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Purpose: To evaluate the agreement of glaucomatous structural defects of the ganglion cell complex (GCC) detected with the spectral domain optical coherence tomography (sdOCT) with the optic nerve head alterations detected with the Heidelberg retina tomography (HRT), of glaucoma patients with ocular hypertension or open angle glaucoma. Material and Methods: Ninety patients eyes with structural glaucomatous defects were enrolled. All of them underwent imaging examination of GCC with sdOCT and the optic disk with HRT. The Cohen's kappa coefficient of agreement was used. Results: The agreement between the optic disc and GCC using the parameters of the programs analysis of the HRT, the moorfields regression analysis (MRA) and glaucoma probability score (GPS) was not significant. Instead between MRA and GPS a good agreement was calculated. Significant agreements were found between MRA and GPS on one hand and GCC on the other, considering location and length of the glaucomatous damage, while non significant agreements were found between GPS and GCC for the location and the length of the glaucomatous structural defect. Conclusions: There is no significance (Please explain further if you are referring to significance in terms of the difference, similarity or agreement) between HRT and sdOCT for the detection of the glaucomatous damage between the optic nerve head and the ganglion cell complex. Instead MRA and GCC detect comparable areas and lengths of the glaucomatous damage. On the other hand GPS records larger deficits relative to MRA and has not a significant agreement with the study of GCC.

Purpose: To evaluate the safety and efficacy of repeated intravitreal dexamethasone implant (Ozurdex) injections administrated on an “as-needed” protocol for retinal vein occlusion patients with ma...

To describe the outcomes of endothelial keratoplasty (EK) for bullous keratopathy in eyes with a retained angle-supported anterior chamber intraocular lens (acIOL). Among 263 consecutive EK procedures, 7 DMEK and 11 DSAEK procedures were identified in eyes with an acIOL and included in the present retrospective case series. Pre- and postoperative status including ocular history, anatomical outcome and complications as well as best-corrected visual acuity was evaluated. Ocular history included complicated cataract surgery (n = 11), ocular trauma (n = 4) and primary intracapsular cataract extraction (n = 3). Surgery-related complications included primary graft failure (n = 1), graft detachment (n = 1), endophthalmitis (n = 1) and allograft rejection (n = 1). A clear cornea at the final examination (14 ± 4 months) was observed in 14/18 (78%), while the visual outcome was limited due to significant ocular comorbidity in 9 out of 14 uncomplicated procedures. The presented short-term outcomes suggest that both DMEK and DSAEK are feasible in eyes with an angle-supported acIOL yielding an acceptable graft survival rate in the first postoperative year.

To describe the utilization of descemetorhexis for reformation of the anterior chamber in eyes with central iridocorneal synechiae before endothelial keratoplasty (EK). A 71-year-old man with a history of trabeculectomy complicated by hypotony presented with bullous keratopathy in the presence of extensive iridocorneal synechiae and a flat anterior chamber. In order to proceed with EK, synechiolysis with the use of viscoelastic and scissors was attempted. Despite successful dissection of the peripheral strands, the pupillary margin of the iris remained attached to the endothelium. Therefore, descemetorhexis was performed to detach the Descemet membrane along with central synechiae and create sufficient space for safe EK at a later stage. Corneal clarity was restored by ultrathin Descemet stripping automated endothelial keratoplasty, leaving a fibrous membrane in the pupillary plane, which was excised 2 months later, allowing an improvement of best-corrected visual acuity to 0.5. Isolated descemetorhexis was successfully employed to reform the anterior chamber and proceed with EK in a case of bullous keratopathy and resistant iridocorneal synechiae. This stepwise approach may be considered in similar cases in order to avoid a more invasive treatment, ie, penetrating keratoplasty and synechiolysis.

Konstantinos Andreanos, Chryssanthi Koutsandrea, Dimitris Papaconstantinou, Andreas Diagourtas, Andreas Kotoulas, Panagiotis Dimitrakas, Marilita M Moschos First Department of Ophthalmology, University of Athens, “G. Gennimatas” General Hospital of Athens, Athens, Greece Purpose: The aim of the study was to assess the influence of central corneal thickness (CCT) and corneal curvature in tonometry measurements taken by Goldmann applanation tonometry (GAT) and Pascal dynamic contour tonometry (DCT).Methods: This was a prospective study of 185 eyes from 97 subjects, attending outpatient ophthalmology appointments, who underwent intraocular pressure measurements by GAT and Pascal DCT. CCT and corneal curvature were obtained using ultrasound pachymetry and Orbscan topography, respectively. All measurements were carried out among males and females during the period 2009–2012. Apart from the usual descriptive and exploratory data analysis, one-way analysis of variance and agreement analysis were performed, linear as well as intraclass correlation coefficients were estimated, and multiple scatter and Bland–Altman plots were produced.Results: Mean IOP measurements obtained were 17.21±4.10 mmHg by DCT and 13.23±4.07mmHg by GAT. Mean difference between the GAT and DCT measurements was 3.88±2.8 mmHg. MeanCCT and corneal curvature were 522.78±52 µm and 43.83±2.9823 D, respectively.Conclusion: Intraocular pressure measured by GAT was consistently lower when compared with DCT, and this difference was greatest with thinner CCT. Flat corneas seem to influence GAT measurements compared to DCT. Keywords: glaucoma, Goldmann, Pascal, tonometry

