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Purpose The use of allografts in primary anterior cruciate ligament reconstruction (ACLR) is increasing although they are still supposed to be associated to greater risk of re-rupture due to a slower and less efficient graft maturation. The aim of this prospective randomized controlled study was to compare the graft maturation after ACLR with allograft and autograft by MRI at 6- and 12-month follow-up and integrate these data with the functional and clinical results observed at 6-, 12- and 60-month follow-up. Methods Fifty patients with indication to primary ACLR were randomly and equally divided into hamstring autograft or allograft tendon groups. The graft maturation was measured at 6- and 12-month follow-up by the SNQ score and other radiological parameters on MRI scans. Clinical and functional recovery was evaluated by Lysholm score, Visual Analogues Scale, Tegner activity scale and modified Cincinnati knee rating system at 6, 12 and 60 months after surgery to estimate the predictive value of the radiological parameters for clinical outcomes. Return-to-sport (ACL-RSI) was measured 60 months after surgery. Results Three patients had retear of the neo-ligament (two from Auto group and one from Allo group). All the clinical/functional parameters significantly improved over time, with no statistically significant difference between the groups. At 6 months, the SNQ value was significantly higher in the Auto than in the Allo group (12.9 vs 7.9, p = 0.038), but at 12 months they were comparable (9.8 vs 10.4). The 6-month SNQ values did not correlate with the clinical scores, whereas the 12-month SNQ values significantly correlated with the Cincinnati score, Lysholm score and Tegner activity scale collected at 60-month follow-up. Conclusion No clinical or functional differences have been found between the two treatment groups, supporting the suitability of using allograft in primary ACLR, when available. The results at MRI scans showed a different graft maturation trend in the two groups, with allografts being more reactive in the first 6 months. MRI together with the subjective evaluation allows to evaluate objectively the status of the neo-ligamentization process and therefore helps the surgeon to dictate the individual time for return-to-sport. Level of evidence Level I. Supplementary Information The online version contains supplementary material available at 10.1007/s00167-021-06785-4.

Purpose To assess retinal vascular involvement in patients with autosomal dominant optic atrophy (ADOA) genetically confirmed by the presence of the OPA1 (Optic Atrophy 1) gene mutation using a multimodal protocol of investigation of retinal posterior pole. Methods In this cross-sectional, case-control, observational study, both eyes of 13 patients with a genetic diagnosis of ADOA were compared with both eyes of 13 healthy controls (HCs). All subjects underwent full ophthalmological examination, spectral domain-optical coherence tomography (SD-OCT), fundus perimetry (FP) and OCT angiography (OCTA). Results Vessel density (VD) of the superficial and deep macular vascular plexi and of the radial peripapillary capillary plexus were significantly decreased (p ≤ 0.001) in ADOA patients compared with HCs. The area under the receiver operating characteristics analysis also revealed high values of sensitivity and specificity of OCTA parameters in distinguish between patients and HCs. A strong correlation (Pearson Coefficient, r = 0.91) emerged between OCTA VD of the superficial retinal plexus and the average Ganglion Cell Layer (GCL) thickness as measured by SD-OCT; a slightly lower correlation (Pearson Coefficient, r = 0.89) was also found between VD of the deep plexus and the average GCL thickness of the same eyes in patients with ADOA. The correlation among values of differential light sensitivity (DLS) measured by FP with VD and GCL thickness parameters was also investigated. The correlation analysis among DLS and the VD parameters showed from low-to-moderate correlation (ranging from r = 0.29 for the deep fovea VD to r = 0.59 for the deep whole image VD). The correlation coefficient between the mean DLS and the average thickness of GCL was more significant (Pearson Coefficient, r = 0.75). A significant correlation emerged also between the VD and the visual acuity, in terms of LogMAR BCVA (best-corrected visual acuity), especially for the VD of the deep capillary plexus (Pearson Coefficient for the Deep whole Image VD and LogMAR BCVA r = -0.75; for the Deep parafovea VD and LogMAR BCVA r = -0.78). Conclusion Retinal microvascular assessment by OCTA angiography can provide relevant clinical information on retinal involvement in ADOA patients. In patients with genetically confirmed OPA1-related ADOA, there is a decrease in retinal vessel density associated with GCL thinning and DLS reduction.

