Juniper Publishers | Open Access Ophthalmology Journal

Ophthalmology is a progressive journal that presents the information concerned with the study and treatment of disorders and diseases of the eye. JOJO has worldwide distribution and supports medical professionals in the delivery of excellent ophthalmic information by publishing

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Visual Rehabilitation and Tolerability Using Hybrid Contact Lenses of Patients with Moderate to Severe Keratoconus-Juniper Publishers

DiscussionThe first treatment choice for a patient with keratoconus is using a RGP lens [3]. Therefore, most of these patients, visions not corrected by glasses or soft contact lenses, have already tried the RGP lenses. The potential challenges associated with fitting rigid lenses are suboptimal initial comfort on non adapted eyes, the potential for lens decentration and the risk of lens ejection. Soft contact lenses have more comfort but less visual correction especially in advanced disease. Aim of hybrid lens is to combine the preferred properties of rigid and soft contact lenses [4]. Hybrid lenses are combines of a center-zone rigid lens and a peripheral zone soft skirt. Clear Kone lens which is used this study requires the determination of two fitting parameters, vault for rigid component and skirt curvature for soft component [5]. Due to design of the hybrid lens, most of the refraction power is provided by the tear layer, which increases the optical quality and oxygen supply of the cornea. Additionally, a little space between cornea and hard part of the lens prevents mechanical abrasion of the cornea [4] (Figure 1).In our study, all patients have moderate to severe keratoconus and discomfort while using RGP lenses. Because of this condition, by other eye centers, corneal ring or keratoplasty were advised. Before the surgical treatment, we wanted to try another non- invasive management, hybrid lens fitting. Disadvantage of using hybrid lens, Clear Kone Synerg Eyes, is that this process is time consuming and requires more patience. Because of this, for appropriate final lens and shortening of process, we used the parameters of RGP lenses. This approach improved patients' compliances. Clear Kone lenses with hard central part and tears between lens and cornea improve vision. In our study, all patients had a good visual outcome. Soft peripheral part provides stability and comfort. Except one patient, 10 of 11 patients had a good comfort.According to findings of this study, using hybrid lens on the keratoconus patients can be good choise for the patients with moderate to severe disease with discomfort of soft or hard lenses before thinking surgical management.

Introduction

Keratoconus is non inflamatuary and progressive disease of the younger age group in which corneal thinning occurs and cornea assumes a conical shape associated with abnormal curvature. This changes often results in irregular astigmatism and myopia and leads to mild to marked visual impairment [1]. Corneal topography is a non-invasive technique to detect and monitor the progression of keratoconus. Contact lenses were used to improve visual conditions in keratoconus. Rigid gas permeable (RGP) lenses are most used type of contact lenses but in patient with severe disease RGP lens is insufficient for visual impairment and comfort [2]. Irregular astigmatism which developed after ectasia is not corrected with glasses and soft contact lenses. Mini-scleral, semi- scleral and scleral contact lenses are safe options in the management of irregular corneas. Because of heavy costs of scleral lenses, hybrid lenses with the comfort of the soft lenses and the optical quality of the hard lenses are developed [2]. This article reports the efficiency and accuracy of hybrid contact lens known as Clear Kone (Synerg Eyes Inc., Carlsbad, CA) in patients with moderate to severe keratoconus.

    Methods

This study was performed in Medical Park Hospital, Antalya, Turkey. The patients were requested to sign informed consent forms. Patients had been previously diagnosed with keratoconus by corneal topography (Pentacam HR, Oculus, Wetzlar, Germany) and bio microscopic findings of Fleisher ring and Vogt lines. Inclusion criteria were keratoconus patients with severe visual problems and indication of intra corneal ring or transplantation surgery by another eye center. Cross linking was performed for all patients before the study. All patients were not appropriate for rigid gas permeable (RGP) lenses. All eyes were fitted with Clear Kone hybrid keratoconus lenses. The fitting is based on the concept of sagittal depth called as vault in relation to the cornea. Skirt curvature was determined as steep, median or flat according to limbus. Proper fitting was observed with using sodium fluorescein. After fitting, control of lens movement, vision and corneal epitelium were performed, 3 hours later. Corneal topography findings, pachymetry and refraction and vision were determined every 6 months.

    Results

In this study, 19 eyes of 11 patients (6 men and 5 women) with a mean age of 26, 4 (16-43) were evaluated. Keratometry findings are between55-75 (Kmax). Before using contact lens, uncorrected and best corrected visual acuity with glasses were 0, 74±0, 3 LogMAR and 0, 58±0, 22 Log MAR respectively. Visual acuity with hybrid contact lenses was 0, 09±0, 05 LogMAR (Table 1). Mean follow-up was 7, 2 months (4-12 months). One patient didn't tolerate because of corneal edema. For more Open Access Journals in Juniper Publishers please click on: https://juniperpublishers.com

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An Interesting Case of Golden Hars Syndrome in 3 Years Male Child-Juniper Publishers

Introduction

Now we have defined d h syndrome as a complex of cong limmal dermoid with cong pre auricular skin tag aor appendage limbal dermoids sometimes are bilateral rarely. Usually they are unilateral involving whole of cornea or may be cofined to conjunctiva only incidence of l dermoids are 1 in 10000 or 500 in 2700 they are graded according to involvement of cornea grade 1. when only corneal epithelium is involved 2 grade 2 des membrane 3 grade 3 whole of ant segment of eye is involved inferno temporal involvement of limbal dermoid is the commonest about 70 percent.

    Case Report

6 months back a 3 years male child was seen by me in my office with parents having noticed a small palish. White infero temporal limbal region left eye with cong presence of pre auricular skin appendage ft delivered child after lsc s no other cong anamolies seen vision mydriatic refraction ant segment and fundi were normal child had grade 1 limbal dermoid with the commonest site being infer temporal.

    Results and Discussion

Golden hars is not a vision threatening disease most of these pts have normal intelligence and vision only in cases where visual axis is involved the we think of surgery conclusion my case was a simple case of gowhar ahmad grade 1 limbal dermoid so it only need observation in cases where visual axis is involved and vision is threatened then the surgical modalities are

1. Visual

2. Cosmotic

We do

1. Lamellar keratoplaty

2. Amionotic membrane graft

3. Stem cell graft

Their families of golden hars syndrome in Greece 2 in middle east in gulf war children born in different military hospital had golden hars syndrome 3 sometimes optic nerve drusen is associated with g h syndrome.

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Visual Rehabilitation and Tolerability Using Hybrid Contact Lenses of Patients with Moderate to Severe Keratoconus-juniper Publishers Introduction Keratoconus is non inflamatuary and progressive disease of the younger age group in which corneal thinning occurs and cornea assumes a conical shape associated with abnormal curvature. This changes often results in irregular astigmatism and myopia and leads to mild to marked visual impairment [1]. Corneal topography is a non-invasive technique to detect and monitor the progression of keratoconus. Contact lenses were used to improve visual conditions in keratoconus. Rigid gas permeable (RGP) lenses are most used type of contact lenses but in patient with severe disease RGP lens is insufficient for visual impairment and comfort [2]. Irregular astigmatism which developed after ectasia is not corrected with glasses and soft contact lenses. Mini-scleral, semi- scleral and scleral contact lenses are safe options in the management of irregular corneas. Because of heavy costs of scleral lenses, hybrid lenses with the comfort of the soft lenses and the optical quality of the hard lenses are developed [2]. This article reports the efficiency and accuracy of hybrid contact lens known as Clear Kone (Synerg Eyes Inc., Carlsbad, CA) in patients with moderate to severe keratoconus. Methods This study was performed in Medical Park Hospital, Antalya, Turkey. The patients were requested to sign informed consent forms. Patients had been previously diagnosed with keratoconus by corneal topography (Pentacam HR, Oculus, Wetzlar, Germany) and bio microscopic findings of Fleisher ring and Vogt lines. Inclusion criteria were keratoconus patients with severe visual problems and indication of intra corneal ring or transplantation surgery by another eye center. Cross linking was performed for all patients before the study. All patients were not appropriate for rigid gas permeable (RGP) lenses. All eyes were fitted with Clear Kone hybrid keratoconus lenses. The fitting is based on the concept of sagittal depth called as vault in relation to the cornea. Skirt curvature was determined as steep, median or flat according to limbus. Proper fitting was observed with using sodium fluorescein. After fitting, control of lens movement, vision and corneal epitelium were performed, 3 hours later. Corneal topography findings, pachymetry and refraction and vision were determined every 6 months. Results In this study, 19 eyes of 11 patients (6 men and 5 women) with a mean age of 26, 4 (16-43) were evaluated. Keratometry findings are between55-75 (Kmax). Before using contact lens, uncorrected and best corrected visual acuity with glasses were 0, 74±0, 3 LogMAR and 0, 58±0, 22 Log MAR respectively. Visual acuity with hybrid contact lenses was 0, 09±0, 05 LogMAR (Table 1). Mean follow-up was 7, 2 months (4-12 months). One patient didn't tolerate because of corneal edema. Discussion The first treatment choice for a patient with keratoconus is using a RGP lens [3]. Therefore, most of these patients, visions not corrected by glasses or soft contact lenses, have already tried the RGP lenses. The potential challenges associated with fitting rigid lenses are suboptimal initial comfort on non adapted eyes, the potential for lens decentration and the risk of lens ejection. Soft contact lenses have more comfort but less visual correction especially in advanced disease. Aim of hybrid lens is to combine the preferred properties of rigid and soft contact lenses [4]. Hybrid lenses are combines of a center-zone rigid lens and a peripheral zone soft skirt. Clear Kone lens which is used this study requires the determination of two fitting parameters, vault for rigid component and skirt curvature for soft component [5]. Due to design of the hybrid lens, most of the refraction power is provided by the tear layer, which increases the optical quality and oxygen supply of the cornea. Additionally, a little space between cornea and hard part of the lens prevents mechanical abrasion of the cornea [4] (Figure 1). In our study, all patients have moderate to severe keratoconus and discomfort while using RGP lenses. Because of this condition, by other eye centers, corneal ring or keratoplasty were advised. Before the surgical treatment, we wanted to try another non- invasive management, hybrid lens fitting. Disadvantage of using hybrid lens, Clear Kone Synerg Eyes, is that this process is time consuming and requires more patience. Because of this, for appropriate final lens and shortening of process, we used the parameters of RGP lenses. This approach improved patients' compliances. Clear Kone lenses with hard central part and tears between lens and cornea improve vision. In our study, all patients had a good visual outcome. Soft peripheral part provides stability and comfort. Except one patient, 10 of 11 patients had a good comfort. According to findings of this study, using hybrid lens on the keratoconus patients can be good choise for the patients with moderate to severe disease with discomfort of soft or hard lenses before thinking surgical management.

