subfoveal choroidal thickening, associated with vein enlargement in Haller’s layer (named pachyvessels) and choriocapillaris thinning. On OCT angiography, PNV reveals tangled hyper-reflective filamentous neovessels in the choriocapillaris itself. The current first-line PNV treatment is intravitreal anti-VEGF (vascular endothelial growth factor) injections with a treat-and-extend regimen. In particular, aflibercept shows a higher rate of fluid absorption than others. In the case of fluid recurrence or persistence, photodynamic therapy is a valid alternative. Ongoing research into pathophysiology and imaging improvements may be helpful in defining prognostic criteria and stratifying patient risk, allowing responsible monitoring and management of PNV.

To compare optic disc, retinal and choroidal measurements in patients with Graves’ disease with or without orbitopathy, and healthy controls. Optical coherence tomography and Heidelberg retinal tomography were performed in 40 patients with Graves’ orbitopathy (GO), 40 subjects with Graves’s disease (GD) with no sign of orbitopathy and 40 healthy controls. Degree of exophthalmos, ocular alignment, clinical activity score (CAS), choroidal thickness, retinal thickness, ganglion cell layer (GCL) thickness, disc area, cup area, rim area, cup/disc area ratio, linear cup/disc ratio and mean peripapillary retinal nerve fibre layer thickness were analysed. GO patients and healthy controls significantly differ regarding mean central retinal thickness (275 ± 19 µm and 285 ± 20 µm, P = 0.017); mean central GCL thickness (14.87 ± 3.0 µm and 17.92 ± 5.02 µm, P = 0.001); mean disc area (2.00 ± 0.44 mm2 and 1.72 ± 0.37 mm2, P = 0.003); mean cup area (0.53 ± 0.52 mm2 and 0.31 ± 0.20 mm2, P = 0.003); cup/disc area ratio (0.22 ± 0.10 and 0.17 ± 0.08, P = 0.010); and linear cup/disc ratio (0.47 ± 0.15 and 0.40 ± 0.13, respectively, P = 0.011). No difference was found between patients without orbitopathy and healthy controls. No significant difference was found regarding the choroidal thickness between the three groups. There was no statistically significant relationship between retinal thickness, ganglion cell layer thickness, mean disc area, mean cup area, cup/disc area ratio, linear cup/disc ratio, CAS, exophthalmometric value and ocular alignment. GO patients showed significant changes in foveal and GCL thickness, and optic nerve head morphology suggesting a possible influence of the orbital inflammatory process.

Glaucoma is one of the principal causes of irreversible blindness worldwide. Yet, intraocular pressure (IOP) is the main modifiable risk factor for disease progression. In the never-ending challenge to develop new and effective drugs, several molecules have been tested as anti-glaucoma agents thanks to their pressure-lowering capabilities. Among these molecules, the cannabinoids have been investigated as possible anti-glaucoma drugs since the early 1970s. Cannabinoids are a large class of chemical compounds that exploit their effects by interaction with cannabinoid receptors 1 and 2. These receptors are widely expressed in the human retina where they may influence important functions such as photo-transduction, amacrine cell network maintenance, and IOP regulation. Therefore, in past years several studies have been conducted in order to assess the IOP lowering effects of cannabinoids. PRISMA guidelines have been used to perform a literature search on Pubmed and Scopus aiming to investigate the mechanism of IOP lowering effects and the potential benefits of orally administered, inhaled, topical, and intravenous cannabinoids in the treatment of glaucoma patients.

Background: Refractory glaucoma still represents a challenge for ophthalmologists to manage intraocular pressure. The present study aimed to evaluate long term efficacy and safety of a second Ahmed valve implantation after the failure of a first implant in patients with refractory glaucoma and elevated intraocular pressure (IOP). Methods: Retrospective, multicenter non-comparative case series. Twenty-eight patients were retrospectively recruited between January 2011 and December 2017. Demographic data, glaucoma type, visual acuity, intraocular pressure, medical therapy, and complications were registered. Three criteria of success were established: Type 1 surgical success: IOP &le, 15 mmHg and a reduction of IOP &ge, 40% from baseline, Type 2 surgical success: IOP &le, 18 mmHg and a reduction of IOP &ge, 30% from baseline, and Type 3 surgical success: IOP &le, 21 mmHg and a reduction of IOP &ge, 20% from baseline. Surgical failure has been established as IOP less than 5 mmHg or over 21 mmHg and less than a 20% reduction of IOP from baseline despite medications in two consecutive visits, light perception loss referable to glaucoma, and the necessity for further glaucoma surgery. Failure was observed in six (21%) patients. (3) Results: Mean IOP and mean glaucoma medication number significantly reduced from baseline after the second implantation, and the surgical success rate at 72 months ranged from 10% to 78% based on the different criteria of success. Failure was observed in six (21%) patients. Conclusions: This study confirmed the safety and efficacy of a second Ahmed valve implantation in patients with refractory glaucoma and elevated IOP at baseline.