Epigenetics is characterized by molecular modifications able to shape gene expression profiles in response to inner and external stimuli. Therefore, epigenetic elements are able to provide intriguing and useful information for the comprehension and management of different human conditions, including aging process, and diseases. On this subject, Age-related Macular Degeneration (AMD) represents one of the most frequent age-related disorders, dramatically affecting the quality of life of older adults worldwide. The etiopathogenesis is characterized by an interplay among multiple genetic and non-genetic factors, which have been extensively studied. Nevertheless, a deeper dissection of molecular machinery associated with risk, onset, progression and effectiveness of therapies is still missing. In this regard, epigenetic signals may be further explored to disentangle disease etiopathogenesis, the possible therapeutic avenues and the differential response to AMD treatment. This review will discuss the epigenomic signatures mostly investigated in AMD, which could be applied to improve the knowledge of disease mechanisms and to set-up novel or modified treatment options.

The review essentially describes genetic and non-genetic variables contributing to the onset and progression of exudative Age-related Macular Degeneration (AMD) in Italian population. In particular, AMD susceptibility within Italian population is contributed to by genetic variants, accounting for 23% of disease and non-genetic variants, accounting for 10% of AMD. Our data highlighted prominent differences concerning genetic and non-genetic contributors to AMD in our cohort with respect to worldwide populations. Among genetic variables, SNPs of CFH, ARMS2, IL-8, TIMP3, SLC16A8, RAD51B, VEGFA and COL8A1 were significantly associated with the risk of AMD in the Italian cohort. Surprisingly, other susceptibility variants described in European, American and Asiatic populations, did not reach the significance threshold in our cohort. As expected, advanced age, smoking and dietary habits were associated with the disease. In addition, we also describe a number of gene-gene and gene-phenotype interactions. In fact, AMD-associated genes may be involved in the alteration of Bruch's membrane and induction of angiogenesis, contributing to exacerbate the damage caused by aging and environmental factors. Our review provides an overview of genetic and non-genetic factors characterizing AMD susceptibility in Italian population, outlining the differences with respect to the worldwide populations. Altogether, these data reflect historical, geographic, demographic and lifestyle peculiarities of Italian population. The role of epigenetics, pharmacogenetics, comorbities and genetic counseling in the management of AMD patients have been described, in the perspective of the application of a "population-specific precision medicine" approach addressed to prevent AMD onset and improve patients' quality of life.

The complex interplay among genetic, epigenetic, and environmental variables is the basis for the multifactorial origin of age-related macular degeneration (AMD). Previous results highlighted that single nucleotide polymorphisms (SNPs) of CFH, ARMS2, IL-8, TIMP3, SLC16A8, RAD51B, VEGFA, and COL8A1 were significantly associated with the risk of AMD in the Italian population. Given these data, this study aimed to investigate the impact of SNPs in genes coding for MIR146A, MIR31, MIR23A, MIR27A, MIR20A, and MIR150 on their susceptibility to AMD. Nine-hundred and seventy-six patients with exudative AMD and 1000 controls were subjected to an epigenotyping analysis through real-time PCR and direct sequencing. Biostatistical and bioinformatic analysis was performed to evaluate the association with susceptibility to AMD. These analyses reported that the SNPs rs11671784 (MIR27A, G/A) and rs2910164 (MIR146A, C/G) were significantly associated with AMD risk. Interestingly, the bioinformatic analysis showed that MIR27A and MIR146A take part in the angiogenic and inflammatory pathways underlying AMD etiopathogenesis. Thus, polymorphisms within the pre-miRNA sequences are likely to affect their functional activity, especially the interaction with specific targets. Therefore, our study represents a step forward in the comprehension of the mechanisms leading to AMD onset and progression, which certainly include the involvement of epigenetic modifications.