Purpose: To evaluate the quality of life related to vision (QoL) in patients with ocular hypertension under treatment. Methods: The study included two groups. The first one consisted of 60 ocular hypertension patients under topical hypotensive medications and the second one of 60 healthy persons. The Greek language version of the National Eye Institute Visual Function Questionnaire 25 (NEI VFQ-25) was completed by all patients. Results: The median scores of the total score and also for almost all the NEI VFQ-25 subscales were significantly decreased for the first group of ocular hypertension patients (OHT) under topical therapy. Females presented higher QoL than that of males. The patients who used one medication presented higher QoL than that of the patients who used more than one. The best corrected visual acuity (BCVA) and the intraocular pressure (IOP) were significantly correlated with QoL. The index of the visual fields, pattern standard deviation (PSD), was significantly related to the quality of life of OHT. The age, the cup to disk ratio and the central corneal thickness had also significant correlations with subscales of the QoL. Conclusions: The quality of life OHT patients under topical treatment is significantly decreased than healthy persons. Male sex and the number of medications affect QoL more. BCVA and IOP represent the clinical findings that best correlate with several subscales of QoL. PSD is a significant index that correlates well with the quality of life of OHT patients.

Purpose To identify the prognostic factors affecting the surgical outcomes in patients with vitreomacular traction syndrome undergoing pars plana vitrectomy. Methods This was a retrospective clinical study of 67 eyes of 67 patients with vitreomacular traction syndrome who underwent pars plana vitrectomy. Demographic, clinical, and optical coherence tomography (OCT) characteristics were collected and analyzed. Univariate and multivariate linear regression analysis were used to examine the effect of parameters on change in best-corrected visual acuity (BCVA). Results At a mean follow-up period of 15.9±12 months (mean±SD), the BCVA improved from 0.7±0.3 LogMAR (mean±SD) to 0.5±0.3. Seven patients developed full-thickness macular hole intraoperatively and tamponade (air, 20% SF6 or 12% C3F8) was used in 41 patients. Retinal breaks were identified intraoperatively in four patients. Regression analysis demonstrated that the preoperative BCVA was the only parameter affecting the postoperative visual outcome. Conclusion In the present study, the preoperative BCVA plays a predictive role in the surgical outcome of patients with VMT undergoing pars plana vitrectomy. No other preoperative OCT characteristics demonstrated prognostic potential. Further prospective studies are needed in order to examine the role of several factors that could potentially facilitate preoperative patient counselling.

Introduction: Ocular trauma is a common cause of visual reduction or loss and relates with a variety of demographic factors. Aim: Investigating the relationship of patients with eye injuries demographic data who were operated in a Public Hospital of the Attica Prefecture with place of accident, cause, classification and complications of trauma. Material and Methods: This is a retrospective study. The sample consisted of 219 patients with ocular trauma who underwent a surgical therapy. For data collection a specific registration form was used. Data analysis was performed with the statistical package Statistical Package for Social Sciences (SPSS) ver.22. Results: The relationship of gender and age of patients, with place of injury, classification and etiology of trauma was statistically significant (p

Objective To determine subtle changes of Heidelberg retina tomography (HRT) stereometric parameters and blue-on-yellow (B/Y) perimetry global indices for the early diagnosis of glaucoma in suspected subjects. Patients and methods Cross-sectional data on 174 eyes of 87 subjects from a larger cohort, attending the Glaucoma Department of the "G. Gennimatas" General Hospital of Athens from January 2004 to February 2014, were used in the study. Subjects were assigned to 3 groups: (a) "normals" not requiring treatment throughout the study (group 1), (b) suspects who developed glaucoma and required treatment during the study (group 2), and (c) patients with incipient glaucoma (group 3). Specific HRT and B/Y perimetry variables were compared among the 3 groups. Results Significant differences were established for the following HRT parameters: "reference height" differed significantly between groups 1 and 2 and groups 1 and 3; "cup shape measure" differed significantly between groups 1 and 2 and groups 2 and 3. B/Y perimetry global index "mean deviation" significantly distinguished group 2 from groups 1 and 3. Conclusions The results of the present study suggest the predictive value of the HRT stereometric parameters "reference height" and "cup shape measure" and of the B/Y perimetry global index "mean deviation" in glaucoma-suspected subjects; further corroboration through longitudinal studies is warranted.

Background Beta-thalassemia is a severe genetic blood disorder caused by a mutation in the gene encoding for the beta chains of hemoglobin. Individuals with beta-thalassemia major require regular lifelong Red Blood Cell transfusions to survive. Ocular involvement is quite common and may have serious implications. Methods Extensive review of observational studies on beta-thalassemia, to determine the prevalence and spectrum of ocular abnormalities, by clinical examination and multimodal imaging, and to investigate risk factors for their development. Results Frequency of ocular involvement differs among various studies (41.3–85 %, three studies). Ocular findings in beta-thalassemia may correlate to the disease itself, iron overload or the chelating agents used. Beta-thalassemia ocular manifestations include ocular surface disease, as demonstrated by tear function parameters (two studies). Lens opacities are present in 9.3–44 % (five studies). Lenticular opacities and RPE degeneration correlated positively with use of desferrioxamine and deferriprone respectively (two studies). Ocular fundus abnormalities characteristic of pseudoxanthoma elasticum (PXE), including peau d’orange, angioid streaks, pattern dystrophy-like changes, and optic disc drusen are a consistent finding in seven studies. Patients with PXE-like fundus changes were older than patients without these fundus changes (two studies). Age (two studies) and splenectomy (one study) had the strongest association with presence of PXE-like fundus changes. Increased retinal vascular tortuosity independently of the PXE-like fundus changes was found in 11–17.9 % (three studies), which was associated with aspartate amino transferase, hemoglobin and ferritin levels (two studies). Fundus autofluorescence and electrophysiological testing (ERG and EOG) may indicate initial stages or more widespread injury than is suggested by fundus examination (two studies). Conclusions Beta-thalassemia may present with various signs, both structural and functional. Pseudoxanthoma elasticum like fundus changes are a frequent finding in patients with b-thalassemia. These changes increase with duration or severity of the disease. Retinal vascular tortuosity may be an additional disease manifestation related to the severity and duration of anemia and independent of the PXE-like syndrome. Patients with long-standing disease need regular ophthalmic checkups because they are at risk of developing PXE-like fundus changes and potentially of subsequent choroidal neovascularization.