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Why Should SLT be the First-Choice Treatment for Glaucoma?-Juniper Publishers

Introduction

  Glaucoma is a chronic, degenerative optic neuropathy which is characterized by changes in the optic disc and visual field loss. Intraocular pressure is considered the major risk factor for the progression of glaucomatous optic neuropathy involving the death of retinal ganglion cells and their axons. Selective Laser Trabeculoplasty (SLT) uses a 532nm frequency-doubled, q-switched neodymium, yttrium-aluminum-garnet laser that delivers a low-energy, large spot, it was designed to selectively target pigmented trabecular meshwork (TM) cells while sparing adjacent cells and tissues from thermal damage.

    Discussion

  Glaucoma is the second leading cause of blindness worldwide. Glaucoma affects more than 70 million people worldwide with approximately 10% being bilaterally blind, making it the leading cause of irreversible blindness in the world [1]. Meta-analysis of many studies showed that there was no statistically significant difference in IOP-reduction or treatment success between SLT and medical treatment [2].

  As a first-line therapy for glaucoma, medications have many disadvantages and drawbacks. Patients have to accept their adverse effects, repeated application of medications and continuous medical costs. The potency of treatments may be undercut when people are non-compliant. The introduction to SLT, which uses a less severe energy to generate IOP-lowering effect without dangerous adverse reactions, has again brought up the question: can laser device treatments defeat eye drops as the main therapy for Glaucoma especially OAG? In the initial released research, SLT was used as the adjunct treatment to medication. Later several researches had recommended that SLT might be the main treatment for POAG or OHT [3]. Melamed et al. [4] found 40 in 45 eyes (89%) which experienced SLT as the main treatment had an IOP loss of 5mmHg or more. Mean IOP- reduction was 7.7±3.5mmHg (30%) at 18 months post-SLT. A potential, multicenter study by McIlraith et al. [5] involved 100 eyes (61 patients) with recently clinically diagnosed POAG or OHT. IOP reduction was 8.3mmHg (31.0%) in the SLT team (74 eyes) in contrast to 7.7mmHg (30.6%) in the latanoprost team (26 eyes) (P=0.208 and P=0.879). The amount of IOP reduction was mathematically considerably less in the latanoprost team than in the SLT team [5].

  Selective laser trabeculoplasty (SLT) has been proven secure, well recognized, low-cost and very efficient at reducing intraocular pressure (IOP) as primary treatment in several types of glaucomas. The maintenance of trabecular meshwork (TM) structure and the confirmed effectiveness in decreasing IOP tend to make SLT a very affordable and secure alternative to argon laser trabeculoplasty (ALT). SLT may also be effective for situations of unsuccessful ALT and is a technique that may also be repeatable, compared with ALT. SLT is also a simple procedure for an ophthalmologist to learn and proceed. SLT has been confirmed to be efficient as main therapy and can be an effective adjunct therapy with medications for early stages of glaucoma. Furthermore, SLT can be regarded as a primary treatment choice for patients who cannot accept or who are noncompliant with their glaucoma medications, without disrupting the success of the forthcoming surgery [6].

    Conclusion

  SLT is easy to perform and well tolerated by patients and provides the benefits of ALT while using much less energy with less obvious harm to the TM. It seems to have comparative effectiveness to eye drops and to be a safe and effective glaucoma treatment without conformity threats or wide spread adverse reactions. Therefore, SLT is now considered the first line therapy for various types of glaucoma and can be an effective adjunct in the early types of glaucoma.

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Rare and Interesting Case of Eye Choriodal Melanoma Presenting as a Congestive Glaucoma in a 55 Years Male Patient-Juniper Publishers

Abstract

55 years male patient presented as a case of a glaucoma in 2011 at ER ophthalmological dept of medical hospital Srinagar Kashmir, he presented with severe pain marked redness of left eye and marked loss of vision on exam he had sever ciliary congestin corneal odema very shallow a chamber and dilated pupil no clear view of fundus and IOP of more than 550mm Hg. He was put on emergency medication of a c glaucoma in form of topical LUPITISS eye drops one drop l eye od 2 britiblu eye drops i drop L eye bd 3 osmotic diuretic 20 percent mannitol 250cc IV 4 500mf of injection diamox I we even with this medication pt dod not respond even after more than 12 hours of this medication he was advised admission which he refused however no a aor B-scan ultrasound was done pt after couple of days sought second ophthalmic consultation this time the con ophthalmologist performed B-scan ultrasound and picked up a solid retinal detachment of l eye to confirm melanoma.ch he was referred for MRI scan of orbits and brain unfortunately for patient and treating ophthalmologist the report of scan was very unsatisfactory the radiologist gave a very unsatisfactory report that pt has pan ophthalmitis l eye however ophthalmologist requested him that this is a case of CD melonoma [1], and it has to be confirmed by MRI in this process p both pt and got confused and patient left the treatment he was unfortunately going from one oph to other as a painful blind eye for two years key words melanoma.ch is the commonest tumor it can be benign or malignant LUPITISS t is prostaglandin analogue and t stands for temilola beta blocker beta blocker 3 britiblu is brimolol 3 mannitol is osmotic duretic 4 diamox is carbonic anhydrase inhibitor od means one dop once a day 5bd is one drop twice a day glaucoma is a v=condition where i o gets raised in eye pathogenesis of IOP aqueous is produced by ciliary process of ciary epethelium im post chamber where [2], the aqueous nourishes lens then through pupil it comes in ant chamber and aqua nourishes cornea and then it is dained though angle of filtration through canal of schlem and finally aqueous comes in aqua veins so any condition which causes obstruction in drainage of aqueous will result in rise of IOP which is called glaucoma classification of glaucoma cong glaucoma occurs during intra uterine life 2 infantile glaucoma if from birth to 3 years 3 juvenile off 3 years to 17 years 2 primary glaucoma open and closed angle 3 sec glaucoma which occurs sec to any intraocular disease 4 ocular hypertension sec to systematic tension dx of cong glaucoma also called buphthalmos big eye ball a large cornea we do under anesthesia in these neonates and measure [3], IOP and measure corneal diameter treatment modalities which r surgical have been

I. Goniotomy

II. Goniopexy

III.Trabeculotomy

IV.Sinostomy

    Case Report

In open angle glaucoma there is no pain moderate rise of IOP causes headache there are 3 features

a. Fundus changes

b. Changes in visual fields

Fundus causing glaucomatous cupping and even optic atrophy most the times pts of open angle glaucoma are diagnosed late due to lack of pain and pt may come when pt already [4], had glaucomatous cupping and optic atrophy that's why we are doing glaucoma screening after 40 years of age where we do routine measuring of IOP refraction and fundus examination in this screening we are able t pick up cases of open angle glaucoma treatment is medical and surgical first [5], we put it on medical therapy and if it doesn't not respond to it or it not coming for regular ophthalmic evaluation or pt belongs to fat of place lack of ophthalmic advice one should do surgery the surgical modalities are 1 trabeculectomy advantages of this procedure