Age-related Macular Degeneration (AMD) represents one of the most sight-threatening diseases in developed countries that substantially impacts the patients' lifestyle by compromising everyday activities, such as reading and driving. In this context, understanding the prevalence, burden, and population-specific risk/protective factors of AMD is essential for adequate health care planning and provision. Our work aimed to characterize exudative AMD in Italian population and to identify the susceptibility/protective factors (genetic variants, age, sex, smoking and dietary habits) which are specific for the onset of disease. Our study involved a cohort of 1976 subjects, including 976 patients affected with exudative AMD and 1000 control subjects. In particular, the sample cohort has been subjected to a large genotyping analysis of 20 genetic variants which are known to be associated with AMD among European and Asiatic populations. This analysis revealed that 8 genetic variants (CFH, ARMS2, IL-8, TIMP3, SLC16A8, RAD51B, VEGFA and COL8A1) were significantly associated with AMD susceptibility. Successively, we performed a multivariate analysis, considering both genetic and non-genetic data available for our sample cohort. The multivariate analysis showed that age, smoking, dietary habits and sex, together with the genetic variants, were significantly associated with AMD in our population. Altogether, these data represent a starting point for the set-up of adequate preventive and personalized strategies aimed to decrease the burden of disease and improve the patients' quality of life.

Background The aim of our study was to evaluate the effectiveness of both clinical and functional benefits after the surgical repair of the rotator cuff in irreparable lesions using a synthetic patch with augmentation of the long head of the biceps (LHB) tendon. Methods This is a retrospective study analysis of a randomized series of 60 patients (45 women and 15 men; average age 66 y) who underwent open repair of irreparable rotator cuff tear with synthetic patch using LHB tendon augmentation between 1999 and 2008.The inclusion criteria were: patients painful symptomatology, presenting a deficit in elevation, who are not responsive to physiotherapy, irreparable tear size, minimum follow-up of 36 months after surgery, and active and motivated patients. We used a control group of 60 patients treated without employment of the synthetic patch and LHB tendon augmentation.Patients were evaluated preoperatively and after 36 months with a Visual Analog Scale (VAS) and the University of California, Los Angeles (UCLA) shoulder rating scale and by measuring elevation of the scapular plane and strength with a dynamometer. All the patients were assessed preoperatively also with plain radiographs (anteroposterior and axillary views), ultrasound, and NMRI of the shoulder. The VAS and UCLA scores were also obtained 3 months postoperatively. Tendon integrity was assessed after 1 year by NMRI. Statistical analysis was conducted by 1-way analysis of variance between groups of treatment, with Dunnett post hoc correction for multiple comparisons. P-values ≤ 0.05 were considered as statistically significant. This surgical technique consisted in a short deltoid splitting, irreparable lesion evaluation, and, after tenodesis, the proximal segment of the LHB tendon was sutured to the remaining cuff tendons to fill the gap of the corresponding lesion. To shield the repaired rotator cuff we inserted a synthetic patch. Results Satisfactory results were achieved in 52 of the patients treated with this procedure; after 3 months the mean VAS was 6.85 ± 1.11 versus 4.9 ± 0.9, whereas the mean UCLA was 11.28 ± 1.43 versus 20.85 ± 1.27, respectively, for control and prolene group. After 36 months the mean VAS was 3.7 ± 1.01 versus 3.23 ± 1.07, whereas the mean UCLA was 14.73 ± 1.96 versus 24.6 ± 3.3, respectively, for control and prolene group. In addition, after 36 months elevation on the scapular plane was 140.75 ± 10.48 degrees versus 174.75 ± 8.1 degrees and abduction strength was 8.57 kg ± 0.63 versus 13.61 kg ± 0.84, respectively, for control and prolene group (P-value = 0.005). Re-tear rate after 12 months was 40% (24/60) in the control group and 15% (9/60) in the prolene group. No adverse side effects (infection, rejection, allergy) were reported during the study period. Conclusions The results of our study suggest that employing this surgical technique in patients (appropriately selected) with an irreparable rotator cuff tear can lead to pain relief and improved clinical outcome.

