Vitreo-Retinal Fellowship Royal Liverpool University Hospital, Liverpool, from 2007 to 2008 (Prof. D. Wong).
Research Fellowship Massachusetts Eye & Ear Infirmary, Harvard Boston from 2005 to 2006 in vitreo-retinal disease (Prof. D. D’Amico)
Clinical attachement: Moorfields Eye Hospital, London (Prof. R. Collins) Humanitas Hospital, Milano in vitreo-retinal surgery and refractive surgery (Prof. P.Vinciguerra) Careggi Hospital, Florence (Prof. U. Menchini). Diploma of Echo-Ophtalmology (SIEO). Royal Liverpool University Hospital, Liverpool in vitreo-retinal surgery (Prof. D. Wong). Massachusetts Eye & Ear Infirmary, Harvard Boston in Electrophysiology (Prof. A. Gaudio) Massachusetts Eye Research and Surgery Institute, Cambridge in Ocular Immunology (Prof. SC Foster)
Graduated at Second University of Study of Naples in 2002 with first class honours (110/110 marks cum laude). Diploma of residency in Ophtalmology at Second University of Study of Naples in 2006 with first class honours (50/50 cum laude).
Abstract: Aims To report the early development of epiretinal membranes (ERM) in eyes with retinal vein occlusions (RVO) treated with intravitreal bevacizumab and to describe possible mechanisms that may be involved in the growth and contraction of these lesions. Methods Retrospective and interventional study that included 25 eyes of 25 patients with RVO (16 eyes with central retinal vein occlusion and nine eyes with branch retinal vein occlusion). After an initial 2.5 mg/0.1 ml intravitreal bevacizumab injection all patients were followed-up every 6 weeks. Re-treatments were based on visual acuity and optical coherence tomography findings. Results Twenty-five eyes were treated with bevacizumab and followed for 8.3 (range 4.5-13.5) months. Four eyes developed an ERM within 6-7 weeks after the administration of bevacizumab. ERM was not associated with further deterioration of visual acuity or metamorphopsia in these patients. A rebound of macular oedema was observed in one patient with ERM and in two other patients. No other side effects were observed. Conclusions Intravitreal bevacizumab may be associated with an early growth of ERM in eyes with RVO, although a causative relationship cannot be established. Future randomised clinical trials are necessary to determine the efficacy and safety profile of this novel therapy.
Abstract: The value of the MP-1 microperimeter in early diagnosis of pituitary tumours by detection of changes in macular sensitivity is described. A 21-year-old female presented with blurred vision in the right eye. Ophthalmic examination was unremarkable. Static perimetry of the central visual field (30°) was performed by use of a Humphrey automatic perimeter, and the retinal sensitivity of the 12 central degrees was measured by use of the MP-1. Static perimetry revealed a peripheral visual field defect without involvement of the macular region. The MP-1 revealed an important loss of sensitivity (3.4 ± 4.8 dB) in the central 12°. Magnetic resonance imaging revealed a pituitary adenoma with sellar and suprasellar extension. Three months after surgical removal, use of the MP-1 revealed complete recovery of the sensitivity (19.28 ± 2.5 dB), fixation location, and fixation stability of the right eye. In pituitary tumours, the presence of a sub-clinical form of macular involvement can be demonstrated and followed-up accurately by use of the MP-1.
Abstract: We report the clinical findings of a patient with severe bilateral keratectasia 34 years after a penetrating keratoplasty (PK) in both eyes. An otherwise healthy 67-year-old man complained of deterioration of the eyesight in both eyes over the last 6 months. The patient was diagnosed with bilateral keratoconus at the age of 32 years, and he underwent a bilateral PK. At presentation, visual acuity was 20/200 in the right eye and light perception in the left eye. A Pentacam pachymetric map revealed a central pachymetry of 720 mum in the right eye and of 710 mum in the left eye, as well as an average paracentral pachymetry of 436 and 270 mum in the 9-mm zone in the right and the left eye, respectively. Corneal topography revealed bilateral irregular and asymmetric bowing with generalized steepening and high corneal power. We describe a case of bilateral keratectasia 34 years after PK in a patient who was originally diagnosed with bilateral keratoconus.