1. It is cosmetically better

2. It can be repeated

3. It is a physiologically better operation

4. It communicates the ant c with canal of schlem by splitting the trabecular mesh work

Nowadays, we have better options of lased and operation of laser choice is an argon laser trabeculoplasty closed angle glaucoma comes very early due [6], to severe pain redness and marked loss of vision in most of the these case they respond to anti glaucoma medication after the eye settled down we do laser iridotomy even in normal eye of these pts we do polylectic laser iridotomy then we have ocular hypertension due to systemic hypertension key is control of b p ten we have a miscellaneous group of glaucoma 1 neo vascularisation glaucoma due to c are c occlusion it is said to subside in 3 months last l by least we have absolute glaucoma pt has painful blind eye treatment modalities.

a) Cyclodiathermy

b) Cyclo croprexy

Sometimes due to severe pain we may inject retrobulbar injection of xylocaine or alcohal to revealve pain sometimes one may have to enuck leation if all measures fail introduction ch melanoma is the most common primary malignan intraocular tumor and the second most common type of primary malignant melanoma in the body it most often whites of northern European descent essential update early treatment may prevent metastatic deaths in patients with melanoma.ch in a prospective cohort study of 3072 patients with melanoma. ch researchers we found for some pts early treatment rather than watching and waiting might better prevent metastatic deaths signs and symptoms melanoma.ch remain asymptomatic for prolonged period of time may be found incidentally during ophthalmoscope in general the more the their origin the longer the delay of any symptoms melanoma.ch present with following symptoms:

a. Blured vision

b. Paracentral scotoma

c. Progressive and painless visual loss

d. Floaters

e. Sever ocular pain

f. Weight loss marked fatigue cough or change in bowel or bladder suggests primary non ocular malignancy with melanoma.

ophthalmological examination may reveal following

A. Small melanoma.ch typically takes the form of a nodular dome shaped and well circumscribed mass under the retinal pigment epethelium

B. Melanoma.ch grow they adopt more irregular configurations

C. Diffuse melanoma.ch characterized by growth throughout the choroid with minimal elevation are more difficult to diagnose and often cause significant exudative redetachment

D. Melanoma.ch may have variable coloration some are more pigmented and others are less

E. If tumor is light colored its abnormal vascularisation usually can be seen ohthalmoscopicaly

F. Overlying melanoma. ch

There are usualy tet pig epethelial changes eg drusen dx 1 liver enzyme are indicated in any pt with uveal melanoma is the most common site of melanoma.ch metastases so one has to do

a. Alkaline phosphates

b. Glutamic oxaloacetic trans aminase

c. Lactase dehyrogenase

Gamma glutamyl transpeptidase a scan and B-scan ultrasound MRI scan ct scan f f angoigraphy can help point toits dx 2 small ch melanomas may show floresene angigrahkic changes similar to choriodal nevi 3 large melanomas may show patchy pattern of early hypoflourence and hyper flourescence followed by late intense staining simultaneous flourescence of retinal [7-8], and ch circulation within is fiarly distintive of melanomas.ch management

I. Observation may be acceptable for post uveal tumors not well established in particular tumors of less than

II. To 2.5mm and 10mm in diameter can be observer until growth is documented

III. Plaque brachy therapy is a widely accepted alternative to enucleation medium sised post uveal melanomas less than 10mm

IV. External beam irradiation with protons and helium ions

V. Pp vasectomy

VI. Block excision

VII. Laser photocoagulation

VIII. Orbital exenteration in extreme cases.

    Introduction

The above mentioned pt b was seen by me in 2013 his all investigations l f t c bc k f t lipid profile f b s were within normal limits ultrasound abdomen normal no evidence of any metastases i requested for MRI scan of orbits and brain it was very satisfactory showing that optic nerve optic tract Chiasm a basal ganglia pit gland thalmoid brain ventricles and cerebral hemispheres all were normal discussion we have aired mentioned that scleral cavity can be

1. Antto lens so it will cause visual impairment

2. Involve vitrous causind floaters

3. Involve angle of filtration and present and a c glaucoma as was seen in our case.

    Discussion

So after all above mentioned investigations under gowhar ahamed I removed whole cornea lens vitrous choriod and retina [9-11], so we were left with intact intra scleral cavity optic nerve and all ocular muscles i stitched ant and pst lips of sclera with 6 zero vicryl kept a drain in intra scleral cavity which was removed after 24 hours later i put a confirmer to give shape to orbit for 15 days after removal of confirmer i fitted a well matching and fitting prosthesis the removed tissues were sent for histopathological examination did not show any evidence of malignancy 3 years [12-15], have passed all repeat tests od blood ultra sonography b abdomen are normal.

    Conclusion

So any pt f ac c glaucoma if does not respond to treatment please do a or b scan ultrasound to pick up solid ret det and rule out m melanoma.ch by MRI review of literature 1 vertex varies can present as Uveal melanoma however it is a benign condition and temporary 2 in dept of ophthalmology manchester a pt came with a c glaucoma vision in normal eye unaided was 6,18 have did not respond to treatment MRI showed melanoma.ch so Enucleation was done 2 in Saudi medical lornal and cairio institute of ophthalmology and nophthalmology one pt came with BSEC glaucoma with imp of 56mmhg pt did not respond to treatment MRI was done it revealed melanoma.ch so Enucleation was done.

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Happy ThanksGiving Day

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Endophthalmitis after Lower Lid Blepharoplasty; A Rare Complication-Juniper Publishers

Case Presentation

A 22-year- old man referred to the emergency ward because of vision loss in his right eye five days after bilateral lower lid blepharoplasty, his right eye showed ciliary injection, cornea showed mild edema and anterior chamber showed 4+cells and faint hypopyon in slit lamp examination, There was severe chemosis, without any site of laceration. However, fundus examination showed severe fibrinous reaction and vitritis. (Figures 1-5 are related to the post-operative status.)

Discussion

Based on the diagnosis of undetermined uveitis the patient underwent diagnostic vitrectomy, interestingly there was a site of laceration in the posterior fundus, leading to peritomy and its repair associated with severe vitreous inflammation and retinal necrosis and vasculitis. The patient underwent pars plana vitrectomy associated with intra vitreal antibiotic injection and silicone oil injection; the culture of the vitreous documented staphylococcus aurous in the vitreous sample. This rare complication has been rarely described in the literature [1,2].

    Conclusion

Although rare, doing blepharoplasty a common cosmetic in inexperienced hand could lead to a severe devastating intra ocular complication.” For more Open Access Journals in Juniper Publishers please click on: https://juniperpublishers.comFor more articles in  JOJ Ophthalmology (JOJO) please click on: https://juniperpublishers.com/jojo/index.phpFor more about juniper publishers  please click on: https://www.juniperpublishersgroup.com/

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Pediatric Cavernous Sinus Syndrome as the Initial Presentation of Intracranial Germinoma: A Case Report-Juniper Publishers

Abstract

8-year girl complained of diplopia and her right eye presented ptosis, supraduction, abduction deficit, slight esotropia, and corneal hypoesthesia. Visual acuity was 20/20 in both eyes. Pupillary light reflex showed full, fast constriction and afferent pupillary defect was negative. No optic disc abnormalities were observed and indicated cavernous sinus syndrome. A brain magnetic resonance imaging indicated a tumor lesion from the sellaturcica to the suprasellar region and advancing into the right cavernous sinus, compressing the optic chiasm. Tumor biopsy was performed. Histo pathological examination led to a diagnosis of intracranial germinoma. Intracranial germinoma manifest hypopituitarism and bitemporal hemianopsia but in this case, intracranial germinoma manifesting as cavernous sinus syndrome initially. Cavernous sinus syndrome represents highly in adults and pediatric cases are rare. Malignant lymphoma and Trosa-Hunt syndrome were occasionally reported as diseases causing cavernous sinus syndrome in children. But, to our knowledge, there were a few reports of intracranial germinoma. Although it is very rare, germinoma should be kept in mind as a disease which causes cavernous sinus syndrome in children.