PURPOSE The purpose of this study was to investigate the tear meniscus in medically controlled glaucoma patients (MCGP) using anterior segment-optical coherence tomography (AS-OCT). MATERIALS AND METHODS Fifty-six MCGP, 24 patients with evaporative dry eye (EDE), and 30 healthy subjects (controls), were enrolled. MCGP were divided into group 1 (14 eyes): β-blockers; group 2 (14 eyes): prostaglandin analogs; group 3 (28 eyes) ≥2 drugs. Ocular Surface Disease Index (OSDI) questionnaire, tear film break-up time, corneal fluorescein staining, Schirmer Test I, and tear meniscus height (lower and upper: L-TMH, U-TMH) and area (L-TMA, U-TMA) using AS-OCT, were performed. RESULTS OSDI score was higher (P

PURPOSE Ultrasound cycloplasty (UCP) acts through the selective coagulation of the ciliary body using high-intensity focused ultrasound (HIFU) technology. The aim of this study was to investigate whether the application of ultrasound beams targeting the ciliary body using an external probe influences astigmatism. METHODS Multicentre, prospective, single-arm, open-label study in adult patients with primary open-angle glaucoma and moderately uncontrolled intraocular pressure (IOP) under glaucoma medication. The primary outcome was induced corneal astigmatism, calculated from topography, and assessed statistically through vector analysis. Secondary outcomes included induced total astigmatism and mean changes from baseline in best-corrected visual acuity (logMAR) and IOP. Subgroup analysis was performed to assess the impact of device centring on corneal and total induced astigmatism. RESULTS Fifty eyes were enrolled. Mean age was 69.6 ± 11.3 years. At 1, 3 and 6 months postprocedure, HIFU-induced corneal astigmatism was 0.88 D × 93°, 0.87 D × 106° and 1.16 D × 97°, respectively, while induced total astigmatism was 0.62 D × 103°, 0.42 × 106° and 0.39 × 107°. By the last follow-up, the percentage of patients with

Background: Optical coherence tomography (OCT) has recently been introduced in the operating theatre. The aim of this review is to present the actual role of microscope-integrated optical coherence tomography (MI-OCT) in ophthalmology. Method: A total of 314 studies were identified, following a literature search adhering to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. After full-text evaluation, 81 studies discussing MI-OCT applications in ophthalmology were included. Results: At present, three microscope-integrated optical coherence tomography systems are commercially available. MI-OCT can help anterior and posterior segment surgeons in the decision-making process, providing direct visualization of anatomic planes before and after surgical manoeuvres, assisting in complex cases, and detecting or confirming intraoperative complications. Applications range from corneal transplant to macular surgery, including cataract surgery, glaucoma surgery, paediatric examination, proliferative diabetic retinopathy surgery, and retinal detachment surgery. Conclusion: The use of MI-OCT in ophthalmic surgery is becoming increasingly prevalent and has been applied in almost all procedures. However, there are still limitations to be overcome and the technology involved remains difficult to access and use.

PurposeTo evaluate and compare the diagnostic accuracy of the Humphrey Field Analyzer (HFA), Octopus perimetry, and Cirrus OCT for glaucomatous optic neuropathy.MethodsEighty-eight healthy individuals and 150 open-angle glaucoma patients were consecutive and prospectively selected. Eligibility criteria for the glaucoma group were intraocular pressure ≥21 mm Hg and glaucomatous optic nerve head morphology. All subjects underwent a reliable standard automated perimetry with the HFA and Octopus perimeter, and were imaged with the Cirrus OCT. Receiver-operating characteristic (ROC) curves were plotted for the threshold values and main indices of the HFA and Octopus, the peripapillary retinal nerve fiber layer thicknesses, and the optic nerve head parameters. Sensitivities at 85 and 95% fixed-specificities were also calculated. The best areas under the ROC curves (AUCs) were compared using the DeLong method.ResultsIn the glaucoma group, mean deviation (MD) was -5.42±4.6 dB for HFA and 3.90±3.6 dB for Octopus. The MD of the HFA (0.966; P

To describe the ocular inflammatory and iatrogenic complications in a cohort of uveitic patients treated in an Italian referral centre.Retrospective non-comparative case series. Medical history and clinical findings of all consecutive patients referred to the uveitis center of Pisa University from January 2015 to January 2017 were reviewed. Only patients with at least three follow-up visits in our center were included in our series.Three hundred and eighty-nine patients were visited in our center during study period; only 142 patients (90 men and 52 female) satisfied the inclusion criteria. Mean age at presentation was 41 ± 14 years. The most common ocular feature was anterior uveitis (46%) and was mainly unilateral. A specific etiological diagnosis was established in 61% of patients. At presentation, 71.43% of patients were on medical therapy for rheumatic disease; 42.86% of patients used systemic steroids Cataract and ocular hypertension were the most common ocular complications during the study period but were not statistically related to systemic steroid treatment.Systemic steroids treatment in uveitis patients does not seem to increase the risk of iatrogenic complications such as cataract and glaucoma. In our series, increasing age appears to be the main risk factor for cataract and glaucoma development. Key points • Cataract, ocular hypertension, and glaucoma are the most common iatrogenic complications. • Systemic steroids can be safely used in uveitis patients.

BackgroundThough several procedures of IOL implantation have been described (sutured scleral fixation, intra-scleral fixation, angle-supported anterior chamber, and anterior chamber or retropupillary iris-claw IOLs), there are no randomized trials which are comparing different techniques. Hence, the surgical treatment of aphakia still remains controversial and challenging. The purpose of this study was to compare the long-term efficacy and the rate of complications of anterior versus posterior Iris-claw intraocular lenses (IOL) implantation to correct for the treatment of aphakia without sufficient capsule support.Methods and findingsConsecutive eyes having secondary implantation of aphakic iris-fixated IOLs with a follow-up of at least 5 years were considered. Mean correct distance visual acuity (CDVA) changes, percentage of eyes with CDVA improvement, mean corneal endothelial cell density (CECD) loss and the rate of other complications were used for statistical analysis. The study evaluated a total of 180 eyes (Group A: 87 anterior chamber iris-claw fixation, Group B: 93 retropupillary iris-claw implantation) of 180 consecutive different patients, with aphakia of various reasons. CDVA improved significantly in both groups after surgery (PConclusionsFive-year follow-up shows that secondary implantation of aphakic IOLs is effective and safe for the correction treatment of aphakia in eyes without capsule support.