Abstract: The purpose of this study is to evaluate the role, the safety and the effectiveness of intravitreal bevacizumab (IVB) injections as an adjunct to vitrectomy in the management of severe proliferative diabetic retinopathy (PDR).
Abstract: To report the safety and effectiveness of a sutureless human sclera donor patch graft covering the subconjunctival portion of glaucoma drainage implant tube to prevent its erosion throughout the overlying conjunctiva.
Abstract: To determine whether the presence of a clinically and/or microscopically detectable epiretinal membrane (ERM) alters the cleavage plane during internal limiting membrane (ILM) peeling.
Abstract: To report the efficacy and safety of intravitreal bevacizumab (IVB) alone versus IVB plus low-fluence photodynamic therapy (PDT) in age-related macular degeneration (AMD) patients and to verify the occurrence of a synergistic effect of the combined approach on visual acuity, size and morphology of lesion, as well as on the treatment rate.
Abstract: The second part of this two part review (please see Expert Opinion on Pharmacotherapy 10(16)) reports the characteristics of other antiglaucoma medications: systemic (acetazomide) and topical (dorzolamide and brinzolamide) carbonic anhydrase inhibitors, which suppress aqueous humour formation; and prostaglandin analogues (latanoprost and travoprost) and prostamides (bimatoprost), which raise aqueous humour outflow. The pharmacologic properties of each compound and its efficacy in the medical treatment of glaucoma, mainly the primary open-angle form, are discussed briefly, focusing on the clinical evidence supporting their use.
Abstract: A solution of perfluorohexyloctane and silicone oil with a specific gravity of 1.06 g/cm(3) (Densiron-68) has similar properties as conventional silicone oil (SO) in terms of the shape of the bubble and its ability to act as an internal tamponade agent. We conducted a case-control study to compare the postoperative intraocular pressure (IOP) in patients treated with Densiron-68 with those treated with SO. METHODS: Seventy-one eyes of 71 patients and 57 eyes of 57 patients who had received Densiron-68 and SO, respectively, were included in our study. Both groups were found to have matched for their preoperative comorbidities (diabetes, glaucoma, phakic status, and refractive errors). IOP at first day, between seventh and fourteenth day, and at 4 week postoperatively was recorded. RESULTS: The mean IOP was higher in patients treated with Densiron-68 at day 1 and between seventh and fourteenth day postoperatively (P=0.05 and 0.01, respectively). By the 4th week, the IOP difference between the two groups was insignificant (P=0.17). The difference in the two groups could still be clinically significant and the raised IOP in Densiron-68 group was more difficult to treat in some cases.On day 1, nine eyes (12.7%) in the Densiron-68 group and two eyes (3.5%) in the SO group had IOP greater than 30 mmHg. At 4 weeks, IOP of more than 30 mmHg was seen in nine eyes (12.7%) in the Densiron-68-treated group and in one eye (1.8%) in the SO group. CONCLUSION: The use of Densiron-68 was associated with a higher IOP in the early postoperative period when compared with SO.
Abstract: Purpose To describe the efficacy of microperimetry (MP-1) in detecting early retinal toxicity as a result of chronic use of chloroquine and in monitoring the changes in macular sensitivity in an asymptomatic patient with best-corrected visual acuity of 20/20 bilaterally. Methods A 60-year-old woman presented for routine ocular examination with a medical history of severe rheumatoid arthritis, for which she had been receiving 3 mg chloroquine (CQ) per kilogram for the past 17 years. The patient was asymptomatic with best-corrected visual acuity of 20/20 bilaterally. Results Microperimeter showed loss of sensitivity in the macular region with a dense scotoma within the central 12 degrees (2.80 +/- 4.7 dB right eye and 2.84 +/- 4.7 dB left eye). CQ treatment was discontinued and substituted by Plaquenil. Conclusions Chloroquine retinal toxicity can be recognized in a subclincal form by the presence of early changes in macular sensitivity, detected by MP-1.