    Introduction

8-year-old girl complained of diplopia from April 2006, and started tilting her head to see things. Intermittent ptosis of the right eye appeared in May. Because right eye movement disorder was noted, she initially visited our department on October. The visual acuity was 20/20 in both eyes, the light reaction was complete and rapid, and relative afferent pupillary defect (RAPD) was negative. Ptosis of the right eye was noted. The pupil diameters were 4.6 and 3.7mm on the right and left sides in a bright room, respectively, and 4.6 and 5.7mm in a dark room, respectively, showing laterality. The pupil diameter after a cocaine eye drop test were 4.5 and 5.7mm in a bright room, respectively, being judged as positive for the test. Regarding eye movement, impairment of abduction and supraduction, mild impairment of adduction, and infraduction disorder of the right eye were observed, and corneal sensory reflex of the right eye was reduced. No abnormality was noted in the anterior segment of the eye, optic media, or fundus.Bitempolal hemianopia in visual field was observed (Figure 1). On brain magnetic resonance imaging (MRI) performed (Figure 2), a mass lesion advancing from inside the sellaturcica to the supra sellar region and right cavernous sinus was observed. Contrast enhancement of the tumor continuous from the right cavernous sinus was observed, and it advanced along the oculomotor and abducens nerves, the serum human chorionic gonad otropin-β (hCG-β) level was high suggesting germ cell tumor. Regarding the systemic condition, panhypopituitarism was present, and hormone replacement therapy was initiated. Tumor biopsy was scheduled but it was postponed by her family. The visual acuity of the left eye decreased to 20/50 in February 2007, and impairment of supraduction of the right eye aggravated. On MRI performed in the same period (Figure 3), compression of the chiasma became stronger in the suprasellar region. On the right side, the tumor advanced along the orbital apex and trigeminal nerve. Tumor biopsy by craniotomy was performed on March 6, 2007. Solitary appearance of large cells containing bright and wide cytoplasm was observed on histopathological examination (Figure 4), and cells were positive for placental alkaline phosphatase (PLAP) and c-kit on immunostaining. Based on these findings, the tumor was diagnosed as intracranial germinoma. Radiotherapy and chemotherapy were immediately performed, and the tumor shrank. On follow-up in July, the visual acuity became 20/20 in both eyes, and the tumor has not recurred for 8 years. DiscussionIn the present patient, diplopia and ptosis were the initial symptoms and the features of cavernous sinus syndrome complicated by Horner's syndrome were observed. These clinical findings were consistent with the mass lesion advancing from inside the sellaturcica to the suprasellar region and right cavernous sinus observed on MRI. To our knowledge, only 3 cases [1-3], of intracranial germinoma causing cavernous sinus syndrome as the initial symptoms. In these 3 cases, the tumor was heterogeneously enhanced with gadolinium on MRI and Serum or cerebrospinal fluid hCG-β was positive.One case is children [1]. 11-year-old girl presented of left 6th cranial nerve Palsty without visual field defect. Her head MRI showed a mass mainly located in the left cavernous sinus. First biopsy want clearly histlogycal evidence of tumor cells. Intracranial germinoma was diagnosed by second biopsy five month later. Retrospective analysis of the first specimen revealed a few cells positive for c-kit immune histo chemical stain. Thus c-kit is useful for the differential diagnosis and might have resulted in early diagnosis at the first exploration. Present case test of c-kit, hCG-β and PLAP were positive in serum or cerebro spinal fluid, so we could suspect for intracranial germinoma.Intracranial germinoma accounts for 15% of pediatric tumor cases and it is higher in Japan than in the other western countries (3-4%) [4]. It arises in the pineal body and suprasellar regions and induces various symptoms. Clinical manifectation are hypopituitarism and bitemporal hemianopsia. In this case, intracranial germinomam anifesting as cavernous sinus syndrome initially. Most cases occuring cavernous sinus syndrome develop in adults and pediatric cases are rare. Malignant lymphoma [5,6] and Trosa-Hunt syndrome [7-9] were occasionally reported as diseases causing cavernous sinus syndrome in children. Although it is very rare, intracranial germinoma should be kept in mind as a disease which causes cavernous sinus syndrome in children.

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Juniper Publishers- JOJ Ophthalmology Nasolacrimal Duct Obstruction Review-JOJ Ophthalmology

Introduction

The lacrimal system comprises two components the main and accessory lacrimal glands and their secretions and the lacrimal excretory system [1]. The lacrimal excretory system is divided into the proximal and distal sections. The proximal section includes the punctum, canaliculus, and the common canaliculus [2,3]. The distal lacrimal drainage system consists of the lacrimal sac and the nasolacrimal duct that finally ends under the inferior turbinate and empties into the inferior meatus [2].

The precorneal tear film is composed of aqueous, mucinous and oily components and is necessary for the maintenance of the cornea as well as the maintenance of the ocular surface epithelium. More than 90% of the lacrimal fluid is removed by the excretory system, whereas less than 10% evaporates between blinks. Outflow is mainly regulated by the pumping effect of the orbicularis oculi muscle (Horner muscle) [3,4]. Tears are thus drawn into the lacrimal excretory system after each blink. The passage of tears down the nasolacrimal duct is influenced by gravity, evaporation in the nose, and inspiration and expiration.

    Diagnosis

A detailed history of any systemic or topical medication, surgery, trauma or scarring, and infection must be obtained. It is valuable to grade the severity of epiphora using a uniform grading system such as the Munk scale [5]. Slit lamp examination starts with recognizing the papilla, presence of a membrane or fibrosis over the punctum, punctum size, tear meniscus height, eyelid margin, conjunctiva around the punctum, eyelid malposition, position of the punctum in the tear lake, and any sign of previous surgery. The Schirmer test [6], tear break up time [7], ocular surface staining, and tear meniscus height will rule out any associated ocular surface abnormalities. Abnormal dye disappearance test is a very maneuver to assess abnormal tear drainage system and is especially helpful in pediatric patients [7].

    Congenital Nasolacrimal Duct Obstruction

Congenital nasolacrimal duct obstruction is the first cause of pediatric epiphora. Other causes include congenital punctum and canaliculus stenosis and/or atresia, nasal malformations and craneofacial abnormalities. It is frequently seen at birth due to lack of perforation of the valve of Hasner or an inferior and distal nasolacrimal duct opening failure. At birth, half of the nasolacrimal new born pathways are not permeable. A spontaneous apoptosis mechanism takes place between 3rd- 4th weeks after birth. Nevertheless, the obstruction persists in approximately 20% of the patients. Symptoms of congenital nasolacrimal duct obstruction consist of epiphora and dacryocystitis. The diagnosis is easily made in the office by observing epiphora and mattering of the eyelashes (Figure 1). It can be confirmed by compression over the nasolacrimal sac, which results in regurgitation of mucopurulent material in those patients who have developed chronic dacryocystitis. Instillation of 2% fluorescein dye and observation of abnormally delayed passage from de cul-de-sac is helpful in confirming the diagnosis.This is a rare entity presented at birth or within the fourth week after birth. The blockage Rosenmüller valve. An edematous, tender and red mass below the medial canthal tendon will be clinically found (Figure 2). Conservative management (medical treatment). If dacryocele is initially sterile, all patients must be treated with warm compresses, local massage and topical antibiotics [8]. Those infected will be treated with broad spectrum intravenous antibiotic therapy [9]. Local massage by pushing down the lacrimal sac is useful and accelerates the lumen duct perforation process (Figure 3). Controversy exists whether conservative management or early probing for decompression are preferable.     Surgical Management of Congenital Nasolacrimal ObstructionProbing consist by introducing a thin metal probe into the lacrimal punctum trough the nasolacrimal pathway, producing a mechanical opening in the obstruction site. It is an operating room procedure under general anesthesia. The ideal time is controversial, most of the time the procedure is performed around the first year of life for those patients that did not show spontaneous improvement or despite conservative treatment [10].Close dacryointubation is performed by placement of silicone stents through the superior and inferior canaliculus and down to the nasolacrimal duct. This dilates the inferior meatus. The duration of the stent employment ranges from 6 weeks to 6 months [10]. Dacryocystorhinostomy surgical procedure involves the removal of bone adjacent to the lacrimal sac draining directly into the nasal cavity and it is performed when siliconte intubation have failed.     Differential DiagnosisDermoid cyst, dongenital glaucoma, acute conjunctivitis, corneal abrasion, trichiasis, ocular foreign body sensation and meningoencephalocele must be discarded.     Acquired Nasolacrimal Duct ObstructionThe primary acquired nasolacrimal duct obstruction is caused by inflammation or fibrosis without any precipitating cause. Appears in middle age and elderly females in 3:1 ratio. The obstruction site is located in the lower nasolacrimal fossa and middle nasolacrimal duct. The secondary acquired obstruction is caused by inflammation or fibrosis with precipitating causes as infectious, inflammatory, neoplastic, traumatic or mechanical factors [11,12].Clinical presentation Patients with primary acquired nasolacrimal duct obstruction most commonly present with a history of epiphora. A chronic dacryocystitis owing to tear stasis can show a mucopurulent discharge at the punctum, or pus can be expressed from the punctum by massage of the lacrimal sac. Two stages can be distinguished [13].     Acute DacryocystitisIs an acute inflammation of the lacrimal sac due mostly to the obstruction of nasolacrimal duct. In most cases is a clinical diagnosis. Lacrimal sac bacterial overgrowth and inflammation? occludes the superior and the natural drainage creating a true abscess. Symptoms and signs include a no compressible painful and erythematous mass below the medial canthal tendon. Medical treatment must be initiated because of the risk of extension to the periocular tissues and the orbit (Figure 4 ) including topical and systemic antibiotics, analgesics and antiinflammatory measures. Local heat and massages helps drainage and the opening of the obstruction site.

Lacrimal sac abscess requires sometimes manual percutaneous drainage, material can be collected and cultivated (Figure 5). Avoid irrigation during the acute phase because the risk of dissemination of the infectious process. Definitive treatment is a dacryocystorhinostomy procedure which can be performed as an external or internal endoscopic. It is preferable to postpone two or three weeks after the acute phase resolution.