Dimitris Papaconstantinou, George Kalantzis, Dimitris Brouzas, Anastasios Kontaxakis, Chryssanthi Koutsandrea, Andreas Diagourtas, Ilias Georgalas Department of Ophthalmology, National and Kapodistrian University of Athens, Athens, Greece Purpose: The aim of this study was to compare the results of phacoemulsification through a small pupil using minimal iris manipulation versus phacoemulsification through a well-dilated pupil.Methods: This prospective randomized control (comparative) study comprised 78 patients (group I) with a maximally dilated pupil size of ≤4.00mm and 45 patients (group II) with dilated pupil size of ≥7.00mm. In group I patients, only viscodilation and minimal push-and-pull iris stretching with two collar-button iris-retractor hooks were utilized without iris manipulation. Phacoemulsification was performed by two senior surgeons and the technique used consisted of either stop and chop or quick chop, infusion/aspiration of lens cortex, capsular bag refill with ocular viscoelastic devices, and implantation of an acrylic foldable intraocular lens. Patients were examined on the first day and 1month postoperatively.Results: Forty-six eyes of group I patients had pseudoexfoliation syndrome, eleven eyes had previous glaucoma surgery, 14 eyes had angle-closure or open-angle glaucoma, and seven eyes had posterior synechiae with iritis. In group I patients, the mean pupil size measured under an operating microscope was 3.2mm preoperatively, 4.3mm after viscoelastic and mechanical pupil dilation, and 4.1mm at the end of a surgical procedure. Rupture of the zonular fibers occurred in six patients of group I and the intraocular lens was implanted in the sulcus. Small iris-sphincter rupture and small hemorrhages occurred in four eyes during pupillary manipulation, but they were not evident at the end of the surgery. In group II patients, no intraoperative complications occurred. Signs of significant corneal edema and iritis were observed more frequently in group I eyes (26 eyes and 20 eyes, respectively) on the first postoperative day in comparison with group II eyes (ten eyes and six eyes, respectively). Intraocular pressure was

Since their introduction by Chang et al. in 1987, perfluorocarbon liquids (PFCLs) have become a useful tool in vitreoretinal surgery. They are synthetic compounds with carbon-fluorine chemical chains that have specific physico-chemical properties, which make them valuable for the intraoperative management of the retina by simplifying vitreoretinal surgical maneuvers in a variety of settings. These maneuvers include retinal detachments associated with proliferative vitreous retinopathy, following penetrating trauma, giant retinal tears, dislocated lenses or lens implants and complications from proliferative diabetic vitreoretinopathy. Purified PFCLs are generally considered to be biologically inert. Despite the stability of PFCLs during vitreoretinal surgery, several studies have indicated that these compounds may be associated with toxicity in ocular tissues. The purpose of this review is to report the use and toxicity of PFCLs in vitreoretinal surgery and to present the latest perspectives on modified PFCLs (hydrofluorocarbon liquids (HFCLs) and HFCL-oligomers).

Purpose: To present the preliminary results of our study comparing the outcomes of trabeculectomy with or without OloGen implant in patients requiring glaucoma surgery for uncontrolled intraocular pressure (IOP). Methods: Forty eyes of 40 patients were assigned randomly to undergo trabeculectomy either with OloGen implant (study group) or without implant (control group). Preoperative data included age, gender, type of glaucoma, IOP and number of preoperative glaucoma medications. Postoperative IOP, number of postoperative glaucoma medications and postoperative complications were recorded. Each patient was followed up for at least 6 months. Results: There were no significant differences between the groups in terms of age, gender, type of glaucoma, preoperative IOP and number of antiglaucoma medications. Mean IOPs for both groups were significantly lower than preoperative levels at all intervals (P < 0.05) The number of glaucoma medications used dropped from a preoperative mean of 3.5 ± 0.7 to a 6-month postoperative mean of 0.3 ± 0.7 (P < 0.001) in the study group and from 3.7 ± 0.4 to 0.5 ± 1.1 (P < 0.001) in the control group. No statistically significant differences between the two groups were observed in terms of postoperative complications. Conclusion: In this pilot study it appears that trabeculectomy with OloGen does not seem to offer any significant advantages compared with trabeculectomy alone. Additionally, even though there were no statistical differences between the two groups as far as complications were concerned, one eye from the study group developed endophthalmitis 10 days after surgery and two eyes presented with positive Seidel test and flat anterior chamber and required additional suturing. Studies with larger numbers of patients and longer follow-ups are required to confirm these findings and to examine the safety and long-term outcomes of trabeculectomy with OloGen.