Abstract: PURPOSE: To report a new approach for removal of Densiron-68 via pars plana with a 23-gauge transconjunctival sutureless vitrectomy system (TSVS). METHODS: Prospective, interventional case series. Ten eyes (4 phakic, 5 pseudophakic, 1 aphakic) of 10 patients underwent Densiron-68 (1480 mPa viscosity and 1.06 g/ml specific gravity) removal via pars plana with a suction pressure of 600-mmHg vacuum through a short 23-gauge silicon cannula.ResultsDensiron-68 was completely removed from all eyes. Retinal reattachment was achieved in all cases. The intraocular pressure was 20.9 (SD 3.5) mmHg at baseline, 12.2 (SD 4) mmHg at day 1 postoperatively, and 13.6 (SD 2.9), 15.4 (SD 2.5), and 16 (SD 1.8) mmHg after 1 week, 1 month, and 3 months, respectively. Five eyes needed suture of at least one sclerotomy. Postoperative hypotony (<or=8 mmHg) was seen in 2 out of 10 eyes (20%). No additional postoperative procedure was necessary. CONCLUSIONS: Active removal of Densiron-68 with a 23-gauge short cannula is a simple, innovative, and safe technique that can help reduce surgical trauma.
Abstract: AIMS: To evaluate the recurrence rate of vitreous haemorrhage (VH) in patients treated with one intravitreal bevacizumab (IVB) injection (2.5 mg/0.1 ml) before planned pars plana vitrectomy for treatment of diabetic non-clearing VH. METHODS: Prospective pilot study of 32 eyes of 31 consecutive diabetic patients who underwent IVB injection within 1 week before surgery for persistent VH in the presence of active proliferative diabetic retinopathy. Three masked retinal specialists graded the amount of VH from grade 0 to grade 3 with slit-lamp biomicroscopy. Main outcome measures were the rate of recurrence of the VH, improvement in visual acuity, incidence of cataract formation, and postoperative complications through a follow-up of 6 months. RESULTS: The percentage of severe recurrent VH with no fundus details (grade 3) was 3% at 1 week follow-up and 3, 6, and 6% respectively at 1-, 3-, and 6-month follow-up. The mean best-corrected visual acuity (BCVA) improved from 1.6 (1/60) to 0.40 (6/15) logMAR (P=0.02) in 29 out of 32 eyes (91%). In all, 12 out of 22 (54%) phakic eyes developed cataract during the follow-up period, and 10 (31%) of them underwent cataract surgery. CONCLUSIONS: Our study suggests that IVB injection few days before planned surgery seems to be efficacious and safe as an adjuvant treatment to prevent rebleeding in eyes undergoing pars plana vitrectomy for treatment of diabetic vitreous haemorrhage. IVB facilitates the surgery and reduces the need for extensive delamination and segmentation, decreasing the possibility of significant early active postoperative VH.
Abstract: BACKGROUND: To report 12-month follow-up results of 156 eyes treated with anti-VEGF for subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration, and to verify the efficacy of this treatment in terms of functional results and changes of morphology of choroidal membrane for the different types of choroidal neovascularization analyzed. METHODS: This prospective case series study included subjects with different forms of subfoveal CNV. After the first intravitreal injection of 1.25 mg bevacizumab at baseline, re-injections of bevacizumab were scheduled at least 4 weeks after initial treatment following standardized criteria. RESULTS: One hundred and fifty six patients were divided into two study groups: 60 eyes with classic CNV (group C) and 96 eyes with occult CNV (group O). The improvement in BCVA was greater in group C than group O, although the difference was not statistically significant (P = 0.26). The area of CNV and subretinal fibrous tissue/disciform scar remained stable over time in both groups. The macular thickness significantly decreased through the follow-up period in both groups. The hyper-reflective area of the neovascular complex remained stable in both groups during the first 6 months of follow-up, whereas a slight increase of hyper-reflective lesion size occurred throughout the second 6 months of follow-up. CONCLUSION: The CNV lesion treated with IVB didn't disappear in neither group, but showed less exudation, demonstrated by a decrease in the area of leakage from CNV, subretinal fluid area, and centre point retinal thickness on OCT.