    Chronic Dacryocystitis

Symptoms and signs include recurrent epiphora, swelling and redness at medial canthus and a painless and compressible mass below the medial canthal tendon. The patient usually refers history of previous acute dacryocistitis or chronic unilateral conjunctivitis.

The lacrimal sac is filled with mucoid or purulent discharge that can be expressed frequently with local massage (Figure 6). Medical treatment includes topic and systemic antibiotics and a dacryocystorhinostomy as the surgical first choice. Differential Diagnosis: Preseptal cell ulitis, sinusitis, canaliculitis, sebaceous cyst and neoplastic tumours. Conclusion For most tearing patients a diagnosis can be arrived at after a thorough history and a few relatively simple office procedures. A small number of cases will require more sophisticated studies to confirm the site of anatomic block. With the various test available, appropriate medical or surgical management can be determined in the vast majority of patient with tear production and drainage imbalance. Nasolacrimal duct obstruction is a common finding and the ophthalmologist must be prepared to recognize signs and symptoms to perform an accurate diagnosis and offer a correct management.

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Juniper Publishers- JOJ Ophthalmology

Translational Research on BDNF may Lead to New Research Therapy in Glaucoma- JOJ Ophthalmology IntroductionGlaucoma is a group of eye disorders, currently recognized to be multi factorial, progressive, leading to reduction in vision and eventual blindness. Glaucoma is characterized by progressive degeneration of the retinal ganglion cells (RGCs) and optic nerve (ON) fibers it is one of the leading causes of vision loss. Usually glaucoma affects the older population. Over 60 million people worldwide were estimated to be affected by glaucoma in 2010, and bilateral blindness from the disease was estimated to be present in 4.5 million people with glaucoma [1] . A generally accepted theory suggests an initial insult to the axons of RGCs in the ON head region, where they exit the eye [2] . Glaucoma is characterized by anomalies such as the RGC degeneration and cell death, loss of RGC axons as well as ON atrophy, impairment of visual function with visual field defects and finally loss of neurons in the lateral geniculate nucleus and visual cortex. Several types of glaucoma are known; these can be divided in primary and secondary. Primary open-glaucoma (POAG) is considered the most common subtype of glaucoma. In POAG, ocular hypertension represents the major risk factor for glaucoma onset and progression. Ocular hypertension is a condition in which intraocular pressure (IOP) is consistently greater than normal. In the presence of ocular hypertension, there is no obvious damage to the ON as detected by an eye examination, ON imaging, or evidence of visual field changes. However, retinal responses to patterned visual stimuli (pattern electro retinogram, P-ERG) together with a transcription factor (Brn3) expressed in RGCs are altered during ocular hypertension in a murine model of glaucoma [3]. It is reasonable to think that ocular hypertension applies some stress to RGCs and their circuitry during a phase preceding the degeneration of RGCs and ON atrophy. In addition, it has been reported that the rate of untreated ocular hypertension patients in developing glaucoma was 9.5 percent in 5 years and 22 percent at 13 years [4]. There are limitations to treating IOP exclusively, including: Several glaucoma patients do not show an elevated pressure (normotensive glaucoma). There are patients who continue to progress with controlled low IOP. Indeed, IOP lowering by means of anti-glaucoma drugs, laser or incisional surgery is unable to arrest the progression of glaucoma till blindness.These observations suggest that IOP-independent mechanisms contribute to disease progression, and require a new therapeutic approach independent of IOP lowering to prevent vision impairment, RGC death and ON degeneration. Neuro protection by neurotrophic factors was initially investigated for neurodegenerative diseases such as the Alzheimer's disease; evidence suggests that treatments with neurotrophic factors such as the brain-derived neurotrophic factor (BDNF), ciliary neurotrophic factor (CNTF), glial cell line-derived neurotrophic factor (GDNF), neurotrophin-4 (NT-4) increase the survival of neurons in rodent models of injury and disease [5]. BDNF appears to provide the highest level of protection by supporting both protective and regenerative functions. The notion of a neuro protective role for BDNF in retinal degenerations derives from the observation that death of photoreceptors is prevented by intravitreal BDNF administration [6]. BDNF has been shown to protect retinal cells, in particular RGCs, in various models of ON injury and disease [7,8], interestingly, BDNF is effective in a rat glaucoma model as shown by Martin and coworkers [9] using AAV-BDNF transfection. BDNF is a high molecular weight protein locally produced by cells in the ganglion cell and inner nuclear layers [10], its TrkB receptor is expressed in RGCs, amacrine and Müller cells [10,11] that represent the cellular target of BDNF trophic action. RGC take up BDNF and transports it along axons towards target neurons and back to the cell body in the retina [12], BDNF is one of the molecules delivered to the retina by way of retrograde axonal transport [13]. These studies suggest a role for BDNF in retinal injury and diseases. A strong rational supports BDNF treatment in glaucoma. Previous work showed that BDNF delivery to the retina is reduced in glaucoma models [13,14] and BDNF level is reduced in ocular tears [15] and blood [16]. BDNF, but not its receptor TrkB, is reduced in murine models of glaucoma [17,18]. Altogether, these studies suggest that BDNF is expressed in the retina, to help protect neurons maintaining their survival and connections when damaged by injury and diseases. Thus, neuro protection by BDNF in glaucoma can be pursued to protect RGCs. However, the therapeutic approach based on BDNF is promising if the restrictions imposed by complex pharmacokinetic of high molecular weight proteins (for example BDNF low propensity to pass blood- brain barrier following systemic treatment) can be overcome. So far BDNF, as well as other growth factors, has been typically administered to the internal ocular tissues by intravitreous or retrobulbar injection, these methods of treatment are associated with the risk of various complications such as the ocular bulb perforation and infections [19]. Given that glaucoma is a chronic condition, developing over several years, the prospect of chronic, intravitreous administration of BDNF is not realistic. To overcome these obstacles we recently settled a simple method of treatment with BDNF in the form of collyrium. We showed that treatment for a short period with BDNF eye drops was able to increase the retinal level of BDNF in the mouse and rat retina [3]. Remarkably, BDNF topical eye treatment was able to rescue retinal responses to visual stimuli in a murine model of glaucoma during an early phase of degeneration characterized by ocular hypertension, visual impairment and RGC alterations [3] . Thus, the specific anatomical construction of the eye and, possibly, the presence of BDNF carriers offer the possibility for local drug delivery that can avoid the barriers. However, in view of therapeutic approach based on BDNF in glaucoma there are fundamental questions to be answered.The first question is whether neuro protection by BDNF in glaucoma depends on the stage of retinal degeneration. In our previous work we showed that a short period of treatment with BDNF eye drops was able to restore vision and protect RGCs during an early phase of retinal degeneration in a murine model of glaucoma [3]. However, whether BDNF protects retinal cells at advanced stages of neuro degeneration in glaucoma is still an open question. The second question concerns the durability of BDNF neuro protective effect. Indeed, for glaucoma like other progressive neurodegenerative diseases, it is challenging to identify clinical outcome measures for use in short term proof-of-concept studies. A related question is whether BDNF treatment results in long-term neuro protective effects [20]. Previous results on this issue were contradictory. Interestingly, recent results showed that over expression of BDNF delayed progressive RGC and axon loss in hypertensive eyes [21].The third question concerns the dose/concentration of BDNF to be used when supplied in the form of eye drops. In other words, does the topical eye application of BDNF represent a safe method of neuroprotection in glaucoma? In a previous work we used high BDNF doses to restore vision in a murine model of glaucoma [3]. This raises concerns over promotion of tumor growth resulting from BDNF taken up from non-retinal tissues; indeed, BDNF, as well as other neurotrophic factors, has been associated with neovascularization and tumor promotion [22]. To reduce the dose/concentration of BDNF we recently formulated BDNF in tamarind seed polysaccharide (TSP) [23], the TSP-BDNF combination appeared to confer a relatively higher bioavailability to BDNF.     Future DirectionsProven neurotrophic factors such as the BDNF should be safe, effective and characterized by long-lasting protection, thus these agents can be taken to clinical trials in glaucoma and other retinal degenerations such as the Retinitis Pigmentosa and age- related macular degeneration (AMD). Drug delivery systems suchas eye drops and, possibly, encapsulated cell technology, AAV-BDNF transfection should be considered for use.     AcknowledgmentSupported by the Department of Biotechnological and Applied Clinical Sciences (DISCAB), University of L'Aquila, and? the scientific consortium IN-BDNF. We thank Ms. S. Wilson for revising the English style. For more Open Access Journals in Juniper Publishers please click on: https://juniperpublishers.comFor more articles in Journal of Physical Fitness, Medicine & Treatment in Sportsplease click on: https://juniperpublishers.com/jpfmts/index.phpFor more about juniper publishers  please click on: https://www.juniperpublishersgroup.com/

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Juniper Publishers- JOJ Ophthalmology

Keratoconus Progression Diagnosis Evidenced by Corneal Epithelium Mapping- Juniper Publishers

Case Report

Background

We are reporting a case of a 16y.o. (y.o.b. 1996) young gentleman that we have followed for keratoconus in our center about a year ago. His first visit occurred on February, 2011. At this time he was informed about the different options such as collagen cross-linking, INTACS, the Athens Protocol (the combination of topography-guided partial ablation PRK with CXL), and lamellar keratoplasty. Following a complete clinical investigation, recommendation was given that the 0S be treated with cross-linking with simultaneous partial topography-guided excimer surface ablation (Athens Protocol) [1], which was performed in May, 2011.