Purpose: The aim of this review is to clarify the role of cross-linked Hyaluronic acid (HA) molecule as a tear supplement and to define its possible applications in dry eye disease. Methods: Current Literature about HA and its cross-linked derivatives has been examined. Results: HA is superior in increasing the viscosity and stability of the tear film compared with other tear supplements such as polyvinyl alcohol, hydroxypropyl methylcellulose, carboximethyl cellulose and polyethylene glycol. Moreover, HA can be modified in different ways to improve its properties such as molecular weight, viscosity, and hydrophobicity to adapt the new artificial molecule to different aims. Conclusions: The current pharmacological trend is to improve the properties of HA by cross-linking parts of the molecule to achieve better bioavailability and resistence to degradation. In dry eye disease, cross-linked HA as tear supplement seems to provide better ocular comfort than linear HA and is therefore subjected to growing interest and diffusion.

PurposeThe aim of this study was to investigate the pathogenic role of obesity on blinding eye diseases in a population of severely obese patients with no history of eye diseases, and to verify whether weight loss induced by bariatric surgery may have a protective effect.MethodsThis was a pilot, monocentric, prospective, and open label study conducted at the University Hospital of Pisa. Fifty-seven severely obese patients with a mean body mass index value of 44.1 ± 6 kg/m2 were consecutively recruited and received a complete ophthalmological evaluation and optical coherence tomography. Twenty-nine patients who underwent gastric bypass were evaluated also 3 months, and 1 year after surgery.ResultsAt baseline, blood pressure value were directly and significantly related to intraocular pressure values (pConclusionsThe results of this study suggest that obese patients may have a greater susceptibility to develop glaucomatous optic nerve head damage and age-related macular degeneration. Moreover, weight reduction and improvement of comorbidities obtained by bariatric surgery may be effective in preventing eye disease development by improving retinal nerve fiber layer and foveal thickness.

Glaucoma, one of the leading causes of blindness, is usually first managed medically, with incisional surgery as a second step. Noninvasive glaucoma procedures attempt to fill the gap between medical and surgical treatments and may work synergistically with them. High-intensity focused ultrasound induces a selective and controlled thermal ablation of the distal part of the ciliary body, and this effect is independent from the degree of tissue pigmentation with limited damage to adjacent structures. This selective and innovative treatment decreases intraocular pressure by reducing aqueous humor production and by increasing uveoscleral outflow. We review the current literature on the use of high-intensity focused ultrasound in glaucoma, exploring present use, safety, efficacy, and future clinical applications.

Purpose: To compare the diagnostic accuracy of minimum rim width (MRW), peripapillary retinal nerve fibre layer (pRNFL) and multilayered macular analysis by Spectralis SD-OCT (Heidelberg Engineering, Germany) in discriminating perimetric glaucoma at different stages of the disease from healthy eyes. Methods: In this multicentre, prospective, evaluation of diagnostic tests study, multilayered macular analysis and MRW and pRNFL were obtained from one eye of 197 glaucoma (76 early, 68 moderate and 53 advanced) and of 83 healthy controls from the Multicenter Italian Glaucoma Imaging Study (MIGIS). The reference standard for classifying eyes as glaucomatous and for staging thedisease was the visual field. The main outcome measures were area under the ROC curve (AUC) and sensitivity at fixed specificity (95%). Results: Average MRW and average pRNFL showed the highest and similar diagnostic accuracy in both the whole study population (AUC 0.968 and 0.939) and early glaucoma (AUC 0.956 and 0.929). Among the macular parameters, the three innermost retinal layers combined as the Ganglion Cell Complex provided the highest diagnostic accuracy (AUC 0.931) in the whole population, which was statistically similar to that of average pRNFL but inferior to that of average MRW. Compared to both average MRW and pRNFL, all macular parameters showed statistically significant lower accuracy in early glaucoma, but accuracy in moderate and advanced glaucoma showed no statistically significant differences among three protocols. Conclusion: The diagnostic accuracy of MRW, pRNFL and macular analysis by Spectralis SD-OCT is overall good. MRW and pRNFL analysis performs statistically and clinically better than macular analysis to discriminate early glaucoma from healthy eyes.

The aim of this study is to investigate potential correlations between age, gender, spherical equivalent and optical coherence tomography (OCT) retinal parameters among healthy children. A macular spectral-domain OCT was performed in all patients using a Spectralis® OCT device, and the macular thickness and volume of each of the early treatment diabetic retinopathy study (ETDRS) subfields were analysed. Ninety-four children were enrolled. Mean central macular thickness was 274.968 ± 18.28 µm, while mean central macular volume was 0.216 mm3. Statistical analysis showed a significant correlation between the factor age and central macular thickness (F(3,90) = 4.96, p = 0.003, η2 = 0.14) and central macular volume (F(3,90) = 4.98, p = 0.003, η2 = 0.14). Statistical analysis showed a significant correlation between the factor gender and macular thickness/volume of several ETDRS subfields. A significant correlation between refractive error and macular thickness/volume was also noted. This study shows significant correlations between macular thickness/volume and the factors age, gender and spherical equivalent. Paediatric spectral-domain optical coherence tomography ranges need further investigations since many significant correlations are still to be confirmed.