Breast cancer is one of the most common malignant diseases occurring in women, and its incidence increases over the years. It is the main site of origin in ocular metastatic disease in women, and, due to its hematogenous nature of metastatic spread, it affects mainly the uveal tissue. The purpose of this paper is to summarize the clinical manifestations of the breast cancer ocular metastatic disease, alongside the side effects of the available treatment options for the management and regression of the systematic and ophthalmic disease.

Purpose To report a case of a patient receiving tamoxifen with visual deterioration and describe the unusual optical coherence tomography (OCT) findings. Method Observational case report. Results A 55-year-old female patient was referred to our department complaining of gradual visual deterioration in both eyes. Medical history was unremarkable apart from breast cancer for which she had received tamoxifen for 10 years (mean dosage 20 mg/day). Best corrected visual acuity was 20/400 in her right eye and 20/40 in her left eye. Fundoscopy in both eyes was without any obvious signs of maculopathy. However, Fourier-domain OCT demonstrated bilateral extensive areas of disruption in inner retinal layers without any signs of crystalline retinopathy. Six months after the cessation of tamoxifen, the situation remains unchanged. Conclusion Patients receiving tamoxifen should be monitored with high-resolution OCT for fundoscopically invisible changes in the inner retinal layers, the progression of which may seriously affect the patient’s vision and subsequently their quality of life.

To examine the efficacy and safety of combined phaco-trabeculectomy in patients with cataract and controlled, open-angle advanced glaucoma and to identify preoperative predictive factors of postoperative glaucoma course.Departments of Ophthalmology, University of Athens, and General Hospital of Lamia, Greece.Prospective, interventional, parallel, cluster (units=examinations), randomized clinical study. 60 patients with visually significant cataract, visual field Mean Deviation (MD) worse than -15.0 dB, and preoperative intraocular pressure (IOP), controlled (consistently below 22 mmHg) on topical medications and with no previous ocular surgery, were randomly allocated (1:1) to phacoemulsification alone or phaco-trabeculectomy group. Intention-to-treat analysis was performed to compare the postoperative outcome and adjusted multivariate longitudinal linear regression analysis was performed to identify predictive factors of the main outcome measures, with postoperative visual field MD change up to two years postoperatively. Participant recruiters and data collectors were masked to group assignment.31 and 29 patients were randomized to phacoemulsification alone and phaco-trabeculectomy groups, respectively. Patients assigned to the phaco-trabeculectomy group experienced a 1.7 mmHg [95% CI:-3.1 to -0.23] reduction in IOP, a 1.4 dB [95% CI: -0.17 to 2.96] improvement in visual fields MD, a 0.6 [95% CI: -1.2 to -0.05] reduction in the number of glaucoma medications needed postoperatively, while the visual acuity improvement was similar between the two groups. Best predictors for visual field MD: degree of nuclear sclerosis, relative afferent pupilary defect (RAPD), preoperative MD deviation from -19.0 dB and preoperative cup-disc ratio deviation from 0.9. The phacoemulsification group experienced more IOP spikes (25 mmHg) with Odds Ratio (OR) of 0.34 [95% CI: 0.11-1.02]. No patient lost light perception.Phaco-trabeculectomy in advanced, controlled, open-angle glaucoma patients with cataract results in better postoperative visual field MD with no major adverse events.

Alexandros Takis,1 Dimitrios Alonistiotis,1 Dimitrios Panagiotidis,1 Nikolaos Ioannou,1 Dimitris Papaconstantinou,2 Panagiotis Theodossiadis1 1Ophthalmological University Clinic of Athens, Attikon Hospital, Athens, Greece; 2Ophthalmological University Clinic of Athens, Geniko Kratiko Hospital, Athens, Greece Background: The retinal nerve fiber layer (RNFL) thickness in patients with diabetes mellitus type 2 was compared to normal subjects of similar age and sex, having first excluded any risk factors for glaucoma. The correlation between the RNFL thickness and the severity of diabetic retinopathy was investigated at its primary stages and with other ocular and diabetic parameters. Methods: A prospective, case series study was carried out. Twenty-seven diabetic patients without diabetic retinopathy, 24 diabetic patients with mild retinopathy, and 25 normal, age-matched subjects underwent a complete ophthalmological examination and imaging with scanning laser polarimetry for the evaluation of the RNFL. Multivariate analysis was applied in order to investigate the correlation between RNFL and diabetic parameters, such as age, duration of diabetes, insulin therapy, levels of glycosylated hemoglobin; and ocular parameters, such as cup to disc ratio, levels of normal intraocular pressure, and central corneal thickness. Results: The mean inferior average of RNFL and the temporal-superior-nasal-inferior-temporal standard deviation were statistically significantly lower in both diabetic groups, and the nerve fiber index was higher (P=0.04) compared to the normal group. There was no statistically significant difference between the diabetic groups. The factor analysis showed no significant correlation between the RNFL and the previously mentioned diabetic and ocular parameters. Conclusion: The existence of diabetes should be seriously considered in evaluating the results of scanning laser polarimetry. Multivariate analysis for RNFL was used for the first time. Keywords: diabetes, glaucoma, RNFL, SLP

Diplopia is an infrequent but distressing adverse outcome after uncomplicated cataract surgery. Many factors may contribute to the occurrence of this problem, including prolonged sensory deprivation resulting in disruption of sensory fusion, paresis of one or more extraocular muscles, myotoxic effects of local anaesthesia, optical aberrations (for example, aniseikonia) and pre-existing disorders (for example, thyroid orbitopathy). The purpose of this review is to present the aetiology and clinical features of diplopia after cataract surgery and to discuss the possible modalities for the prevention and treatment of this frustrating complication.