The 0D had reasonable good correction (BCVA 20/20) and therefore, due to his age and good corneal thickness (CCT in the vicinity of 500μim), we recommended for him to follow eight months to a year's time in order to evaluate a possible progression and the possibility of intervention. This paper is about our investigation of the 0D keratoconus progression not only by optical anterior segment imaging technologies, but also by the epithelium mapping, which supported our findings relating to correlation of keratectasia and elevated corneal overall epithelium.

Methods and technologies

Anterior-segment imaging of keratometric, topometric and topographic parameters can be an important tool in the decisionmaking process and prompt action. The optical instruments involved in this report were Biometry by I0L Master (Carl Zeiss Meditec Inc., USA), Anterior-Segment 0ptical Coherence Tomography (AS OCT) by Optovue RTVue (Optovue Inc. Fremont, CA), Placido topography and Scheimpflug topography by Wave light (Erlagen, Germany), specifically the Topolyzerand the Pentacam High Resolution (Oculus Optikgerate GmbH), a.k.a. Oculyzer II, which is a Pentacam HR that has been specially configured to export topometric data to Alcon's refractive suite [2]. The ultrasound bio microscopy (UBM) instrument was the Artemis II + superior (Artemis Medical Technologies Inc. Vancouver, British Columbia, Canada) [3]. To our knowledge this is the first such documented case combining these optical modalities with epithelium mapping by HF ultrasound for keratoconus screening in the peer-reviewed literature.

Patient follow-up

The initial anterior segment parameters recorded during the first visit (late February, 2011) are summarized in (Figure 1 &Table 1). Based on these findings, astigmatism was determined -1.25 D, with the flat axis was determined at 21°. We saw the patient several months later (late January, 2012). The data (Figure 2 & Table 2), indicated keratoconic progression, despite that overall corneal thickness was found increased by an average of 13μim. For example, the difference with the Pentacam (Oculyzer II) preimposed on the old and newer topometric measurement showed a change in the central steepening. For example, sagittal curvature increased, K1 (flat axis) by +0.2 D and K2 (steep axis) by +0.8 D. Likewise, anterior surface elevation was found increased by approximately + 13μim, also there was change between lowest elevation to pupil center (20711, -13 -> +3μiM, 2012 -18 -> +8μim). Based on these findings, astigmatism was determined at 40°:

We decided to further evaluate this finding because on topometric terms this finding suggested progression of the keratoconus. We obtained Artemis II+ HF UBM corneal epithelium mapping. Careful evaluation of the UBM findings revealed that the epithelium (Figure 3) was overall thicker compared to a population of 33 patients (50 eyes) [4]. The patient’s epithelium featured mean thickness 56μm (normal population 50.8μim), central thickness 60μm (normal population 52.1μm), and average peripheral thickness 50μm (normal population 49.54μm), while over the cone (located superiorly - temporal) the epithelium was thicker, at 53μm.

    Discussion

We feel that this is a good example where the -at first sight- progression of keratoconus is accompanied by epithelium whose thickness is overall thicker than the control population, particularly at the pupil center by a significant amount (+8μm). This would be impossible to establish with Scheimpflug imaging maps alone. It appears the HF Ultrasound is able, by giving the specific epithelium maps to point to that direction. Obviously, for the definite diagnosis of this theory would be re-evaluation of the cornea with Oculyzer and UBM. In case where the epithelium returned to a thinner thickness we would expect that the Pentacam maps would flatten and that would establish that there is no actual progression of the keratoconus. It is interesting to compare the posterior curvature maps of past and current and see in these maps that there is a change in posterior curvature. One has to take into account that the increase of irregularity by the epithelium thickening may be the factor that creates this bias.

    Acknowledgement

Dr. Kanellopoulos is a Consultant to Alcon Wave light.

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Juniper Publishers- JOJ Ophthalmology

A Review of the Data on the Recently Approved Xen Surgical Gel Stent in the Management of Glaucoma- Juniper Publishers

Abstract

The cornerstone of glaucoma surgery includes trabeculectomy and tube shunting procedures, which utilize an ab externo approach to divert aqueous humor from the anterior chamber to the sub conjunctival space. The XEN Gel Stent is a 6.0mm tube consisting of porcine-derived collagen that similarly creates a non-physiologic shunt but through an ab interno approach. The XEN gel stent has the potential to effectively lower intraocular pressure and medication use with lower complication rates than traditional glaucoma surgery. This mini-review surveys the data of the XEN implant in current literature.

    Introduction

Glaucoma maintains a significant disease burden worldwide. It is the most common cause of irreversible blindness, affecting over 64 million individuals [1]. Therapy is focused on lowering intraocular pressure (IOP) by a variety of methods, including topical medications, laser, and incisional surgeries. These surgical interventions-traditionally trabeculectomy or tube shunt surgery-rely on creating an additional subconjunctival reservoir for aqueous humor (AH) drainage and subsequent resorption. However, the three-year results of the Tube Versus Trabeculectomy Study found failure rates of 15 and 28 percent, respectively. Serious postoperative complications such as persistent corneal edema, endophthalmitis, and chronic or recurrent iritis were also reported [2].

There has been a recent proliferation in procedures and medical devices that provide similar IOP-lowering effects to trabeculectomy or tube shunt surgery with fewer complications. One such product is the XEN Glaucoma Treatment System (Allergan, Inc., Irvine, CA, USA), which consists of the XEN Gel Stent and XEN Injector. The XEN stent is derived from porcine collagen, measuring 6.0mm long with inner diameters of 140|im, 63|im, or 45|im, although the 45|im stent is currently recommended. Previous studies in animal models have demonstrated no significant inflammatory response to implantation and no signs of degradation of the stent itself [3]. It was recently approved by the United States FDA in November 2016 for use in refractory glaucoma, including those with a history of failed prior surgical treatment, primary open-angle glaucoma (POAG), and pseudoexfoliative glaucoma with open angles that are inadequately controlled on maximal medical therapy.

The XEN stent is inserted into the angle through the scleral spur via an ab interno approach with its disposable injector. Ideally, the device should extend 3.0mm posteriorly from the limbus and into the subconjunctival space and 2.0mm anteriorly into the anterior chamber (AC). Once placed in an aqueous environment, the device hydrates, becoming soft and flexible, helping to maintain its position. By taking advantage of the resistance to flow in a cylinder as determined by the Hagen- Poiseuille equation, the XEN45 produces a pressure gradient 7.56mm Hg at the physiologic flow rate of AH within the AC, at 2.5 microliters/minute [4]. Thus, this stent can theoretically reduce the risk of hypotony seen in IOP-lowering surgeries despite being a valve less device. The fact that it is inserted ab interno obviates the need from conjunctival dissection, theoretically reducing the potential for conjunctival fibrosis and leaving the ophthalmologist with the option to perform ab externo surgeries if necessary in the future.

    XEN Gel Stent in the Literature  

Several studies were performed evaluating the XEN Gel Stent with multiple inner diameters. Sheybani, Dick, and Ahmed reported on the results of 49 eyes of 49 patients treated with the XEN140 stent (140um internal diameter) without the use of mitomycin C (MMC) [5]. Of the 49 patients, 22  received previous glaucoma surgery, and nine (18%) had a prior laser trabeculoplasty. Complete success was defined as an IOP <18mm Hg and a greater than 20% reduction of IOP at the primary endpoint of 12 months without glaucoma medications. Criteria for treatment failure included visual acuity less than or equal to light perception, need for additional glaucoma surgery, or a less than 20% reduction of IOP at 12 months. This study revealed that the mean IOP reduced from 23.1±4.1mm Hg preoperatively to 14.7±3.7mm Hg at 12 months, a 36.4% decrease. In all, 40% met the criteria for complete success and 88.9% for partial success. Three patients (6%) failed the study criteria and required additional surgery. The most common complication was needling (47%), with nearly half of the cases occurring within the first month.

Another early study by Sheybani and Ahmed used the XEN140 and XEN63 stent (63um internal diameter) without MMC in patients undergoing phacoemulsification [6]. Of the 37 eyes, 47.1% were considered complete successes while 85.3% were qualified successes. Mean IOP significantly decreased from 22.4±4.2mm Hg preoperatively to 15.4±3.0mm Hg at 12 months, and mean medications were significantly reduced from 2.5±1.4 to 0.9±1.0.