Purpose. To describe a modified guarded filtration surgery, stab incision glaucoma surgery (SIGS), for primary open angle glaucoma (POAG).Methods. This prospective, interventional case series included patients with POAG (IOP ≥21 mmHg with glaucomatous visual field defects). After sliding superior conjunctiva down over limbus, 2.8 mm bevel-up keratome was used to create conjunctival entry and superficial corneoscleral tunnel in a single step starting 1.5 mm behind limbus. Lamellar corneoscleral tunnel was carefully dissected 0.5–1 mm into cornea and anterior chamber (AC) was entered. Kelly Descemet’s punch (1 mm) was slid along the tunnel into AC to punch internal lip of the tunnel, thereby compromising it. Patency of ostium was assessed by injecting fluid in AC and visualizing leakage from tunnel. Conjunctival incision alone was sutured.Results. Mean preoperative IOP was27.41±5.54 mmHg and mean postoperative IOP was16.47±4.81 mmHg (n=17). Mean reduction in IOP was38.81±16.55%. There was significant reduction of IOP (p<0.000). 64.7% had IOP at final follow-up of Conclusion. Satisfactory IOP control was noted after SIGS in interim follow-up (14.18±1.88months).

Glaucoma is the second leading cause of blindness in the world, affecting more than 60 million people globally. In order to reduce the progression of the disease, both medical and surgical treatments are used. Frequent side effects of both treatments include a range of modifications of the ocular surface grouped as the Ocular Surface Disease (OSD), which include Dry Eye Disease (DED). DED and other OSD negatively impact on the success of anti-glaucoma treatments and reduce the adherence to medical therapies. Tear film osmolarity (TFO) is a relatively novel test which has become a hallmark of DED. The aim of this paper was to review the association between OSD, DED and glaucoma in view of published TFO data, and to discuss future fields of research and treatments on the topic of glaucoma iatrogenic damage.

To evaluate the safety of two commercially available formulations of bimatoprost eye drops: 0.03 and 0.01% ophthalmic solutions. This was a randomized, prospective, parallel-group, open-label, cohort study. A total of 60 glaucoma patients (60 eyes) under bimatoprost 0.03% monotherapy since at least 1 year were enrolled. Selected patients were randomized to receive a single drop of bimatoprost 0.01% (n=30) or bimatoprost 0.03% (n=30) ophthalmic solutions for 12 months. Statistical analysis was performed using paired t-test and repeated measures ANOVA test. Global clinical score (the sum of pruritus, stinging/burning, blurred vision, sticky eye sensation, eye dryness sensation, and foreign body sensation) significantly decreased in the bimatoprost 0.01% group from baseline 4.7±3.8 to 2.9±2.3 (P

Purpose: This study aimed to evaluate choroidal thickness modifications before and after vitrectomy with or without phacoemulsification for idiopathic epiretinal membrane in the operated eye and in the unaffected fellow eye. Methods: In total, 53 eyes of 53 patients underwent 25-gauge pars plana vitrectomy plus internal limiting membrane peeling and air tamponade. Twenty-seven eyes underwent combined surgery with phacoemulsification and intraocular lens implantation. Choroidal thickness was measured using enhanced deep image spectral-domain optical coherence tomography at the fovea and at 500 and 2,500 µm from the fovea. Fellow eyes without any previous ocular surgery history served as controls. Results: Baseline comparison did not show significant differences between study and fellow eyes (p > 0.05). Choroidal thickness significantly decreased in the subfoveal area (p = 0.004) as well as at 500 µm (p = 0.026) and 2,500 µm nasally (p = 0.019) and at 500 µm (p = 0.039) and 2,500 µm (p = 0.005) temporally to the fovea. No significant changes were observed postoperatively in the superior and inferior areas (p > 0.05). No differences were found between eyes which underwent combined surgery and those which underwent vitrectomy alone (p > 0.05). The unaffected eyes did not show any significant changes (p > 0.05). Conclusions: Comparison of baseline values did not show any differences between affected and unaffected eyes, meaning that choroidal thickness was not influenced by the development of epiretinal membrane. Vitrectomy plus epiretinal and inner limiting membrane removal may influence choroidal homeostasis, leading to a decrease in choroidal thickness in the subfoveal, nasal, and temporal areas. Combined surgery did not show significant differences when compared to vitrectomy alone.

Purpose:To determine whether surgical manipulation steps of the internal limiting membrane (ILM) flap, such as ILM trimmed, ILM tuck inside the hole, ILM massage, are mandatory to obtain satisfactory outcomes for the repair of large stage IV idiopathic macular hole using the inverted ILM flap techni

Mini glaucoma devices for external filtration may be implanted with an ab externo procedure (Ex-PRESS and InnFocus Microshunt) or with an ab interno procedure (XEN Gel stent). The Ex-PRESS is an FDA-approved mini glaucoma device that has been developed in order to simplify anterior guarded filtering procedures, making them faster, safer and easier. It is positioned under a scleral flap and it is introduced in the anterior chamber through a needle hole, avoiding the excision of the corneal-scleral button and the iridectomy. Like other anterior filtering guarded procedures, it may be associated with releasable sutures and with an everting suture (the safe Ex-PRESS procedure) in order to increase safety and efficacy. The InnFocus Microshunt is a new ab externo filtering device currently under investigation; it is very easy to implant and highly promising in terms of safety and efficacy. The XEN Gel stent is an ab interno implanted soft, collagen tube that makes a permanent bypass between the anterior chamber and the subconjunctival space. It is a smart, quick, effective and simple procedure that recently gained FDA approval.