Abstract: PURPOSE. To evaluate the recurrence of vitreous hemorrhage (VH) in patients treated with intravitrealbevacizumab (IVB) injection (2.5 mg/0.1 mL) intraoperatively at the end of vitrectomy for treatment of diabetic nonclearing VH. METHODS. A prospective pilot study of 30 eyes of 28 consecutive diabetic patients who underwent pars plana vitrectomy and IVB injection intraoperatively at the end of vitrectomy was performed. The amount of VH was graded with slit lamp biomicroscopy by three masked retinal specialists from grade 0 to grade 3. Main outcome measures were rate of recurrence of the VH, improvement in visual acuity, incidence of cataract formation, and postoperative complications through a follow-up of 6 months. RESULTS. The percentage of severe recurrent VH with no fundus details (grade 3) was 7%, 13%, 27%, and 30%, respectively, at 7 days and 1-, 3-, and 6-month follow-up. At 6-month followup, the best-corrected visual acuity improved from 1.00 to 0.4 logMAR (p=0.01) in 21 out of 30 eyes (70%). Nine out 20 (40%) phakic patients developed cataract during the follow-up period, and 7 (31%) of them underwent cataract surgery. CONCLUSIONS. The study suggests that intravitreal bevacizumab injection cannot prevent rebleedingin eyes undergoing pars plana vitrectomy for treatment of diabetic vitreous hemorrhage.
Abstract: BACKGROUND: We investigate the safety and feasibility of large retinal pigmentary epithelium (RPE)-Choroid-free graft after surgical drainage of massive sub-macular hemorrhage (SMH) due to age-related macular degeneration (ARMD). METHODS: Four previously untreated patients (three females and one male) underwent to three port pars plana vitrectomy, induction of retinal detachment and peripheral temporal 180 degrees retinotomy. The retina was then folded nasally, to allow access for removal of sub-macular Hg and CNV complex. A full-thickness-large autologous Chorio-RPE patch was grafted. Silicone oil was used as endotemponade for approximately 12 weeks. After removal of silicone oil, the patients were followed-up for 6 months. RESULTS: SMH was completely removed in all cases. It was possible to graft a large RPE patch safely that is sufficiently large to cover the entire defect of macular RPE. At last follow-up, improvement in visual acuity (from 3 +/- 0.9 to 55 +/- 9 ETDRS letters) and recovery of central fixation was observed in all patients. CONCLUSIONS: Our surgical technique for large elevated SMH seems to be feasible and efficacious approach to harvest and relocate large RPE patch and to save limited vision in selected patients.
Abstract: BACKGROUND: To report a retrospective non-comparative interventional study on the effectiveness and ocular tolerance of a heavy silicone oil tamponade (HSO, Densiron-68) for primary inferior rhegmatogenous retinal detachment (RRD). METHODS: Forty-one eyes of 41 consecutive patients were recruited between January 2004 and August 2006. Primary vitrectomy with Densiron-68, a heavy silicone oil, was used in all cases. Inclusion criteria were primary RRD with at least one retinal break between 4 and 8 clock hours. The study protocol consisted of a minimum of eight clinic visits: baseline, surgery, 1 week, 1 month and 3 months after the initial surgery; removal of oil and 1 week, 1 month and 3 months postoperatively. The primary endpoint was anatomical re-attachment of the retina. Cases were judged successful when there was reattachment of the retina in the absence of any tamponade agent. The secondary endpoint was to record the visual function and any complications arising from the surgery. Out of 41 patients initially included in the study, 33 completed all follow-up visits. RESULTS: Anatomical success was achieved in 91% of cases (30 out of 33) with one retinal operation, and rose to 94% (31 out of 33) with additional surgery. Mean visual acuity improved from logMAR 1.19 (SD 0.9) to 0.5 (SD 0.51, p = 0.001). No significant ocular hypertension, clinically significant emulsification of the tamponade or inflammation developed during follow-up. CONCLUSION: With Densiron-68, high anatomical and functional success rates can be achieved with primary vitrectomy for RRD and predominantly inferior pathology.
Abstract: AIMS: Neovascular glaucoma (NVG) represents one of the most severe forms of secondary glaucoma, caused by a number of ocular and systemic conditions, which share the common element of retinal ischaemia/hypoxia that initiates the subsequent release of angiogenesis factors, with consequent development of new abnormal vessels through the ciliary body. The aim was to examine the potential efficacy and safety of intravitreal injection of bevacizumab (IVB) (Avastin) in the treatment of NVG in patients who had already undergone the standard retinal ablative procedure. METHODS: This was a prospective pilot trial. Clinical data of 26 eyes from 23 patients, including diagnosis, visual acuity, iris fluorescein angiography stage and intraocular pressure (IOP), were collected. Three injections of bevacizumab were scheduled for each recruited eye at 4-week intervals from the start. All investigations were repeated the day before the IVB (1.25 mg/0.05 ml) and at the 1-, 3-, 6-, 9- and 12-month follow-up. RESULTS: Regression of corneal oedema together with significant pain reduction was achieved in all eyes already after the first IVB, without any noteworthy improvement of visual acuity. At the end of the scheduled protocol (three IVB), regression of iris neovascularization was documented in all patients, together with significant improvement of visual acuity. The IOP reduction from baseline ranged from 30 to 0 mmHg (12.1 +/- 8 mmHg). CONCLUSIONS: Intravitreal bevacizumab, as adjunctive treatment to the standard retinal ablative procedure, seems promising for the management of conditions responsible of retinal ischaemia/hypoxia associated with NVG.