One of the first reports involving the exclusive use of the XEN45 stent (45um internal diameter) involved 31 eyes receiving phacoemulsification and MMC treatment at the time of implantation. Mean IOP and medication use were reduced significantly from 20.8±4.6mm Hg to 13.1±3.6mmHg at 12 months and 2.7±1 to 0.9±1.1 at 12 months, respectively, and without significant complications [7].

Pérez-Torregrosa et al. [8] were among the first to describe the efficacy of the XEN45 in patients with mild and moderate glaucoma (defined as a mean deviation between 0 and -12dB on Humphrey 24-2 perimetry) [8]. Additionally, subjects included in this study had pressures<30 while being managed on two or more medications. Twelve months after concomitant phacoemulsification and XEN45 implantation, 27 of 30 (90%) subjects met the successful treatment criteria of IOP≤18mm Hg with no glaucoma medications. The authors reported several intra operative complications, including sub conjunctival hemorrhage with MMC instillation (36.6%), and minor hemorrhage intra camerally (86.6%) and at the scleral exit point (90%). A total of six (20%) stents required relocation, and one eye required re-implantation of the device. One subject was excluded from analysis due to extensive subconjunctival hemorrhage after MMC injection and another due to extrusion of the device into the subconjunctival space intra operatively.

Two studies have addressed the effect of simultaneous implantation and phacoemulsification versus the XEN alone. One such study involved 567 eyes, of which 54% underwent XEN implantation only, and 46% the combined implantation and phacoemulsification [9]. There were no inclusion or exclusion criteria regarding the grade of POAG, and data from all three diameters of XEN stents were not separated. The data revealed a mean preoperative IOP of 21.9±4.2mm Hg that was significantly decreased at 12 months (15.7mm Hg), 24 months (15.0mm Hg), and 36 months (13.2mm Hg) of follow-up. Likewise, a significant decrease in medications by 74, 77, and 74 percent from the mean of 2.7 was observed at 12, 24, and 36 months, respectively. The percentage of patients who were converted to another procedure was 4% by 12 months, 5% by 24 months, and 5% by 36 months. After analysis, it was determined that there was no statistical difference in mean IOP or medications between eyes receiving the implant alone and the combination procedure. Likewise, a 75 patient cohort demonstrated no significant difference in IOP reduction between the standalone and combination procedures at 12 months [10]. The most frequent complications from this study were needling (15.4%) and hypotony defined as an IOP <6mm Hg on postoperative day 1 (12.6%).

The most recent article involving the XEN stent evaluated its use in eyes with suboptimal IOP and medication intolerance, medication noncompliance, or maximum therapy with no history of glaucoma surgery [11]. A total of 13 eyes underwent XEN45 implantation in addition to phacoemulsification if previously phakic. At the 12-month end point. 41.7% were complete successes, with a>20% drop in IOP and discontinuation of all glaucoma medications, while an additional 25% met the IOP goal but remained on at least one medication. Among the reported complications, four eyes required needling, two eyes developed choroidal detachment and hypotony requiring systemic steroids and atropine treatment, one implant extruded, and two eyes required subsequent trabeculectomy.

    Discussion

The current literature available for the XEN Gel Stent demonstrates its effect on IOP and medication reduction in addition to reducing severe intra operative and postoperative complications. The data also suggests a lower early failure rate than those published from trabeculectomy and tube shunt surgery. There remains little data on long-term outcomes of the XEN stent at this time, inherent with a newly approved procedure. Thanks to its earlier implementation outside the USA, data are available for the XEN from mild to refractory glaucoma. However, this data should be evaluated in light of the fact that some studies were performed using the XEN140 and XEN63 stents, which are no longer recommended by the manufacturer.

Of the complications encountered with the XEN stent, subconjunctival hemorrhage and needling were most common, and extrusion of the device was the most common serious complication. It should be noted that the rates of needling varied widely in the literature, from 15.4% to 47%. This could be due in part to varying degrees of experience with the XEN stent and injector as well as different technical approaches such as the use and dose of anti fibrotic used at the time of implantation.

It is well known that cataract extraction provides some improvement in IOP [12]. Thus, the efficacy of the XEN stent may be confounded by those studies in which patients also underwent phacoemulsification. In fact, higher preoperative IOP, older age, and greater anterior chamber depth have all been shown to correlate to the amount of IOP improvement with phacoemulsification in medically managed glaucoma patients [13]. However, two studies with the XEN stent reported no significant difference in IOP reduction and medication use postoperatively between XEN implantation combined with phacoemulsification and XEN implantation alone. Indeed, this is one relationship that will be unlikely to be discerned until more data from more eyes is available for analysis.

Looking forward, several clinical trials in various stages of progress will look to further elucidate the properties of the XEN device and its role in the management of glaucoma. One trial - NCT02036541 - is a Phase 3 trial currently past its primary completion date that will further assess the XEN45 in patients with refractory glaucoma. Another is a parallel assignment, Phase 4 trial for XEN45 in moderate POAG patients (NCT02006693). Yet another study, soon to begin enrollment, will assess the in vivo effects of various interventions on outflow at Schlemm's canal, of which the XEN stent is part of the surgical branch (NCT02807935).

    Conclusion

At present, there are multiple surgical options available for effective glaucoma management. The XEN Gel Stent is one such intervention that provides advantages over traditional glaucoma surgery and newer minimally invasive glaucoma surgery (MIGS) procedures while lowering IOP and medication dependence. The device is well tolerated by the ocular tissues and can be placed via an ab interno approach but still creates a non- physiologic subconjunctival shunt or bleb to increase aqueous outflow without the use of a valve system. Since it involves little manipulation of the conjunctiva, implantation of the XEN stent does not preclude future conjunctival surgeries if necessary. Questions remain as to what long-term outcomes of the XEN Gel Stent will demonstrate, as well as which types of glaucoma patients stand to benefit the most from the surgery. Larger-scale studies are needed to resolve these questions and confirm the initial optimistic results.

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Dendritic Cells and Regulatory T Cells Changes During ECP for Chronic GvHD in Pediatric Patients | Juniper Publishers

Juniper Publishers-Open Access Journal of Blood Research & Transfusion

Authored by Berger Massimo

Mini Review

Graft-versus-host disease (GvHD) is a leading cause of post HSCT morbidity and mortality. It is mediated by alloreactive mature donor T lymphocytes, resulting in a harmful inflammatory response and tissue injury [1]. The pathophysiology of GvHD is constituted by precise sequences of immunological events such as the activation of antigen-presenting cells (APCs), activation, differentiation and migration of T cells, and finally the development of their full effector functions [2-4]. Dendritic cells (DCs) constitute the most professional APCs, promoting alloreactivity or clonal antigen-specific T cell responses. Moreover, tolerogenic DCs may play a pivotal role in GvHD exerting an immunomodulatory or even immunosuppressive effect on T cells [5]. DCs can be divided into two major subsets, plasmacytoid DCs (pDCs) and myeloid DCs (mDCs) which have distinct functions. pDCs play a pivotal role in peripheral tolerance through the generation of regulatory T (Treg). In addition to pDCs, mDCs also promote Th2 and Th0/Tr1 responses, depending on the activation signal types [6,7].

Although corticosteroids, with potent immunosuppressive and anti-inflammatory effects, are the first-line treatment for GvHD, only 25-50% of patients respond [1,8]. Extracorporeal photopheresis (ECP) is an alternative therapeutic strategy in patients who are resistant/refractory to steroids. ECP appears to act in an immunomodulatory fashion, inducing immunotolerance in GvHD by regulatory T lymphocytes, dendritic cells, in concert with the normalization of a T lymphocyte subset.

This pilot study focuses on these two cell populations, as well as on the patients’ whole immunological pattern [9-11]. Data from eleven patients affected by chronic GVHD were included and analyzed. The median age was 9 years (range 2-18), 6 out of 11 patients were females and suffered of myeloid malignancies (4 patients), acute lymphoblastic leukemia (2 patients), neuroblastoma (1 patient), Hemophagocytic Lymphohistiocytosis (1 patient), Ewing sarcoma (1 patient), Blackfan-Diamond Anemia (1 patient).

Seven patients received an unrelated Hematopoietic Stem Cell Transplantation HSCT (3 bone marrow, 3 peripheral blood, 1 cord blood), three patients had a sibling HSCT (1 patient with 1 Ag mismatch graft, all patients had bone marrow as the stem cell source) and one patient had an phenotypic identical-HSCT). All patients suffered moderate to severe cGvHD which was resistant/refractory to steroids. All patients received ECP from January 2016 to December 2016 in our center according to previously published techniques [12]. The aim of this study was to: i) monitor peripheral blood changes after 30 days of ECP and ii) describe the immunological changes in aphaeresis samples after UVA treatment.