AIMS OR PURPOSE: To evaluate short-term changes in optic nerve head topography and visual field induced by surgical reduction of intraocular pressure.A prospective study was performed on 56 eyes of 56 patients with uncontrolled primary open-angle glaucoma despite maximum medical therapy, which underwent trabeculectomy. Optic nerve head evaluations by means of Heidelberg Retina Tomograph, and visual field tests were performed pre-operatively, and at 3 and 6 months after surgery. Differences in intraocular pressure, visual field indices, and Heidelberg Retina Tomograph parameters were evaluated with the t-test for paired data. A linear regression model was calculated to analyze the relationship between intraocular pressure reduction and visual field changes, and optic nerve head changes.Mean intraocular pressure decreased from 24.4 ± 5.0 mm Hg to 12.1 ± 3.1 mm Hg (month 3, P0.001), and 10.6 ± 2.8 mm Hg (month 6, P0.001) after trabeculectomy. Mean retinal nerve fiber layer thickness (baseline, 0.19 ± 0.034; month 3, 0.24 ± 0.039, P=0.05; month 6, 0.21 ± 0.037, P=0.05) showed a statistical significant change compared with baseline values.In this 6-months study, a significant increase in retinal nerve fiber layer thickness was detected after glaucoma filtration surgery.

PURPOSE To evaluate the influence of central corneal thickness (CCT) and its 24-hour fluctuation on 24-hour intraocular pressure (IOP) fluctuation in primary open-angle glaucoma. METHODS Forty consecutive patients underwent 24-hour evaluation (8 PM, midnight, 4 AM, 8 AM, noon, and 4 PM) of supine and sitting IOP, measured with handheld Perkins and Goldmann tonometer respectively, and of CCT measured using ultrasonic pachymeter. Thirty patients were treated with timolol 0.5% twice daily and latanoprost 0.005% once daily; 10 patients were untreated. Measurements were taken in both eyes, but only one eye per patient was used for analytical purposes. Three IOP curves were drawn: sitting position, supine position, and habitual body position (diurnal sitting measurements and nocturnal supine measurements). Fluctuation was calculated as the SD over the 24-hour curve. Differences in the 2 groups were inspected by means of t test; the correlations between IOP fluctuation and mean CCT, respectively, and its fluctuation were evaluated by means of regression analysis. RESULTS Untreated patients had higher IOP than the treated group (habitual body position: 22.1+/-5.1 mm Hg vs. 16.0+/-3.0 mm Hg, P=0.004), but no differences were found for IOP fluctuations (habitual body position: 2.5+/-1.2 mm Hg vs. 2.3+/-0.8 mm Hg, P=0.32), mean CCT (542+/-38 microm vs. 534+/-39 microm, P=0.44), and CCT fluctuation (8.7+/-5.6 microm vs. 6.5+/-3.0 microm, P=0.09). The correlation between IOP fluctuation and mean CCT and its fluctuation was not statistically significant at supine, sitting and habitual body positions (P>or=0.07; R

Intraocular pressure (IOP) results from a dynamic balance between aqueous humor formation and outflow. The simplest technique to measure IOP is indentation tonometry. Another technique is applanation. These methods are related to the elasticity of the eye, which mainly depends on its thickness and hysteresis. For several decades, Goldmann applanation tonometry has been the most accepted method of measuring IOP; the Goldmann tonometer is still used in all important trials. The relationship between IOP values and central corneal thickness (CCT) is well known; Goldmann stated that this relationship only holds for an average corneal thickness of 520 microm measured by optical pachymetry. The Ocular Hypertension Treatment Study (OHTS) showed that CCT is an important risk factor for a change from ocular hypertension to primary open-angle glaucoma. In a multivariate model that included IOP, CCT was the most powerful component of the predictive model. In the Early Manifest Glaucoma Trial (EMGT) with an 11-year follow-up, CCT was a significant predictive factor for glaucoma progression in patients with higher baseline IOP but not in those with lower baseline IOP. Clinical trials such as the OHTS and EMGT cannot prove that CCT is linked to a risk for glaucoma on a biological level. Thus, in eyes with glaucoma, IOP must be treated because it has a significant influence on progression of glaucoma, regardless of the baseline IOP and CCT.