Abstract: PURPOSE: To verify the influence of a non-steroidal anti-inflammatory drug (NSAID), ketorolac (topical and oral) on the intraocular pressure reduction induced by 0.005% latanoprost topical administration, both in patients affected by primary open-angle glaucoma and in healthy controls. METHODS: Two groups of subjects were enrolled for this randomized, prospective, masked clinical study: 16 glaucomatous patients well controlled with 0.005% latanoprost eyedrops (group I) and 16 healthy adult volunteers (group II). Group I subjects were treated at one-week intervals with 10 mg of oral ketorolac, oral placebo, topical ketorolac, and topical placebo, respectively; for each administration modality, the switch between drug and placebo was performed in a randomized, crossover, double-blind fashion. Group II subjects followed the same protocol, with the topical once-daily 0.005% latanoprost treatment starting three days prior to the ketorolac/placebo administration. Intraocular pressure (IOP) was investigated in both groups on the day of oral/topical administration of ketorolac or placebo at baseline (8:00 AM) and at the following intervals: 1, 2, 4, 8, 12, and 24 hours. RESULTS: No significant IOP changes after oral and topical placebo administration were observed in either group. In contrast, when the subjects received ketorolac (either oral or topical), a marked decrease in IOP was recorded, with a noticeable fall at the first hour after the NSAID administration (p = 0.01), which remained still significant 8 hours later (p < 0.05). CONCLUSION: Topical and oral ketorolac strengthens the latanoprost-induced IOP-lowering effect both in glaucomatous patients and in healthy subjects.
Abstract: Purpose: To evaluate the role of erythropoietin and vascular endothelial growth factor (VEGF) in a patient with retinal neovascularization from a rhegmatogenous retinal detachment of long duration.
Methods: Fundus photography, fluorescein angiography, and vitreous analysis were performed. The vitreous concentrations of erythropoietin and VEGF were measured by enzyme-linked immunosorbent assays and compared with control levels.
Results: An adolescent with a history of mild retinopathy of prematurity presented with a retinal detachment found by routine examination. The patient had a rhegmatogenous retinal detachment with signs of chronicity and extensive retinal neovascularization. The patient's erythropoietin level was higher than those of patients with proliferative diabetic retinopathy. The patient's VEGF level was not as high as those of patients with proliferative diabetic retinopathy but was elevated compared with those of patients without neovascularization.
Conclusion: Vitreous concentrations of erythropoietin and VEGF can be elevated in patients with neovascularization secondary to a rhegmatogenous retinal detachment of long duration.
Abstract: PURPOSE: To describe the efficacy of MP-1 in detecting early multiple sclerosis (MS) retinal lesions and in monitoring the effectiveness of treatment in terms of changes in macular sensitivity. METHODS: A 21-year-old woman with MS was referred to us complaining of recurrent episodes of eyesight loss in both eyes. At ophthalmologic examination, best-corrected visual acuity was 20/25 bilaterally; ophthalmoscopy showed bilateral slight optic neuritis without swelling of the disc. Static perimetry of central visual field (30 degrees, by Octopus 101, Haag-Streit AG, Switzerland) and retinal sensitivity of the 12 central degrees (by MP-1 Micro Perimeter, Nidek Inc., Italy) were performed on the patient at that time. The micro perimeter (MP-1) showed a loss of sensitivity in the macular region with 0.28+/-0.9 dB sensitivity in the right eye and 19.42+/1.5 dB in the left. The mean fixation stability was 91% considering 2 degrees and 99% considering 4 degrees around the fixation points in the right eye, and 97% in 2 degrees and 100% in 4 degrees central degrees in the left. In the weeks that followed vision continued to get worse in both eyes, so she underwent a steroid therapy with methylprednisolone IV 1000 mg/day for 5 days and 500 mg/day for 3 days. RESULTS: After 8 days of therapy the MP-1 showed a significant recovery in the right eye, with mean light sensitivity being 19.61+/-1.3 dB in the right eye and 20.0+/-0 dB in the left eye in both macular and peripapillary regions. The mean fixation stability was 100% considering 2 degrees and 100% considering 4 degrees around the fixation points in both eyes. CONCLUSIONS: The MP-1 can be an interesting tool for neuro-ophthalmologists as it allows a more precise evaluation of the macular and peripapillary region, which is not easily studied with conventional automated perimetry. In MS, the presence of a subclinical form of optic nerve involvement can be demonstrated in a very early stage, and well followed by the introduction of micro perimeter testing in the standard examination protocol.