Background To assess posterior pole (PP) retinal structure in patients with genetically confirmed autosomal dominant optic atrophy (ADOA) using new spectral domain optical coherence tomography (SD-OCT) segmentation technology. To analyze retinal PP thickness in relation to retinal sensitivity data from microperimetry (MP) in ADOA patients. Methods and findings This prospective cross-sectional study included 11 patients with ADOA and 11 age-matched healthy subjects. All participants underwent both a “Posterior Pole” and “peripapillary RNFL (pRNFL)” scanning protocol using SD-OCT. Functional mapping of the PP was also performed using MP. A customized program was implemented in order to achieve accurate superimposition of MP sensitivity map onto SD-OCT map. The thickness of the PP different retinal layers and pRNFL was obtained and measured for each eye. Mean retinal sensitivity values and fixation stability were obtained and compared between ADOA patients and healthy subjects. Correlation analysis was performed on a point-to-point basis to evaluate the association between mean thickness and retinal sensitivity of each retinal layer. Total retinal thickness (TRT), Retinal Nerve Fiber Layer (RNFL), Ganglion Cell Layer (GCL), Inner Plexiform Layer (IPL), Inner Nuclear Layer (INL) and Inner Retinal Layers (IRL) at the posterior pole as well as pRNFL were significantly thinner in ADOA patients (P < 0.0001). On the contrary, the Outer Plexiform Layer (OPL) and the Outer Nuclear Layer (ONL) were significantly thicker in the ADOA group (P < 0.001). No significant differences were found in Retinal Pigment Epithelium (RPE) and Outer Retinal Layers (ORL) thickness between ADOA and controls. The average PP retinal sensitivity was significantly reduced in ADOA patients compared with controls (P < 0.001), as measured by microperimeter Nidek MP-1 (MP1). Fixation stability was significantly worse in the ADOA group (P = 0.01). The most severe sensitivity defects in ADOA patients were found at the level of the papillo-macular bundle (PMB). Conclusions Inner retinal layers showed pathological changes in ADOA patients. In addition, the whole retinal PP (not only the PMB) was significantly altered in ADOA, both in terms of retinal thickness and sensitivity.

The actions of nutrients and related compounds on age-related macular degeneration (AMD) are explained in this review. The findings from 80 studies published since 2003 on the association between diet and supplements in AMD were reviewed. Antioxidants and other nutrients with an effect on AMD susceptibility include carotenoids (lutein and zeaxanthin, β-carotene), vitamins (vitamin A, E, C, D, B), mineral supplements (zinc, copper, selenium), dietary fatty acids [monounsaturated fatty acids, polyunsaturated fatty acids (PUFA both omega-3 PUFA and omega-6 PUFA), saturated fatty acids and cholesterol], and dietary carbohydrates. The literature revealed that many of these antioxidants and nutrients exert a protective role by functioning synergistically. Specifically, the use of dietary supplements with targeted actions can provide minimal benefits on the onset or progression of AMD; however, this does not appear to be particularly beneficial in healthy people. Furthermore, some supplements or nutrients have demonstrated discordant effects on AMD in some studies. Since intake of dietary supplements, as well as exposure to damaging environmental factors, is largely dependent on population habits (including dietary practices) and geographical localization, an overall healthy diet appears to be the best strategy in reducing the risk of developing AMD. As of now, the precise mechanism of action of certain nutrients in AMD prevention remains unclear. Thus, future studies are required to examine the effects that nutrients have on AMD and to determine which factors are most strongly correlated with reducing the risk of AMD or preventing its progression.