The use of intravitreal injections of anti-Vascular Endothelial Growth Factor (anti-VEGF) has been used for a broad spectrum of ocular pathologic entities. Although the dose of anti-VEGF agents used for treating eye disease is minute compared with that used intravenously, intraocular administration can lead to systemic absorption and reduce serum VEGF levels. Several systemic side effects, such as hypertension and cardiovascular complications have been rarely reported in the literature. Renal complications of intravenous administration of anti-VEGF, are well known and include a variety of renal pathological damage which can induce proteinuria and hypertension. We describe herein, 2 cases of diabetic patients with preexisting kidney disease who presented severe reduction of their renal function after intraocular administration of anti-VEGF. Although a cause –effect correlation cannot be established unless further studies are performed, we believe that pretreatment counseling should include a discussion outlining the possible risk of aggravating of the renal function in patients with kidney disease. Close cooperation with the patient’s nephrologist and close monitoring of the patient may be required, in such cases, in order to monitor the renal function before and after the intravitreal administration of anti-VEGF.

Purpose To report the unusual occurrence of peripheral ulcerative keratitis, 10 days after trabeculectomy in a 35-year-old patient with rheumatoid arthritis (RA). Methods Observational case report. Results A 35-year-old patient with RA and secondary Sjogren disease underwent an uneventful fornix-based trabeculectomy. Ten days after surgery, slit-lamp examination revealed a peripheral corneal ulcer extending from 5- to 7-o'clock positions with a surrounding inflammatory infiltrate and adjacent conjunctival injection. The ulcer was treated with systemic and topical steroids, antibiotic eyedrops, artificial tears, and a bandage soft contact lens. Since then, corneal re-epithelialization started and the patient's symptoms subsided. The ulcer improved steadily within 2 months while the patient used a soft contact lens. The ulcer did not reoccur in the 18 months follow-up while the patient remained under systemic treatment. Conclusion This report highlights the importance of careful examination and close postoperative follow-up in patients with RA undergoing any intraocular surgery, to diagnose a possible development of peripheral ulcerative keratitis. Although the incidence is rare, prompt diagnosis of the peripheral ulceration is essential because if untreated it may seriously affect patient's vision.

To assess and compare the safety and the efficacy of VisThesia™ and Viscoat® in cataract surgery.This prospective randomized clinical trial included 44 eyes of 44 patients that were assigned randomly to undergo phacoemulsification either with VisThesia™ or with Viscoat®. Preoperative data included age, gender, visual acuity, IOP and mean endothelial cell density. Postoperative, best corrected visual acuity (BCVA), IOP, mean endothelial cell density and painful sensation during surgery were recorded.BCVA, evaluated with Snellen chart in decimal fraction, was statistically improved in both groups. Specifically, mean BCVA in VisThesia group was increased from 0.28 ± 1.8 SD preoperatively to 0.83 ± 1.4 SD postoperatively, whereas, in the Viscoat group, BCVA was increased from 0.31 ± 2.1 SD preoperatively, to 0.85 ± 1.2 SD after surgery (p 0.1). The mean postoperative IOP was lower in the VisThesia group, but the difference was not statistically significant (p 0.1). Preoperatively, the mean endothelial cell count was 2322.3 ± 161.1 SD cells/mm(2) in Viscoat group and 2304.8 ± 142.8 SD cells/mm(2) in the VisThesia group, similar between groups (p 0.1). At day 15 after cataract surgery the postoperative endothelial cell count was 2102.9 ± 182.8 SD cells/mm(2) in Viscoat group and 2032.6 ± 160.4 SD cells/mm(2) in the VisThesia group (p 0.1). The mean endothelial cell decrease was 212 cells/mm(2) (9.1%) in the Viscoat group and 272 cells/mm(2) (11.8%) in the VisThesia group. The difference was not statistically significant between the two groups (t-test = 0.18, p 0.1). This value is within standard normal endothelial cell decrease after a cataract surgery. Painful sensation was not reported during any stage of the procedure.Topical-intracameral anesthesia with VisThesia™ allows cataract surgery without any painful sensation in the majority of patients. Both Viscoat® and VisThesia™ have similar safety profile during intra- and post-operative period and identical endothelial protection, as endothelial cell loss is within normal limits.

Laser peripheral iridotomy is the procedure of choice for the treatment of angle-closure glaucoma caused by relative or absolute pupillary block. Nd: YAG laser iridotomy has been reported to have several complications such as Iris bleeding, hyphema, transient IOP elevation, intraocular inflammation, choroidal, retinal detachment and vitreous hemorrhage. We report a case of a 74 year old lady on anticoagulant treatment who developed pupillary block and angle closure glaucoma after cataract surgery and anterior chamber intraocular lens (ACIOL) insertion complicated with intraoperative bleeding. The patient was treated with Nd: YAG laser iridotomy , however, the ACIOL was inadvertently fractured after a single shot of laser and it had to be replaced. Although the incidence is rare. Ophthalmologists and Opticians should be aware that an ACIOL may be fractured even after a single Nd:YAG laser shot and avoid to perform it close to the ACIOL. Pretreatment counseling should include this rare complication.

