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Abstract Introduction Despite an improved understanding of its pathogenesis, dry eye disease (DED) remains relatively underestimated and its treatment challenging. A better alignment between the clinical evaluation and the patient self-assessment also requires capturing the whole patient experience of DED. This project aimed to unveil this experience through narrative medicine (NM). Methods The project involved 38 expert centres in Italy and one in San Marino, targeting adult patients with DED, their informal caregivers and their treating ophthalmologists. Written narratives and sociodemographic and quality of life (QoL)-related data were anonymously collected through the project’s webpage. Narratives were analysed through MAXQDA (VERBI Software, Berlin, Germany), NM classifications and content analysis. Results A total of 171 patients with DED, 37 informal caregivers and 81 ophthalmologists participated in the research. DED was defined as a disabling condition by 19% of patients and 35% of caregivers; 70% of patients reported that a therapeutic alliance is an integral part of DED treatment and 32% hope for more effective therapies. Forty-four per cent of patients assessed their own QoL as good; however, DED emerged as importantly impacting work performance and social events. DED physical, emotional and economic burden and the cruciality of a trusting care relationship represent the main themes that emerged across all narratives, while empathy and effective treatment are among the factors favouring coping with DED. Conclusion This project marked a pioneering initiative investigating the lived experience of patients with DED through NM, simultaneously involving all viewpoints involved in the care pathway. NM enabled the unveiling of factors favouring the ability to cope with DED and its associated QoL implications and provided valuable insights to improve the therapeutic alliance.

Background: Fluorescein angiography (FA) has been a pivotal tool for studying the pathophysiology of retinopathy of prematurity (ROP) in vivo. We examined the course of ROP using FA to assess the predictive value of angiographic features. Methods: This is an observational retrospective cohort study of eyes screened for ROP with a binocular indirect ophthalmoscope and FA. RetCam fundus imaging and video digital fluorescein angiography were performed in the neonatal intensive care unit of Santa Maria Hospital of Perugia. The masked grading of the FA images was retrospectively conducted by two ROP expert ophthalmologists. Results: A total of 80 eyes of 40 patients were included for this study. Among the angiographic features evaluated, leakage, shunts, and tangles were predictive of the development of treatment-requiring ROP (p < 0.05). Conclusions: FA can add to our understanding of the evolution of vascular abnormalities in the course of ROP and can help predict which eyes will go on to treatment.

Purpose. The primary objective of this study is to evaluate the efficacy and safety profile of PreserFlo MicroShunt implantation in the medium- to long-term follow-up of patients with open-angle glaucoma. The secondary objective is to analyze laser flare meter (LFM) values before and after PreserFlo MicroShunt implantation. Methods. This prospective, observational, longitudinal single-center study included a total of 62 eyes from 54 patients. A subgroup of 27 eyes (26 patients) reached the 12-month follow-up. Success was defined based on three criteria: criterion A: IOP ≤21 mmHg and ≥20% reduction; criterion B: IOP ≤15 mmHg and ≥25% reduction; and criterion C: IOP ≤12 mmHg and ≥30% reduction. Success was further categorized as complete if achieved without IOP-lowering medications and qualified if achieved with medication administration. Other aspects evaluated included the number of IOP-lowering medications (baseline and postoperative), development of postoperative complications, 5-FU injections or implant revision, and LFM values. Results. The 12-month follow-up group (27 patients) was composed by 50% males and had a mean age of 75.54 ± 9.98 years. Success rates at 12 months were as follows: 78% for criterion A, 56% for criterion B, and 26% for criterion C. Complete success, as defined by criterion A, was achieved by 67% of the patients, 29% achieved qualified success, and one eye (4%) experienced failure. IOP decreased from 25.26 ± 1.67 mmHg at baseline to 14.81 ± 0.74 mmHg at 12 months. The number of medications decreased from 3.67 ± 1.30 at baseline to 0.48 ± 0.75 at 12 months. Reported complications were choroidal detachment (11%), hyphema (5%), and athalamia (flat anterior chamber) (2%) 13 eyes (48%) received 5-FU injections, while 7 eyes (26%) underwent implant revision. No significant increase in LFM values was observed. Eyes with a regular postoperative course and IOP ≤15 mmHg showed significantly lower LFM values than patients with unfavorable outcomes (IOP >15 mmHg, development of complications, 5-FU injection, or implant revision). Conclusions. PreserFlo MicroShunt showed a significant reduction in IOP and a decrease in the number of IOP-lowering medications. Complications occurred at a modest frequency. The implant provides a minimally invasive approach with no significant increases in LFM values postoperatively. Higher LFM values correlate with unfavorable postoperative outcomes.