Purpose: To measure Ganglion Cell Layer (GCL) and Retinal Nerve Fiber Layer (RNFL) thickness of the retinal posterior pole in patients with early stage primary open-angle glaucoma (POAG) using the new automatic segmentation technology of spectral domain optical coherence tomograph (SD-OCT). Methods: 37 clinical records of patients with early glaucoma (grade 1 to 2 according to the Glaucoma Staging System 2) and 40 age and sex-matched controls were considered in this case-control observational retrospective study. Automated segmentation of GCL and RNFL was performed in one randomly selected eye from the electronic OCT records of each participant using the new Spectralis SD-OCT segmentation technology (Heidelberg Engineering, Inc., Heidelberg, Germany). Thickness of different retinal layers was obtained from each Posterior Pole volumetric scan. Measurements of the peripapillary RNFL thickness (pRNFLt) were also obtained and then compared with those of posterior pole RNFL thickness (ppRNFLt). Results: Both GCL and RNFL were significantly thinner at the retinal posterior pole in the POAG group as compared to the control group (p

To report a case of overlapping choriocapillaritis that initially presented as multifocal choroiditis (MFC) but later showed features compatible with acute zonal occult outer retinopathy (AZOOR) resistant to standard immunosuppression that responded only to adalimumad therapy. A 41-year-old patient presented with multiple small, discrete yellow-whitish spots in both eyes, compatible with MFC. A few weeks later, despite treatment with sub-Tenon and systemic corticosteroids, a choroidal neovascularization occurred in the right eye. The patient was treated with intravitreal anti-vascular endothelial growth factor. After 2 months, reduced visual acuity, photopsia and visual field defect in the left eye occurred. Spectral domain optical coherence tomography revealed photoreceptor outer segment defects common to all choriocapillaritis. The additional finding of an annular scotoma and a 360° ring on indocyanine green angiography led us to make the diagnosis of presumed AZOOR. Despite the combination of several immunosuppressive agents leading to temporary control of the disease, the patient experienced a further worsening. At that point, adalimumab was introduced, which led to an obvious improvement. This case supports the hypothesis that two different entities of the so-called AZOOR complex can be possible in the same eye, even asynchronously. In our case, anti-tumor necrosis factor alpha monoclonal antibody therapy represented a valid treatment option in a patient unresponsive to traditional immunosuppressive treatments.

Age-related macular degeneration (AMD) is a progressive neurodegenerative disease that affects approximately 8.7% of elderly people worldwide (>55 years old). AMD is characterized by a multifactorial aetiology that involves several genetic and environmental risk factors (genes, ageing, smoking, family history, dietary habits, oxidative stress, and hypertension). In particular, ageing and cigarette smoking (including oxidative compounds and reactive oxygen species) have been shown to significantly increase susceptibility to the disease. Furthermore, different genes (CFH, CFI, C2, C3, IL-6, IL-8,andARMS2) that play a crucial role in the inflammatory pathway have been associated with AMD risk. Several genetic and molecular studies have indicated the participation of inflammatory molecules (cytokines and chemokines), immune cells (macrophages), and complement proteins in the development and progression of the disease. Taking into consideration the genetic and molecular background, this review highlights the genetic role of inflammatory genes involved in AMD pathogenesis and progression.

Objective: The aim of this report is to describe the technology of three-dimensional (3-D) ultrasonic imaging and its impact on improved diagnosis and monitoring of ocular disease. Design: The authors reviewed techniques for acquiring and displaying 3-D ultrasound data of the eye. Participants: The authors applied these techniques to representative individual cases, including a choroidal hemorrhage, a ciliary body melanoma, a ciliary body detachment, a displaced posterior chamber intraocular lens, and topographic analysis of a normal cornea. Intervention: A computer-controlled motion system was used to perform very high-frequency (VHF) (50-MHz) and conventional (10-MHz) digital 3-D ultrasound data collection. The scanning system allowed digitization of ultrasound data from a series of parallel planes. The 3-D data could be manipulated interactively to obtain two-dimensional images in any plane through the scan volume. The 3-D images were constructed by volume rendering and could be positioned for viewing from a variety of perspectives. The 3-D ultrasound parameter images representing acoustic scatterer properties were generated by spectrum analysis of digitized echo data. Color maps representing the contour and thickness of the epithelium and stroma of the central corneal were generated by digital signal processing of 3-D echo data. Results: Quantitative volume measurement and biometric techniques enhanced the diagnostic and treatment planning information content in 3-D ultrasound images. The location and extent of hemorrhage and clots within the suprachoroidal space were shown with solid modeling. Volume changes in ciliary body melanoma over time were documented and 3-D ultrasound parameter image changes associated with radiation therapy observed. In ciliary body detachment, the extent of the detachment was shown. Solid modeling of a posterior chamber intraocular lens showed misplacement of the haptic in relation to the lens capsule remnants. Keratopachymetric maps showed the range and variance of thickness and local radius of curvature measurements in the cornea. Conclusions: Quantitative volume measurement and biometric tools combined with segmentation of 3-D ultrasound images improve diagnostic and treatment planning informational content of 3-D ultrasound images through improved localization of tissue structures.