Ioannis Havvas,1,2 Dimitris Papaconstantinou,1 Marilita M Moschos,1 Panagiotis G Theodossiadis,1 Vasilios Andreanos,1 Pantelis Ekatomatis,1 Ioannis Vergados,1 Dimitrios Andreanos1 1Department of Ophthalmology, School of Medicine, University of Athens, General Hospital of Athens, Athens, 2Department of Ophthalmology, General Hospital of Patras, Patras, Greece Background: The purpose of this study was to compare the two perimetric modalities, SWAP (short wavelength automated perimetry) and SAP (standard automated perimetry), on the point of conversion to glaucoma. Methods: In this prospective, longitudinal, follow-up study, 282 patients with ocular hypertension were recruited consecutively and tested with both SAP and SWAP annually for 5 years or until the onset of conversion to glaucoma. SAP and SWAP perimetry was performed with the Humphrey Field Analyzer II using the 24-2 full-threshold test. Abnormality for both SAP and SWAP fields was determined on the pattern deviation plot and defined as either a) one point below the 0.5% probability level or b) a cluster of 2 or more points below 1% or c) a cluster of 3 or more points below 2% or d) a cluster of 4 or more points below 5%. Abnormal tests had to be confirmed on a subsequent test within one year to be classified as conversion. Results: Of the 282 patients initially recruited, 32 were excluded. Of the 250 remaining patients, a total of 38 converted during the follow-up period; 36.8% of conversions were detected earlier with SWAP, 29% simultaneously, and 34.2% were not detected with SWAP during the follow-up period; 2.4% of patients showed SWAP visual field loss that did not result in conversion during the follow-up period. Conclusion: The results in our study are inconclusive. There were patients with earlier, simultaneous, or no SWAP conversion, with SAP conversion as the golden standard criterion. One should consider both SAP and SWAP with confirmation when visual field loss is evident to maximize early detection of glaucoma, because it appears that each method identifies early glaucoma in a subset of patients and these subsets overlap only partially. Keywords: short wavelength automated perimetry, standard automated perimetry, blue on yellow, glaucoma conversion, ocular hypertension

Torjesen clearly sums up the results of a recent trial showing that off-label use of bevacizumab (Avastin) is as effective as the more expensive licensed treatment for wet age related macular degeneration—ranibizumab (Lucentis).1 2 This will provide an …

Panagiotis Stavrakas1, Gerasimos Georgopoulos1, Maria Milia1, Dimitris Papaconstantinou1, Maria Bafa2, Efthymios Stavrakas2, Mihalis Moschos11Department of Ophthalmology, University of Athens Medical School, General Hospital of Athens (Geniko Kratiko Hospital), Athens, Greece; 2Department of Ophthalmology, Thriassio General Hospital, Athens, GreeceBackground: To investigate the effectiveness of amniotic membrane transplantation (AMT) on improving the outcomes of trabeculectomy in primary open-angle glaucoma (POAG).Methods: Fifty-nine eyes affected by primary open-angle glaucoma were enrolled in this prospective randomized study. Thirty-two eyes underwent amnion-shielded trabeculectomy (study group) and 27 eyes underwent trabeculectomy without any antimetabolites (control group). Success was defined as intraocular pressure (IOP) 21 mmHg in contrast to seven patients from the classic trabeculectomy group. The study group had 61.0% less risk of developing IOP >21 mmHg (P = 0.203). No major complications in the AMT group were observed. AMT blebs were diffuse with mild vascularization.Conclusion: In patients with POAG, AMT showed favorable effects on bleb survival, however data failed to provide firm evidence that AMT could be used as a routine procedure in trabeculectomy.Keywords: amniotic membrane, trabeculectomy, primary open-angle glaucoma, glaucoma filtering blebIn memory of Professor Mihalis Moschos. "We thank him for his encouragement as well as his leadership and commitment to public health."

Background To report a case with hypotony due to late leakage of the filtering bleb performed during childhood and treated surgically using human pericardium graft. Case Presentation A man with hypotony related to bleb's leakage in his right eye was presented. During his childhood trabeculectomy was performed to manage ocular hypertension due to pediatric glaucoma. Biomicroscopy revealed choroidal tissue incarcerated in the sclerectomy under the conjunctiva. Bleb revision was performed. Human pericardium graft was used to cover the sclerectomy and a new bleb with controlled outflow was created. The intraocular pressure (IOP) and Seidel test represent the main outcomes. Intraoperative and postoperative complications were recorded. Fifteen days postoperatively the IOP was of 7 mmHg and the bleb seemed to filter properly. Five months later the IOP was 9 mmHg and no complications were noticed. During the follow up time, the Seidel test was negative. Conclusion We used human pericardium graft with no complications in a case of bleb leakage performed for pediatric glaucoma.