A five classes (A-E) aggregate risk score predicting 90-day mortality after video-assisted thoracoscopic lobectomy for lung cancer, including as independent factors male sex (3 points), DLCO 150 minutes (1 point), has been recently published. This study aims to assess the effectiveness and reliability of this risk model in a large, independent cohort of patients, to confirm its generalizability. From the Italian VATS Group Database, we selected 2,209 patients [60% males; median age 69 years (IQR:63-74)] who underwent video-assisted thoracoscopic lobectomy for non-small cell lung cancer. We calculated the aggregate risk score and the corresponding class of 90-day mortality risk for each patient. The correlation between risk classes and mortality rates was tested by Spearman’s r-test. Model calibration was evaluated by Hosmer-Lemeshow goodness-of-fit test. Class A-E 90-day mortality rates were 0.33%, 0.51%, 1.39%, 1.31% and 2.56%, respectively. A strong uphill correlation was identified between risk classes and 90-day mortality (r=0.90; p=0.037), showing a positive correlation between increased mortality rate and class A to E. Hosmer-Lemeshow chi-squared value was 67.47 (p

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

Nephrobronchial fistula is an extremely rare complications of renal infections. We present a case of nephrobronchial fistula in a middle age immunocompetent woman who complained cough and weight loss, with underlying asymptomatic nephrolithiasis. She underwent a chest X-ray that showed left lower lobe infiltrate and abdominal ultrasound. Abdominal ultrasound showed a complicated pyonephrosis ; CT of chest-abdomen-pelvis with intravenous contrast was performed in order to stage and define the extension of the pathology. At CT, a suspected diagnosis of stage III xanthogranulomatous pyelonephritis complicated with pyonephrosis and a nephrobronchial fistula was formulated. A nephrostomy tube was placed, and the patient was treated with antibiotics. Follow up CT, performed after 15 days, showed the healing of the fistulous connection between the perinephric abscess and bronchi; the patient underwent nephrectomy with no airway complication during intubation. Histopathological diagnosis confirmed the presence on complicated xanthogranulomatous pyelonephritis.

Pleural empyema of extra pulmonary origin is uncommon and empyema secondary to a fistula between the urinary tract and thorax is extremely rare. We report a case of nephropleural fistula causing massive pleural empyema in a 64-year-old woman with a long history of urological problems, including nephrolitiasis and urinary tract infection. She was admitted with sepsis, fever, chills, tachypnea, productive cough and pyuria. At clinical examination, breath sounds were reduced over the left hemithorax. CT revealed a fistulous connection from the upper left calyceal group and the pleural space. Drainage of thoracic and perinephric collection was carried out, but nephrectomy and pleural decortication were required due to haemopurulent urine and decreased hemoglobin levels during the hospitalization. This case demonstrates the unusual and prolonged evolution of an obstructive hydroureteronephrosis complicated by pyonephrosis, culminating in retroperitoneal abscess that fistulized into the pleural space, leading to empyema.

Purpose: To visualize photoreceptors using the Spectralis High Magnification Module (HMM) in a case of central serous chorioretinopathy (CSCR) and to correlate the findings with those of optical coherence tomography (OCT) and optical coherence tomography angiography (OCT-A). Observations: A 35-year-old Caucasian male presenting with chronic CSCR in the left eye was examined using HMM, OCT and OCT-A. The photoreceptors mosaic was assessed both in diseased and apparently uninvolved areas. A partial topographic correlation between the loss of photoreceptors on HMM images and an altered reflectivity of the photoreceptor layer on en-face OCT was noted. Interestingly, a correlation between the photoreceptor damage on HMM and choriocapillaris flow-void areas on OCT-A was seen. Conclusions and Importance: HMM is a non-invasive imaging modality, allowing the in-vivo visualization of photoreceptor damage in a diseased retina. A focal abnormal perfusion of the choriocapillaris might influence the integrity of the overlying photoreceptors in CSCR.

Background Increased lipoprotein (a) [Lp(a)] has been associated with enhanced risk of cardiovascular events and more recently with venous thromboembolism. However, there is inconclusive data on the association between enhanced Lp(a) and retinal vein occlusion (RVO). We aimed to assess the role of Lp(a) in RVO. Methods We performed a systematic review and meta-analysis of the studies addressing the role of Lp(a) in RVO. A systematic literature search was performed to identify all published papers reporting Lp(a) levels. Main outcome measures consisted of Lp(a) levels in patients with (cases) or without (controls) RVO. Results We included 13 studies for a total of 1,040 cases and 16,648 controls. Lp(a) levels above normal limits were associated with RVO (OR 2.38, 95% CI 1.7–3.34) and patients with RVO had higher Lp(a) levels than controls (weighted mean difference: 13.4 mg/dL, 95% CI 8.2–18.6). Conclusion Increased Lp(a) levels associate with RVO and should be included among diagnostic and prognostic indexes for this unusual-site vein thrombosis. Therapeutic interventions aimed to lower Lp(a) should be tested in RVO patients.