Author Francesco Viola was omitted from the author byline. The full, correct list of authors and affiliations is as follows

To clarify the mechanical difficulties experienced when performing anterior capsulorhexis in vitrectomized eyes filled with silicone oil. Five anterior lens capsules removed from eyes with a silicone oil history were submitted to light and electron microscopic analysis and then compared to two capsules from eyes with trauma history and seven capsules from eyes without silicone oil or trauma history. Comparable abnormalities of the inner and outer surface of the anterior lens capsule were consistently observed after silicone oil fill of the vitreous cavity or after traumatic impact to the lens: patches of multilayer epithelial cells with interspersed capsule material and connective tissue were observed on the posterior surface of the anterior lens capsule. The development of this anterior subcapsular tissue plaque is obviously influenced not only by the PVR process or by side effects of the surgical procedure but also by the silicone oil tamponade or a trauma history. The plaque can be considered primarily responsible for the increased mechanical resistance of the lens capsule in all eyes with silicone oil / trauma history examined in this study.

Background: Epithelial interface cysts have been occasionally observed after lamellar keratoplasty. The authors report the incidence, clinical significance, and management of this complication in epikeratophakia patients. Methods: From August 1987 to January 1991,108 consecutive patients undergoing epikeratophakia entered a prospective study aimed at evaluating both clinical results and changes in corneal physiologic parameters. After an average hospitalization of 6 days, all patients underwent complete ophthalmologic examinations at regular intervals after surgery. All postoperative complications, including the development of epithelial interface cysts, were recorded and photographed. Results: Over a 3-year period, epithelial interface cysts were observed in 8 eyes, with an overall incidence of 7.4%. All cysts originated under the periphery of the epilens. In five patients, the cysts enlarged centripetally but eventually ceased to grow, causing no visual impairment. In two patients, after an initial increase in size the cysts slowly regressed and finally disappeared. In only one patient, a cyst migrated over the visual axis, thus necessitating surgical removal. The cyst did not recur during an observation time of 18 months after debridement, allowing full recovery of visual acuity. Conclusions: The incidence of epithelial interface cysts after epikeratophakia is relatively high. Because of their peripheral location and self-limited growth, the clinical significance of this complication is low. The possibility of spontaneous regression of the cysts supports a conservative approach, as long as the visual axis is not affected. Surgical removal is possible without compromising the epi-lens and is compatible with an excellent visual outcome.

BACKGROUND:Age-related macular degeneration (AMD) is the main cause of blindness in the developed world. The etiology of AMD is multifactorial due to the interaction between genetic and environmental factors. IL-8 has a role in inflammation and angiogenesis; we report the genetic characterization of IL-8 allele architecture and evaluate the role of SNPs or haplotypes in the susceptibility to wet AMD, case-control study. METHODS:Case-control study including 721 AMD patients and 660 controls becoming from Italian population. Genotyping was carried out by Real Time-PCR. Differences in the frequencies were estimated by the chi-square test. Direct sequencing was carried out by capillary electrophoresis trough ABI3130xl. RESULTS:rs2227306 showed a p-value of 4.15*10(-5) and an Odds Ratio (OR) for T allele of 1.39 [1.19-1.62]. After these positive results, we sequenced the entire IL-8 regulatory and coding regions of 60 patients and 30 controls stratified for their genotype at rs2227306. We defined two different haplotypes involving rs4073 (A/T), rs2227306 (C/T), rs2227346 (C/T) and rs1126647 (A/T): A-T-T-T (p-value: 2.08*10(-9); OR: 1.68 [1.43-1.97]) and T-C-C-A (p-value: 7.07*10(-11); OR: 0.60 [0.51-0.70]). To further investigate a potential functional role of associated haplotypes, we performed an expression study on RNA extracted from whole blood of 75 donors to verify a possible direct correlation between haplotype and gene expression, failing to reveal significant differences. CONCLUSIONS:These results suggest a possible secondary role of IL-8 gene in the development of the disease. This paper outlines the importance of association between inflammation and AMD. Moreover IL-8 is a new susceptibility genomic biomarker of AMD.