Glaucoma still represents the most frequent cause of irreversible blindness worldwide. The technological advances lead to innovative surgeries, which are rapidly introduced in clinical practice. New devices to lower intraocular pressure without opening the eye wall, bypassing the trabecular meshwork, or shunting the aqueous humor to the suprachoroidal space have been approved undergoing clinical assessment within clinical trials. Currently, other devices under evaluation are showing promising results. Although these methods will increase the options available for glaucoma surgeons, it is unclear if they could replace the present standard surgeries, such as trabeculectomy, deep sclerectomy, and glaucoma drainage devices. Moreover, the standard procedures are continuously modified in different ways to become safer and more effective. In this issue L. Choritz et al. investigate whether increased concentrations of endothelin-1 in the aqueous humor samples of glaucoma patients influenced wound healing and bleb fibrosis after standard trabeculectomy with mitomycin C. Endothelin-1 is a potent vasoconstrictor produced in the eye by the ciliary epithelium and to be released into the aqueous humor. It has been implicated in the pathophysiology of glaucoma. Endothelin-1 is believed to be involved in the regulation of intraocular pressure (IOP) via effects on the contractility of ciliary muscle and trabecular meshwork. W. Niu et al. evaluated the efficacy and safety of three different biodegradable terpolymers after trabeculectomy in rabbit eyes compared with Ologen™. The use of these implants aims to reduce the use of mitomycin C as an antiscarring agent. The first implant used was a porous collagen-glycosaminoglycan matrix, which prevents the adhesion of the conjunctiva and sclera and the collapse of the subconjunctival space after trabeculectomy, leading to collagen deposition and microcyst formation after penetrating antiglaucomatous surgery. Despite the increasing use of antifibrotic agents to modulate the wound healing response, bleb failure remains a common complication of glaucoma filtration surgery. In the paper by W. Liu et al. the needle revision and subconjunctival mitomycin C injection were compared with needling and subconjunctival 5-Fluorouracil injection for early dysfunctional filtration blebs after trabeculectomies. Neovascular glaucoma is one of the most recalcitrant glaucoma types to treatment and has one of the worst outcomes compared to other types of glaucoma. Neovascular glaucoma often needs surgical treatment because medical treatment fails to adequately control intraocular pressure. In a retrospective study, H. Yan investigated the long term surgical outcomes, treating neovascular glaucoma complicated by vitreous haemorrhage with 23-gauge vitrectomy combined with phacoemulsification, panretinal laser photocoagulation, and trabeculectomy without using anti-VEGF agents. C. Cagini et al. explored the role of canaloplasty in the surgical management of glaucoma with an extensive review. Canaloplasty is a nonpenetrating blebless surgical technique for open-angle glaucoma, similar to viscocanalostomy, in which a flexible microcatheter is inserted within Schlemm's canal for the entire 360 degrees. The results of this ab externo technique are really encouraging. S. A. Gandolfi et al. compared canaloplasty with an ab interno minimally invasive glaucoma surgery, the Hydrus™ implant. Both techniques are innovative and aim to restore the natural pathway, dilating a large size of Schlemm's canal. The results of this retrospective, comparative case series were collected after 2-year follow-up. A. F. Resende et al. presented a review on the iStent. This trabecular bypass stent is another minimally invasive glaucoma surgery device that has quickly gained popularity in the last years. Randomized controlled trials are still needed to assess the role of these devices in glaucoma surgery. Finally, S. Jacob et al. presented a new surgical technique, the stab incision glaucoma surgery. Even though it looks similar to standard trabeculectomy the main advantages are the sliding of the superior conjunctiva without dissecting, the creation of a superficial corneoscleral tunnel in a single step, the punch of the internal lip of the tunnel, and finally the suture of the conjunctival incision alone. In summary, this issue includes different approaches presented by diverse authors covering several topics related to improving of standard filtering surgery and wound healing and to new surgical techniques. This publication will provide valuable information that should be helpful in clinical practice for the whole ophthalmology community, mainly for glaucoma surgeons. Michele Figus Shlomo Melamed Antonio Ferreras Giorgio Marchini Vital P. Costa

PURPOSE Most filtering surgery failures develop in the early postoperative period. The possibility to apply an everting suture to lift the flap in the postoperative period and reduce the possibility of an early failure is reported. METHODS Surgical technique description. RESULTS An everting suture may be applied to the scleral flap in all types of ab externo anterior filtering surgeries. It could allow the surgeon to lift the scleral flap after the removal of the releasable sutures. CONCLUSIONS The use of an everting suture would eliminate the need to use procedures for lifting the flap that involve puncturing the conjunctiva and may cause hemorrhages and leakage and promote scarring.