BackgroundTransition to digital pathology usually takes months or years to be completed. We were familiarizing ourselves with digital pathology solutions at the time when the COVID-19 outbreak forced us to embark on an abrupt transition to digital pathology. ObjectiveThe aim of this study was to quantitatively describe how the abrupt transition to digital pathology might affect the quality of diagnoses, model possible causes by probabilistic modeling, and qualitatively gauge the perception of this abrupt transition. MethodsA total of 17 pathologists and residents participated in this study; these participants reviewed 25 additional test cases from the archives and completed a final psychologic survey. For each case, participants performed several different diagnostic tasks, and their results were recorded and compared with the original diagnoses performed using the gold standard method (ie, conventional microscopy). We performed Bayesian data analysis with probabilistic modeling. ResultsThe overall analysis, comprising 1345 different items, resulted in a 9% (117/1345) error rate in using digital slides. The task of differentiating a neoplastic process from a nonneoplastic one accounted for an error rate of 10.7% (42/392), whereas the distinction of a malignant process from a benign one accounted for an error rate of 4.2% (11/258). Apart from residents, senior pathologists generated most discrepancies (7.9%, 13/164). Our model showed that these differences among career levels persisted even after adjusting for other factors. ConclusionsOur findings are in line with previous findings, emphasizing that the duration of transition (ie, lengthy or abrupt) might not influence the diagnostic performance. Moreover, our findings highlight that senior pathologists may be limited by a digital gap, which may negatively affect their performance with digital pathology. These results can guide the process of digital transition in the field of pathology.

Indoleamine 2,3-dioxygenase 2 (IDO2) is an analog of the tryptophan degrading and immunomodulating enzyme indoleamine 2,3-dioxygenase 1 (IDO1). Although the role of IDO1 is largely understood, the function of IDO2 is not yet well-elucidated. IDO2 overexpression was documented in some human tumors, but the linkage between IDO2 expression and cancer progression is still unclear, in particular in non-small cell lung cancer (NSCLC). Immunohistochemical expression and cellular localization of IDO2 was evaluated on 191 formalin-fixed and paraffin-embedded resected NSCLC. Correlations between IDO2 expression, clinical-pathological data, tumor-infiltrating lymphocytes (TILs), immunosuppressive tumor molecules (IDO1 and programmed cell death ligand-1 – PD-L1 –) and patients' prognosis were evaluated. IDO2 high expression is strictly related to high PD-L1 level among squamous cell carcinomas group (p = 0.012), to either intratumoral or mixed localization of TILs (p < 0.001) and to adenocarcinoma histotype (p < 0.001). Furthermore, a significant correlation between IDO2 high expression and poor non-small cell lung cancer prognosis was detected (p = 0.011). The current study reaches interesting knowledge about IDO2 in non-small cell lung cancer. The close relationship between IDO2 expression, PD-L1 increased levels, TILs localization and NSCLC poor prognosis, assumed IDO2 as a potential prognostic biomarker to be exploited for optimizing innovative combined therapies with immune checkpoint inhibitors.

Aim: The aim of this study is to compare the efficacy of different dexamethasone eye drops formulations in controlling postoperative inflammation. Methods: Cataract surgery was carried out in 72 patients (35 males) divided into two groups: group A (36 patients, mean age = 78.0 ± 5.6) received four times daily for 2 weeks a suspension containing tobramycin 0.3% mg/ml + dexamethasone 0.1% mg/ml, and group B (36 patients, mean age = 76.2 ± 6.8) a solution containing tobramycin 0.3% mg/ml + dexamethasone 0.1% mg/ml. Both groups received ofloxacin 0.5% four times daily for 7 days, and nepafenac 0.1% three times daily for 3 weeks. Best-corrected visual acuity, intraocular pressure, corneal thickness, endothelial cells count, aqueous flare and macular thickness were evaluated preoperatively and at 1 day, 15 days, 1 and 2 months. Results: In group A, intraocular pressure, corneal thickness and aqueous humour flare values preoperatively and at the end of follow-up were 14.3 ± 1.8 and 13.2 ± 1.8 mmHg, 546.4 ± 34.6 and 539.6 ± 36.1 µm, 11.84 ± 4.44 and 13.52 ± 5.54 ph/ms, respectively, with no statistically significant difference. In group B, intraocular pressure, corneal thickness and aqueous humour flare values preoperatively and at the end of follow-up were 14.3 ± 1.5 and 13.1 ± 1.7 mmHg, 552.9 ± 37.4 and 548.1 ± 39.3 µm, 11.45 ± 4.06 and 13.73 ± 4.99 ph/ms, respectively, with no statistically significant difference. No difference was detected in the macular thickness values in the parafoveal area preoperatively and at 2 months follow-up in group A (332.18 ± 16.19 and 337.71 ± 16.33 µm) and group B (329.11 ± 18.28 and 334.37 ± 20.86 µm), respectively. Conclusion: The two different formulations of dexamethasone eye drops reached the same anti-inflammatory effects.