Intraocular lenses (IOLs) were removed from 11 eyes with chronic low-grade endophthalmitis after cataract extraction to restore useful vision and prevent recurrence. One anterior chamber lens, one iris-supported lens, and nine posterior chamber lenses were removed. In the eyes with posterior chamber lenses, the posterior capsule was intact; total (n = 7) or partial (n = 2) capsulectomy was performed in these eyes. Aqueous humor specimens obtained at surgery were positive for bacteria in five eyes, but scanning electron microscopy showed bacteria on all removed IOLs and capsular bags. Final best corrected visual acuity was 20/40 or better in seven eyes. Reduced visual acuity, between 20/50 and 20/400 in three eyes and counting fingers in one eye, was related to retinal detachment (n = 2) and age-related macular degeneration (n = 2). Transient hyphema was seen in one eye. With a mean follow-up of 21 months (range 10 to 31 months), no recurrence of inflammation was observed. The results show that negative cultures do not preclude a bacterial cause for infection and that primary IOL removal with partial or total capsulectomy provides a surgical approach to the treatment of chronic low-grade endophthalmitis not responsive to medical therapy.

Bacterial endophthalmitis is a severe but rare postoperative complication of cataract surgery with implantation of an intraocular lens (IOL).1Recent epidemiologic data have shown that IOLs with polypropylene (Prolene) haptics are associated with a significantly higher risk for postoperative endophthalmitis than all—polymethyl methacrylate (PMMA) lenses.1Further experimental work by the same authors has shown in vitro preferential adherence of coagulase-negative staphylococci to polypropylene haptics in comparison with PMMA haptics.2With the development of foldable IOLs for smallincision cataract surgery, new materials (eg, silicone and hydrogel) other than PMMA have been used to manufacture IOLs. To quantify bacterial growth on the surface of IOLs of various materials, commercially available silicone, hydrogel, and PMMA IOLs were tested. Two IOLs for each type of material were suspended in 500 mL of a peptone culture of coagulase-negative staphylococci at its maximal growth concentration. Five cultures were done (a total of 10

The accessory lacrimal glands form up to 60 small nodules, which are located close to the conjunctival fornix and at the edge of the upper tarsus. In spite of the fact they are believed to play an important role in the pathogenesis of dry eye disease, they have escaped the attention of morphologists. Recently, we have developed a technique to biopsy those glands at the occasion of ptosis operations.

Glycoproteins constitute a major component of human tears and play an important role in the maintenance of the precorneal tear film (Holly and Lemp 1977, Nichols et al. 1985).

BACKGROUND: Incomplete epithelial removal from the peripheral keratectomy at the time of repeat epikeratophakia surgery can lead to interface downgrowth and consequent failure, as observed in the case reported herein. We present a modification of the standard surgical technique aimed at avoiding such complication. METHODS: A 69-year-old white female underwent a third aphakic epikeratophakia modified to reduce the risk of epithelial interface downgrowth, which had caused a previous failure. The aphakic tissue lens, 8.5 mm in diameter, was sutured into a corneal pocket obtained at a deeper level, inside the peripheral keratectomy used for the previous two procedures. RESULTS: Useful visual acuity (20/60) was obtained and the refractive outcome remained stable up to 1 year postoperatively. Epithelial interface downgrowth did not recur. CONCLUSIONS: Despite the possible risk of perforation while undermining the recipient cornea at a deeper level, the modified technique might offer a more effective method of preventing epithelial downgrowth after repeat epikeratophakia surgery. [Refract Corneal Surg 1992;8:382384).