Current diagnostic and therapeutic decisions based on the outcomes of imaging technologies have become a common practice in every ophthalmic subspecialty. New devices and tools for evaluating the retina and optic nerve head, such as scanning laser polarimetry and spectral-domain optical coherence tomography (OCT), are widely used in clinical practice. These technologies provide objective quantitative measurements and in vivo real-time images of ocular structures. The performance of imaging devices is continuously being improved, and thus knowledge of their applications, advantages, and limitations must also be continuously updated to optimize their management by clinicians. While imaging technologies require relatively transparent media, the variability of the measurements acquired by these devices is low, making these instruments useful for monitoring changes over time. In this issue, M. Ara et al. report excellent reproducibility of scanning laser polarimetry in healthy and glaucoma patients. In their review article, J. J. Garcia-Medina et al. evaluated the effects of posterior capsule opacification and found that image quality improves after capsulotomy, but a new baseline for future comparisons should be established. Additionally, R. L. Brautaset et al. report that OCT allows for the acquisition of reliable macular measurements in individuals with moderate to severe keratoconus. M. Cavallari et al. developed a semiautomated, computer-based method to detect and quantify retinal vessel abnormalities by analyzing digital fundus photographs. This tool was successfully used to evaluate patients with hypertensive retinopathy and cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy. G. S. K. Yau et al. compared central macular thickness measured by OCT in Chinese children and found that it was thicker in myopic eyes compared to emmetropic and hyperopic eyes. Three papers regarding the role of the ganglion cell complex in different disorders, multiple sclerosis, age-related macular degeneration, and glaucoma, demonstrated that the same tool could be used with different approaches depending on the disease: “Comparative Diagnostic Accuracy of Ganglion Cell-Inner Plexiform and Retinal Nerve Fiber Layer Thickness Measures by Cirrus and Spectralis Optical Coherence Tomography in Relapsing-Remitting Multiple Sclerosis” by J. J. Gonzalez-Lopez et al.; “Can Variability of Pattern ERG Signal Help to Detect Retinal Ganglion Cells Dysfunction in Glaucomatous Eyes?” by A. Mavilio et al.; and “Ganglion Cell Complex Evaluation in Exudative Age-Related Macular Degeneration after Repeated Intravitreal Injections of Ranibizumab” by A. Perdicchi et al. J. J. Gonzalez-Lopez et al. observed a better sensitivity-specificity balance for the macular ganglion cell complex measured with OCT in relapsing-remitting multiple sclerosis than peripapillary retinal nerve fiber layer thickness, while A. Mavilio et al. found that reduction of the ganglion cell complex was related to reduced amplitude and increased variability of the phase of the steady-state pattern electroretinogram in glaucoma. On the other hand, A. Perdicchi et al. demonstrated that the loading phase for ranibizumab in aged-related macular degeneration had no toxic effects on the ganglion cell complex. R. Mastropasqua et al. and M. Di Nicola et al. provide reviews regarding advanced morphologic and functional magnetic resonance techniques in glaucoma and functional and structural abnormalities in deferoxamine retinopathy, respectively. Information concerning magnetic resonance imaging in glaucoma is limited and mostly based on mouse models and patients with advanced glaucoma. Nevertheless, some results support the potential for these techniques to detect early glaucomatous changes. M. Di Nicola et al. revealed that imaging technologies (color fundus photographs, autofluorescence, and OCT) may facilitate the management of deferoxamine retinopathy and their report highlights the need for guidelines to enhance the diagnosis and follow-up of these patients. A wide variety of image modalities and optic enhancements, including fundus autofluorescence, microperimetry, adaptive optics, or faster OCTs, recently emerged. Using different image modalities, clinicians can emphasize the features of a particular anatomic structure of a tissue. M. Bertolotto et al. evaluated various paracentral hyperautofluorescence retinal patterns and their relationship with changes in the retinal layers. Hyperautofluorescence was mainly related to a “window effect” rather than an accumulation of lipofuscin. Adaptive optics combined with OCT or fundus photography allow for high-resolution images due to the improvement in lateral resolution by correcting for aberrations in the eye. This technology reaches resolutions close to 2 to 4 µm, which is high enough to identify even cone photoreceptors. D. Supriya et al. report strong correlations between retinal sensitivity, evaluated by microperimetry, and the mean cone packing density at different macular eccentricities measured with an adaptive optics retinal camera. Further studies are required, however, to determine normative variations in cone structure-function correlation. OCT has changed many protocols and ways of managing different ocular diseases. Moreover, OCT has modified how clinicians look at the retina. The assessment of retinal abnormalities based on evaluation of every layer rather than the global thickness has advanced ophthalmology. Because images evaluated through OCT provide information of the actual retina anatomy, but not exactly the same information as obtained with histology; last year an international panel of experts in vitreoretinal diseases and imaging suggested a consensus nomenclature for the classification of retinal and choroidal layers and bands observed in OCT scans (IN•OCT consensus). P. Tortorella et al. evaluated the changes in two of these retinal layers, the photoreceptor inner segment ellipsoid band and the interdigitation zone, in eyes with uveitic macular edema. Interruption of these lines was related to poor visual acuity. R. L. M. Wong et al. report that the outer retinal layer thickness (distance between the external limiting membrane and retinal pigment epithelium) correlated better than total thickness with visual acuity in patients with diabetic macular edema. In summary, this issue includes different points of view presented by diverse authors covering several topics related to advances in imaging techniques for ophthalmic diseases. This publication will provide valuable information that should be helpful in clinical practice. Antonio Ferreras Michele Figus Paolo Frezzotti Michele Iester

Objective. To assess the intrasession repeatability and intersession reproducibility of peripapillary retinal nerve fiber layer (RNFL) thickness parameters measured by scanning laser polarimetry (SLP) with enhanced corneal compensation (ECC) in healthy and glaucomatous eyes.Methods. One randomly selected eye of 82 healthy individuals and 60 glaucoma subjects was evaluated. Three scans were acquired during the first visit to evaluate intravisit repeatability. A different operator obtained two additional scans within 2 months after the first session to determine intervisit reproducibility. The intraclass correlation coefficient (ICC), coefficient of variation (COV), and test-retest variability (TRT) were calculated for all SLP parameters in both groups.Results. ICCs ranged from 0.920 to 0.982 for intravisit measurements and from 0.910 to 0.978 for intervisit measurements. The temporal-superior-nasal-inferior-temporal (TSNIT) average was the highest (0.967 and 0.946) in normal eyes, while nerve fiber indicator (NFI; 0.982) and inferior average (0.978) yielded the best ICC in glaucomatous eyes for intravisit and intervisit measurements, respectively. All COVs were under 10% in both groups, except NFI. TSNIT average had the lowest COV (2.43%) in either type of measurement. Intervisit TRT ranged from 6.48 to 12.84.Conclusions. The reproducibility of peripapillary RNFL measurements obtained with SLP-ECC was excellent, indicating that SLP-ECC is sufficiently accurate for monitoring glaucoma progression.

Background/Aims. To evaluate optic nerve head with spectral domain optical coherence tomography (OCT) in patients with Chiari I malformation (CMI) compared to healthy controls.Methods. Cross-sectional study. OCT of the optic nerve head of 22 patients with CMI and 22 healthy controls was quantitatively analyzed. The healthy controls were matched for age and sex with the study population. Mean retinal nerve fiber layer (RNFL) thickness was calculated for both eyes; the mean thickness value was also registered for each quadrant and for each subfield of the four quadrants.Results. CMI patients showed a reduction of the RNFL thickness in both eyes. This reduction was more statistically significant (P<0.05) for the inferior quadrant in the right eye and in each quadrant than nasal one in the left eye.Conclusion. A distress of the retinal nerve fibers could explain the observed reduction of the RNFL thickness in patients with CMI; in our series the reduction of the RNFL thickness seems lower when CMI is associated with syringomyelia.