Abstract Background Intravascular lymphoma is a rare type of non-Hodgkin lymphoma mostly of B-cell lineage. A few cases of intravascular lymphoma have been found to be of NK/T-cell origin, mainly affecting the skin and central nervous system. Case presentation A 54-year-old Caucasian man sought care because of a 2 weeks history of jaundice and intermittent fever, not responsive to antibiotics and antipyretics. Laboratory tests showed low blood oxygen concentration and pancytopenia. Serum microbiological tests were negative. Computerized tomography (CT) scan revealed hepatosplenomegaly and diffuse ground-glass opacities in both lungs without interlobular septal thickening. Despite oxygen therapy, the clinical conditions rapidly deteriorated leading to death 3 days after admission. Autopsy revealed a multiorgan involvement by an Epstein-Barr virus positive NK/T-cell lymphoma, strikingly growing within the blood vessel lumina, in absence of skin lesions. Conclusions The current case highlights the pathological features of this rare entity, the protean clinical presentation of which is often misleading, resulting in delayed diagnosis and treatment.

AIM: To analyze the visual outcomes and the posterior capsule opacification (PCO) with the new Incise® MJ14 intraocular lens (IOL) implanted through a 1.4 mm clear corneal incision (CCI) in patients who underwent bimanual microincision cataract surgery (B-MICS). METHODS: Eighty eyes which underwent cataract surgery using B-MICS technique performed by the same experienced surgeon were included in the study: 40 eyes were implanted with an Incise® MJ14 IOL through a 1.4 mm CCI (group A) without enlargement of the main CCI, while 40 eyes were implanted with an Akreos® MI60 IOL with enlargement of the main CCI to 1.8 mm (group B). Best corrected visual acuity (BCVA), astigmatism and endothelial cell loss were evaluated before and after surgery at 7, 30d and 6mo. Anterior segment-optical coherence tomography (AS-OCT) of CCI was performed at 1, 3, 7, 30d, 6 and 18mo. PCO incidence was evaluated at 18mo using EPCO 2000 Software. RESULTS: Mean BCVA improvement and endothelial cell loss were statistically significant at 18mo in both groups with no difference between the two groups; no statistically significant difference in surgically induced astigmatism (SIA) was noticed in the two groups. At AS-OCT the only significant alterations in the CCI were endothelial gaping and local detachment of Descemet’s membrane at 1 and 7d after surgery; no statistically significant alterations were found at 1, 6 and 18mo. PCO score at 18mo was 0.03±0.07 for group A and 0.08±0.18 for group B (P=0.11) with no sign of central optic plate invasion in both groups. CONCLUSION: The implant of the new Incise® MJ14 IOL through a 1.4 mm CCI and B-MICS technique appeared to be a safe and effective procedure with rapid visual recovery. PCO rate resulted very low and the CCI presented few morphological alterations which were only detectable in the first days postoperatively and achieved fast corneal healing during the long-term follow-up.

Canaloplasty is a nonpenetrating blebless surgical technique for open-angle glaucoma, in which a flexible microcatheter is inserted within Schlemm’s canal for the entire 360 degrees. When the microcatheter exits the opposite end, a 10-0 prolene suture is tied and it is then withdrawn, by pulling microcatheter back through the canal in the opposite direction. Ligation of prolene suture provides tension on the canal and facilitates aqueous outflow. The main advantage of canaloplasty is that this technique avoids the major complications of fistulating surgery related to blebs and hypotony. Currently, canaloplasty is performed in glaucoma patients with early to moderate disease and combination with cataract surgery is a suitable option in patients with clinically significant lens opacities.

The purpose of this study was to evaluate posterior corneal surface variation after femtosecond laser-assisted keratomileusis in patients with myopia and myopic astigmatism. Patients were evaluated by corneal tomography preoperatively and at 1, 6, and 12 months. We analyzed changes in the posterior corneal curvature, posterior corneal elevation, and anterior chamber depth. Moreover, we explored correlation between corneal ablation depth, residual corneal thickness, percentage of ablated corneal tissue, and preoperative corneal thickness. During follow-up, the posterior corneal surface did not have a significant forward corneal shift: no significant linear relationships emerged between the anterior displacement of the posterior corneal surface and corneal ablation depth, residual corneal thickness, or percentage of ablated corneal tissue.