Purpose: To assess the impact of open versus masked adherence monitoring on adherence with topical brimonidine using two different dosing schedules. Methods: Thirty-seven patients with glaucoma or ocular hypertension were enroled in a prospective, observational cohort study. Patients were randomly assigned to open or masked adherence monitoring and to brimonidine twice daily (BID) or three times daily (TID). Patients received conventional brimonidine eye drops with attached electronic monitoring devices for 4 weeks with weekly intraocular pressure measurements. Adherence calculations comprised dosing intervals, adherence rate and time covered. Subgroup analysis with anova included the factors masking, regimen, diagnosis and age. Results: Among 36 individually analysed patients, 12 (33%) had adherence rates above 75%, therein two (5%)>90%. The mean adherence rate in 19 patients aware of adherence measurements was 70 ± 17% for brimonidine BID and 65 ± 14% for TID, not significantly different to the rates of 17 patients not informed about adherence measurements (77 ± 6% BID, 62 ± 9% TID, p = 0.24). On average, patients with brimonidine TID achieved significantly lower adherence rates (64 ± 12%) than patients on BID (73 ± 13%, p = 0.02). Still, patients on TID applied brimonidine more often (TID 1.9 ± 0.3, BID 1.5 ± 0.1 mean applications per day). The median coverage was 70% and showed no statistically significant difference between patients on BID and TID (p = 0.36). Conclusion: The study findings suggest that adherence measurements are not significantly altered by open adherence monitoring, which may simplify future adherence studies. Adherence with brimonidine eye drops was insufficient for most patients. These results demonstrate the necessity to develop new strategies to improve compliance in glaucoma therapy.

To report our experience from a case with a retinal detachment in an eye with aphakia, an Artisan phakic anterior chamber lens, and an ExPress valve and describe its course after vitrectomy and gas tamponade.Interventional case report.A 65-year-old man who had previously undergone cataract extraction, Artisan/Verisyse lens implantation, and ExPress valve insertion for the treatment of aphakia and refractory glaucoma presented with a superior retinal detachment. The patient underwent a 20-g pars plana 20g vitrectomy, cryotherapy, and sulfur hexafluoride (SF(6)) tamponade. Twenty days after vitrectomy, the Artisan lens remained in place and the retina attached. Twelve months postoperatively, the situation remained unchanged.Iris-claw lenses have been introduced in 2004 as an alternative option for the correction of aphakia. Vitreoretinal surgeons face a new therapeutic challenge since data with regard to retinal detachment repair in patients with Artisan lenses are very limited. In our case, all intraoperative vitrectomy manipulations were performed without difficulty through the Artisan lens, which remained stable during fluid-air exchange as well as postoperatively, despite the movements of the gas bubble and the presence of the ExPress valve. Moreover, there was no displacement of the ExPress valve during the intraoperative manipulations of vitrectomy or dysfunction of the valve due to the existence of the gas in the postoperative period.

To evaluate the efficacy of sulfur hexafluoride tamponade, as an adjunct to vitrectomy and internal-limiting-membrane peeling, for the treatment of retinal detachment (RD) associated with macular hole (MH).Our study was a retrospective interventional case series. We evaluated 9 phakic eyes of 9 consecutive patients with retinal detachment secondary to macular hole (MHRD) treated with 20-gauge (g) pars plana vitrectomy, which was followed with trypan blue-assisted internal-limiting-membrane peeling, fluid-air exchange, and 20% sulfur hexafluoride tamponade (SF(6)) gas exchange. All patients underwent optical coherence tomography, best-corrected visual acuity (BCVA) measurement, and dilated fundus examination with indentation, pre- and postoperatively.The mean (± standard deviation) follow-up time was 13 ± 3 months (range 9-18). Postoperatively, all eyes demonstrated an attached retina, whereas MH closure was achieved in only 1 eye, and in a second eye after additional injection of gas and further posturing. The BCVA improved from 2.2 ± 0.4 logMAR (logarithm of the minimum angle of resolution) at baseline to 2.0 ± 0.5 logMAR at the end of follow-up (p = .05).The failure in MH closure in most of our cases strengthens the view that short-term tamponade with SF(6) may not suffice for achieving MH closure, and either prolonged tamponade (with C(3)F(8) or silicone oil) or additional photocoagulation may be a better option for eyes with MHRDs. In addition, it is possible that intravitreal injection of gas might be an option for the treatment of persistent MHs after vitrectomy for MHRD, especially when the MH is small. Further studies are required to evaluate the above findings, although the implementation of large series studies remains a challenge because of the rarity of cases with MHRDs.

Introduction We report a case of early lactobacillus endophthalmitis which occurred ten days after trabeculectomy. Case presentation A 76-year-old Caucasian diabetic woman underwent uncomplicated trabeculectomy with a collagen implant as an adjunct, in her left phakic eye, for the treatment of uncontrolled open-angle glaucoma. Ten days post-operatively, our patient complained of left phakic eye discharge pain and visual acuity decreased to "light-perception". The anterior chamber had 3+ cells and flare, and there was also 2 mm layered hypopyon. Vitreous involvement was present obscuring visualization of the fundus. On the same day our patient underwent vitrectomy surgery and intra-vitreal and systemic antibiotics were administered. Vitreous cultures grew Lactobacillus brevis. Our patient responded well to treatment and 30 days after vitrectomy visual acuity improved to 1/10. Six months later our patient underwent cataract surgery. Eight months after initial surgery visual acuity was 2/10 and intra-ocular pressure was 14 mmHg without any anti-glaucoma medication. Conclusions This is the first report of acute lactobacillus endophthalmitis in the phakic eye of a diabetic patient after trabeculectomy. Glaucoma surgeons should be aware of the potential for acute post-operative endophthalmitis due to rare microorganisms, such as lactobacillus, in glaucoma filtration surgery, especially in diabetic patients. The literature shows an increased risk of endophthalmitis when anti-metabolites are used in conjunction with trabeculectomy. Perhaps, any type of wound healing modulation, such as collagen or mitomycin-C may increase this risk. However, it is unclear at this time and more studies need to be done. In this single case, vitrectomy combined with intra-vitreal and systemic antibiotics were efficient in limiting the devastating sequels of this complication.