Purpose To evaluate frequency, conversion rate, and risk factors for blindness in glaucoma patients treated in European Universities. Methods This multicenter retrospective study included 2402 consecutive patients with glaucoma in at least one eye. Medical charts were inspected and patients were divided into those blind and the remainder (‘controls’). Blindness was defined as visual acuity≤0.05 and/or visual field loss to less than 10°. Results Unilateral and bilateral blindness were respectively 11.0% and 1.6% at the beginning, and 15.5% and 3.6% at the end of the observation period (7.5±5.5 years, range:1–25 years); conversion to blindness (at least unilateral) was 1.1%/year. 134 eyes (97 patients) developed blindness by POAG during the study. At the first access to study centre, they had mean deviation (MD) of -17.1±8.3 dB and treated intraocular pressure (IOP) of 17.1±6.6 mmHg. During follow-up the IOP decreased by 14% in these eyes but MD deteriorated by 1.1±3.5 dB/year, which was 5-fold higher than controls (0.2±1.6 dB/year). In a multivariate model, the best predictors for blindness by glaucoma were initial MD (p

Purpose: To evaluate the effects of intravitreal ranibizumab monotherapy on predominantly hemorrhagic choroidal neovascularization with foveal involvement associated with age-related macular degeneration. Materials and Methods: Twenty-two consecutive eyes with hemorrhagic neovascularization were treated with 3 monthly intravitreal ranibizumab injections. Additional injections were administered according to retreatment criteria during 12 months of follow-up. Results: A mean of 6.64 ± 1.36 injections was administered. Overall, the mean visual acuity increased from 10.90 ± 6.02 to 12.81 ± 8.34 ETDRS letters (p > 0.05) at 12 months. The ‘early treatment group' gained a mean of 2.83 ± 2.24 ETDRS letters (p < 0.05), while the ‘late treatment group' gained a mean of 0.30 ± 1.25 ETDRS letters (p > 0.05) with significant differences between the groups (p < 0.05). A progressive resolution of macular bleeding was registered in 20 patients (mean time: 5.3 ± 1.6 months). Conclusions: Ranibizumab injections can be considered a beneficial approach for the management of predominantly hemorrhagic choroidal neovascularization with foveal involvement associated with age-related macular degeneration. Furthermore, the time interval between hemorrhage and the first injection seems to be an important predicting factor of final visual acuity.

Purpose To compare the detection rate of central visual field defect (CVFD) between the 30-degree Octopus G1 program (Dynamic strategy) and the HFA 10–2 SITA-Standard test in early glaucoma eyes not showing any CVFD on the HFA 24–2 SITA-Standard test. Methods One eye of 41 early glaucoma patients without CVFD in the central 10° on HFA 24–2 test was tested with both the HFA 10–2 test and the Octopus G1 program 15 minutes apart, in random order. The primary outcome measure was the comparison of CVFD detection rates. Secondary outcome measures comprised the agreement in detecting CVFD, and the comparison of test durations and the numbers of depressed test points outside the central 10-degree area between the HFA 24–2 test and the Octopus G1 program. Results The mean age of the population was 65.2±10.1 years, and the mean deviation with HFA 24–2 was -3.26±2.6 dB. The mean test duration was not significantly different between the tests (p = 0.13). A CVFD was present in 33 (80.4%) HFA 10–2 test and in 23 (56.0%) Octopus G1 tests (p = 0.002). The overall agreement between the HFA 10–2 and Octopus G1 examinations in classifying eyes as having or not having CVFD was moderate (Cohen’s kappa 0.47). The Octopus G1 program showed 69.6% sensitivity and 100% specificity to detect CVFD in eyes where the HFA 10–2 test revealed a CVFD. The number of depressed test points (p

Objective. To evaluate the relationship between spectral-domain optical coherence tomography (OCT) and standard automated perimetry (SAP) in healthy and glaucoma individuals.Methods. The sample comprised 338 individuals divided into 2 groups according to intraocular pressure and visual field outcomes. All participants underwent a reliable SAP and imaging of the optic nerve head with the Cirrus OCT. Pearson correlations were calculated between threshold sensitivity values of SAP (converted to linear scale) and OCT parameters.Results. Mean age did not differ between the control and glaucoma groups (59.55 ± 9.7 years and 61.05 ± 9.4 years, resp.;P=0.15). Significant differences were found for the threshold sensitivities at each of the 52 points evaluated with SAP (P<0.001) and the peripapillary retinal nerve fiber layer (RNFL) thicknesses, except at 3 and 9 clock-hour positions between both groups. Mild to moderate correlations (ranging between 0.286 and 0.593;P<0.001) were observed between SAP and most OCT parameters in the glaucoma group. The strongest correlations were found between the inferior RNFL thickness and the superior hemifield points. The healthy group showed lower and weaker correlations than the glaucoma group.Conclusions. Peripapillary RNFL thickness measured with Cirrus OCT showed mild to moderate correlations with SAP in glaucoma patients.

Purpose Vitreomacular traction syndrome is a clinical entity characterized by partial posterior vitreous detachment in combination with persistent macular adherence. Recently, optical coherence tomography (OCT) allowed visualization of incomplete posterior vitreoschisis leading to vitreomacular traction. Methods The authors report on a 57-year-old woman with blurred vision in her left eye. Results OCT scan showed incomplete posterior vitreoschisis with vitreomacular traction syndrome and impending macular hole in her left eye. Conclusions The intraoperative findings together with the evidence that the internal limiting membrane (ILM) thickness is thinner than the axial resolution of the Stratus OCT (8 μm) and a spontaneous ILM detachment has never been demonstrated are likely to support the hypothesis that posterior vitreoschisis exists and can be associated with vitreomacular traction syndrome.