A case of mycotic infection after uncomplicated extracapsular cataract extraction with implantation of a posterior chamber modified C-loop intraocular lens (IOL) is reported. Severe postoperative intraocular inflammation, diagnosed by aqueous cultures as secondary to Staphylococcus aureus endophthalmitis, did not respond to antibiotic therapy. Despite IOL and capsular bag removal and further antibiotic treatment, the inflammation persisted and phthisis followed. Retrospective electron microscopic examination of the explanted material demonstrated the presence of abundant fungal elements in the capsular bag and spores on the IOL surface. Vitreous taps performed at the time of explantation were negative for bacteria and fungi, confirming the localized nature of the mycotic infection. To our knowledge this report represents the first observation of a mycotic infection confined to the capsular bag after cataract surgery with implantation of a posterior chamber IOL.

In an effort to better understand the cause of chronic intraocular inflammation after intraocular lens (10L) implantation, both scanning and transmission electron microscopy were used to compare 1 anterior chamber, 1 irisfixated, and 3 posterior chamber IOLs removed for this condition between 2 and 16 months after implantation with 8 IOLs explanted for other reasons (decentration in 4 cases, bullous keratopathy in 4 cases). Colonization with nonslime-producing, as well as slime-producing bacteria (1 case) in the presence of a thin membranous structure of cellular origin (multinucleated giant cells and macrophage-like cells) was demonstrated on all of the 5 IOLs explanted from inflamed eyes. Neither bacteria nor membranous structures could be identified on the IOLs removed because of dislocation or from eyes with bullous keratopathy. These observations indicate that bacterial colonization and the consequent host response may be characteristic features of many otherwise unexplained cases of intraocular inflammation after IOL implantation.

In spite of the numerous changes in surgical technique, epikeratophakia for the correction of myopia is still far from achieving optimal results. The removal rate of myopic lenticules is much higher than that of aphakic or keratoconus lenticules and has prompted the FDA to deny its approval to the industrial production of epi-lenses for the correction of myopia. We report a patient who underwent epikeratophakia for the correction of high myopia in his left eye and required removal of the lenticule because of unsatisfactory visual outcome. The histologic and electron microscopic examination of the removed lenticule revealed the presence of folds in both Bowman's layer and superficial stroma. These had been described in the past and related to the surgical technique used at that time; they were thought to be the cause of poor visual acuity in two patients, and had prompted, therefore, a change in surgical technique. Our findings suggest that the present lenticule design could be responsible for the presence of folds and the consequent poor visual result. [Refractive and Corneal Surgery 1990; 6:120-124.]

Morphologic changes secondary to cryolathing and lyophilization have been described in tissue lenses used for epikeratophakia. We report the electron microscopic findings of an aphakic tissue lens which could not be used because of sudden preoperative myocardial infarction of the patient. Scanning electron microscopy revealed the presence of three distinct zones (peripheral, intermediate, and central) on the stromal side of the lens. The surface of the central zone appeared to be the smoothest, as a consequence of the different angle of lathing. The Bowman's layer side of the tissue lens exhibited a uniform, smooth surface. Transmission electron microscopy revealed a largely normal collagenous structure of both stroma and Bowman's layer. Interfibrillary distances were within normal limits. Several giant stromal spaces of various dimensions filled with homogeneous material were observed. Variably preserved keratocytes were a regular finding among the lamellae. Our findings confirmed some of the structural changes previously observed in tissue lenses not used for epikeratophakia in humans. The limited size of a smooth central zone of the posterior surface could explain some postoperative complaints such as persistent glare phenomena, as well as prolonged visual rehabilitation time, especially in those cases where centration of the epi-lens onto the recipient cornea is not optimal.