Background To report the rare association of peripheral retinal ischemia in a patient with Waldenström's macroglobulinemia. Case Presentation A 39-year old man with a recent diagnosis of asymptomatic Waldenström's macroglobulinemia (WM) was referred from his physician for ocular evaluation. The fundus examination in his right eye (RE) revealed very mild central vein dilation, while retinal hemorrhages associated with microaneurismal alterations of the vascular plexus were detected at the temporal periphery. Fluoroscein angiography of his RE revealed an extended area of capillary dropout distal to the microaneurismal lesions. In our patient with WM an extensive area of capillary non-perfusion, in the absence of severe involvement of the posterior pole was documented; this association to the best of our knowledge has never been reported before. Conclusion Although the incidence of the disease is rare, meticulous examination of the retinal periphery should be performed in all patients with WM and vice versa the differential diagnosis of peripheral retinal ischemia of unknown origin should include an investigation to rule out asymptomatic Waldenström's macroglobulinemia.

Lens-induced glaucoma comprises a number of different glaucomatous processes occurring in the elderly that share in common the role of the crystalline lens in the mechanism of increase in intraocular pressure. We will review the anatomic predisposing factors, their physiology, signs and symptoms, and therapeutic approach. We will consider two studies and discuss the visual results and risk factors associated with these pathologic conditions.

Dimitris Papaconstantinou1, Ilias Georgalas2, Nikolaos Kourtis1, Christos Pitsas1, Efthimios Karmiris1, Chrysanthi Koutsandrea1, Ioannis Ladas1, Gerasimos Georgopoulos11Department of Ophthalmology, “G Gennimatas” Hospital of Athens, University of Athens, Athens, Greece; 2Department of Ophthalmology, “G Gennimatas” Hospital of Athens, NHS, Athens, Greece Purpose: The purpose of this prospective study was to evaluate the efficacy in intraocular pressure (IOP) control and the tolerance of a topically administered fixed combination of timolol–brimonidine in 50 patients with ocular hypertension and primary open-angle glaucoma.Methods: After determining a baseline IOP, the fixed combination timolol–brimonidine was used twice daily for two months, while IOP, ophthalmic signs, and/or symptoms were monitored.Results: The mean IOP value was decreased from 23.09 mm Hg (±1.98 SD) to 17.46 mm Hg (±1.47 SD) during the 1st month (paired Student’s t test = 9.88 και p

Sergios Taliantzis, Dimitris Papaconstantinou, Chrysanthi Koutsandrea, Michalis Moschos, Michalis Apostolopoulos, Gerasimos GeorgopoulosAthens University Medical School, Department of Ophthalmology, Athens, GreecePurpose: To compare the functional changes in visual fields with optical coherence tomography (OCT) findings in patients with ocular hypertension, open angle glaucoma, and suspected glaucoma. In addition, our purpose is to evaluate the correlation of global indices with the structural glaucomatous defect, to assess their statistical importance in all the groups of our study, and to estimate their validity to the clinical practice.Methods: One hundred sixty nine eyes (140 patients) were enrolled. The patients were classified in three groups. Group 1 consisted of 54 eyes with ocular hypertension, group 2 of 42 eyes with preperimetric glaucoma, and group 3 of 73 eyes with chronic open angle glaucoma. All of them underwent ophthalmic examination according to a prefixed protocol, OCT exam (Stratus 3000) for retinal nerve fiber layer (RNFL) thickness measurement with fast RNFL thickness protocol and visual fields (VF) examination with Octopus perimeter (G2 program, central 30–2 threshold strategy). Pearson correlation was calculated between RNFL thickness and global index of VF.Results: A moderate correlation between RNFL thickness and indices mean sensitivity (MS), mean defect (MD) and loss variance (LV) of VF (0.547, -0.582, -0.527, respectively; P < 0.001) was observed for all patients. Correlations of the ocular hypertension and preperimetric groups are weak. Correlation of RNFL thickness with global indices becomes stronger as the structural alterations become deeper in OCT exam. Correlation of RNFL thickness with the global index of VF, in respective segments around optic disk was also calculated and was found significant in the nasal, inferior, superior, and temporal segments.Conclusion: RNFL average thickness is not a reliable index for early diagnosis of glaucoma and for the follow-up of patients with ocular hypertension. Segmental RNFL thickness seems to be a more reliable index. Deep structural alterations with OCT examination constitute an important indication of early functional changes, even if they are not still detected with achromatic perimetry. The MD index of VF seems to be more sensitive for the follow-up of patients with ocular hypertension.Keywords: glaucoma, ocular hypertension, OCT, visual fields, RNFL thickness

Jensen and Bulova’s otherwise excellent review of the care of adults with Down’s syndrome did not mention the ocular manifestations of Down’s syndrome, which are common and can seriously reduce quality of life.1 All ocular structures can be affected,2 and the prevalence of ophthalmic disorders in Down’s syndrome is estimated at 77%.3 Anatomical …

RE: Long-term outcomes and risk factors for failure with the EX-press glaucoma drainage device

Cerebral blindness is an extremely rare complication of cardiac catheterisation. We report a case of a patient who presented with bilateral ischaemic infarcts of the occipital lobe and severe visua...