Abstract: PURPOSE: To verify the potential efficacy of intravitreal bevacizumab (IVB) injections for the treatment of retinal angiomatous proliferation (RAP). DESIGN: Retrospective interventional case series. METHODS: Four consecutive patients affected by RAP at different stages and refractory to photodynamic therapy (PDT). All patients underwent a complete ophthalmic examination including best-corrected visual acuity (BCVA), fluorescein and indocyanine green angiographies, and optical coherence tomography (OCT) at baseline, and after one, three, six, nine, and 12 months. All patients received IVB injections (1.25 mg/0.05 ml). RESULTS: The best functional response has been achieved in patients with RAP at stages 1 and 2; whereas in stage 3, a detectable recovery of visual acuity was not observed. This improvement was stable over the follow-up period with a concomitant reduction of macular thickness. CONCLUSIONS: The use of IVB in patients affected by RAP seems to exert morphologic benefits at all RAP stages that does not always correspond a functional improvement.
Abstract: BACKGROUND: Neurofibromatosis type 2 (NF2) is a disorder usually diagnosed later in life since the features are subtle in children. The hallmark is bilateral vestibular schwannomas, which may not appear until after the second decade. Other cranial nerve schwannomas occur as well. In addition, there may be schwannomas of spinal nerve roots or peripheral nerves, as well as meningiomas, gliomas, and ependymomas. Here is described a rare case of NF2 associated with a superior rectus muscle paralysis and severe ptosis. A complex surgical procedure, which achieved satisfactory results, is also described. CASE REPORT: A 17-year-old patient with NF2 was referred to us with diagnosis of left-eye superior rectus muscle paralysis, with a later onset of unilateral severe ptosis. Best-corrected visual acuity was 20/20 in both eyes; pupillary reflexes to light and near vision were normal, and subcapsular posterior opacity of the lens was detected. Eye motility examination confirmed a left-eye superior rectus paralysis and a severe ptosis with almost absent palpebral levator muscle function. The patient showed positive familiar history for NF (the father was affected), bilateral involvement of the acoustic nerves (schwannoma), multiple neurofibromas, and bilateral posterior subcapsular lens opacity. Magnetic resonance imaging (MRI) showed bilateral acoustic neuromas in the left temporal region close to the cavernous sinus; since neurological examination and ocular motility problems had remained stationary over time, surgical correction of ptosis and strabismus was suggested. CONCLUSION: Palpebral ptosis has rarely been reported in NF2. In the case described, ptosis associated with rectus superior palsy was caused by expansive processes in the temporal region close to the cavernous sinus. In order to resolve ptosis and vertical diplopia, we performed a complex surgery that achieved satisfactory results.
Abstract: PURPOSE: To describe ischemic maculopathy as a cause of sudden bilateral decreased vision in a patient with human immunodeficiency virus (HIV) infection. METHODS: A 44-year-old HIV-positive woman presented with bilateral decreased vision and normal examination, except for pale maculae and retinal vascular tortuosity. Fluorescein angiography showed bilateral enlargement of the foveal avascular zone with perifoveal dye leakage. CONCLUSIONS: Ischemic maculopathy is a potential cause of decreased vision in patients with acquired immunodeficiency syndrome, even in patients with immune sustained recovery. This condition can be almost totally reversible, in the absence of other concomitant ocular pathologies.