A sample of peripheral blood (PB), a sample of apheresis pre-UVA photoactivation (pre-PA) and a sample of photoactivated apheresis (PA) were collected at the first day of ECP and every week for the first month of treatment. Informed consent was obtained from all patients. PB, pre-PA and PA samples were characterized at day 0, 8, 15, 21, 30 of ECP treatment. The percentage obtained by cytofluorimetric analysis was used to calculate the absolute number of cells/μl based on the white blood cell (WBC) number counted using a standard hemacytometer (DASIT).

Statistical analysis was performed using NCSS for Windows. Descriptive statistics are reported as medians, continuous variable differences between groups were calculated with the Student T test. The fold change was calculated by the ratio between the difference (day 30 – day 0) /day 0. The P value below 0.05 was considered as statistically significant.

As shown in Table 1, at day 30 we observed a 0.48 change of CD3+. After 30 days of treatment there was an improvement of the CD4+/CD8+ ratio from 0.49 to 0.86 (0.75 times), that resulted in a change of CD3+CD4+ (from 234 to 384 x109/L) compared to CD3+CD8+ (from 475 to 448 x109/L). Moreover, in the same period of study, we had a change of 0.75 times of CD3-CD56+ from 272 to 478 x109/L 62 and a smaller rise of CD19+ from 214 to 256 x109/L. The naïve CD4+ and CD8+ lymphocytes rose from 4 to 39x109/L (8.75-fold change, P=0.02) and from 27 to 58x109/L (1.14-fold change) over a month while their memory counterpart fell by 0.62 and 0.55-fold. When we calculated the CD4+ and CD8+ naïve/memory ratio we found a 35- and 4-fold change (P=0.01 and 0.02). Comparing the day 0 and day 30 peripheral blood samples, we observed a high rise of 0.66 and 1.14 times for mDCs (mDC from 9 to 15 x109/L [P=0.03] and pDC from 7 to 15 x109/L [P=0.05]) respectively together with a change of Tregs (from 2.9 to 9.1 x109/L, 3.5-fold change [P=0.04]). Finally, when we analyzed the changes between pre- and post-UVA photoactivation a significant change of Treg was observed (0.35-fold change, P=0.05), while a decrease in cell number was observed for CD8+ (P=0.05) (Table 2).

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Preemptive Inferior Fornixstabilizing Procedure to Reduce Chemosis During Lower Eyelid Ectropion Repair: Surgical Technique and Outcomes- Juniper Publishers Juniper Publishers- JOJ Ophthalmology

Results

A total of 19 patients underwent the inferior fornix suture stabilization procedure at the time of ectropion repair surgery. The average age was 82.5 years old (Range: 63-95), 13 were male (68.4%) and 6 were female (31.6%). Of the 19 patients included in the study, a total of 24 eyes underwent the inferior fornix stabilization procedure (5 OD, 9 OS, 5OU). The average number of postoperative follow-up visits was 2.2 (Range: 1-4), and the average total follow-up length was 8.5 weeks (Range: 1-16). In 79.2 percent (19 of 24) of the cases, no postoperative chemosis was noted following the ectropion repair in combination with the inferior fornix stabilization procedure described above. The incidence of chemosis noted postoperatively was 20.8 percent (5 of 24). The following chemosis classification system described by Weinfeld et al. [4] was used for classifying postoperative chemosis:

Type 1 (acute mild) involves mild edema and inflammation, yellow and/or pink conjunctiva color, absent lagophthalmos, and less than three weeks duration.

Type 2 (acute severe) involves severe edema and inflammation, yellow and/or pink conjunctiva color, lagophthalmos present laterally, and less than three weeks duration.

Type 3 (subchronic) involves mild to severe edema, chronic inflammation, pink color, absent lagophthalmos, and duration of chemosis between three weeks and six months.

Type 4 (subchronic because of lower lid malposition) involves severe edema, moderate to severe inflammation, pink color, lower lid malposition and/or ectropion, and duration lasting until lid malposition is corrected [4].

All five cases of postoperative chemosis were classified as Type 1, acute mild. In all cases, chemosis ultimately resolved without any permanent sequela. No secondary entropion was observed in any case. All patients maintained good function, motility, and cosmesis of lower eyelids, and physician and patient satisfaction was achieved in all cases.

    Discussion

This surgical technique may be used for preventing postoperative chemosis, thus limiting the deleterious effects that conjunctival edema may have on wound healing. Indications for this chemosis limiting procedure may be for severe ectropion repair, patients with high likelihood of ectropion repair failure, or those at high risk for postoperative chemosis. Chemosis or severe lid instability on preoperative physical exam, as well as a history of previous chronic chemosis following ocular surgery may provide indication for inferior fornix stabilization at the time of the initial surgery. Additionally, this chemosis limiting procedure may be used for postoperative patients who have chronic chemosis resistant to medical management requiring a return to the operating room for surgical treatment of the conjunctival edema.

Sutures have been used for correcting eyelid malrotation for centuries [11]. Snellen described the Snellen Suture Technique in 1869 for correcting ectropion by passing a suture through the conjunctiva in the inferior fornix and out the skin inferiorly, therefore rotating the eyelid margin. Snellen used two horizontal mattress sutures about 3 mm apart just inferior to the tarsus, nearest the margin of the eyelid. The first was placed at the junction of the outer and middle third of the conjunctiva, and the second at the junction of the inner and middle third [1,12]. A modified Snellen suture technique was described by Laval and Schneider and later by Barrett aimed at correcting inferior prolapsed conjunctiva, differing from Snellen by incorporating the arcus marginalis and inferior orbital rim [13,14]. This incorporation, however, resulted in an increased risk of secondary entropion [10,13]. Malone and Tse described a inferior fornix suture technique for treating postoperative prolapsed conjunctiva using three double-armed 4-0 chromic gut sutures inserted in a horizontal mattress fashion to invaginate prolapsed inferior forniceal conjunctiva. The suture needle was passed through the dome of the prolapsed conjunctiva, into the inferior cul-de-sac, and brought out through the skin 8-9mm below the lash margin, and tied without a bolster. By not incorporating the arcus marginalis and inferior orbital rim, and by passing the suture full thickness through the eyelid, the likelihood of causing eyelid malrotation was likely reduced [10]. Unlike the technique described by Malone and Tse, the inferior fornix suture technique in this study was done at the time of the primary surgery in a preemptive effort aimed at prevention of postoperative chemosis and inferior fornix conjunctival prolapse in high risk patients. Additionally, foam bolsters were used when tying the sutures and the procedure did not include a temporary tarsorraphy.

This simple surgical procedure offers several advantages over medical management alone. It can be used as a corrective treatment for persistent chemosis, and also as a preventative measure for those with a high likelihood of postoperative chemosis. Also, preventing the inferior fornix conjunctiva from prolapsing or repositioning intra operative prolapsed conjunctiva will minimize exposure, inflammation, and epidermalization of the conjunctiva [10].

This study, however, has some limitations. The lack of control arm comparing chemosis incidence following severe ectropion repair without the proposed inferior fornix stabilization procedure restricts us from comparing the natural history of chemosis independent of the inferior fornix stabilization. Future studies of this technique could be performed prospectively. We do, however, feel that this technique significantly reduced the likelihood of postoperative chemosis given that only 20.8 percent of severe ectropion repairs in patients who were at high risk of postoperative chemosis actually manifested chemosis, all of which were characterized as Type 1, acute mild. Additionally, all cases of chemosis ultimately resolved without any permanent sequela. We believe this surgical technique can be used as a successful preventative measure for postoperative chemosis as well as for a surgical treatment option of postoperative chemosis resistant to conservative management.

    Acknowledgment/Disclosure

The authors have no proprietary or commercial interest in any materials discussed in this article.

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Visual Impairment and Smart Cities: Perspectives on Mobility- Juniper Publishers

Juniper Publishers- JOJ Ophthalmology

Abstract

Introduction: Visually impaired people face many problems when it comes to urban mobility, even though law guarantees their rights. Many of them are able to guide well themselves using white canes and tactile devices, but they still needs some help from the others to successfully complete their journey or assignment, which reduces their autonomy or even their safety. When using public transportation, the visually impaired report lack of awareness and sensitivity of people in general. Improvements of labor field are also important in order to evidence the value of the visually challenged manpower to economy, exercising social inclusion and meliorating their self-esteem. Thus, the idea of a smart city is extremely relevant, because it characterizes progress of infrastructure and services using technology, making city administration, education, public security, health service, housing and transportation even more connected and efficient. The purpose of this study is to show that the combination between concepts related to mobility of unsighted people and to smart cities results in benefits for both the visually impaired and the society.

Discussion: Improving visually impaired autonomy in mobility gathering concepts based on smart cities.

Conclusion: The fusion of concepts related to visual impairment and smart cities is extremely beneficial for autonomy, mobility and economy.

Keywords: Visual impairment; Autonomy; Technology; Mobility; lob market; Smart cities, White cane

    Introduction

The term "visual impairment" refers to irreversible visual loss, even after medical treatment. World Health Organization (WHO) classifies visual function in 4 levels: normal vision, moderate visual impairment, severe visual impairment and blindness. Moderate visual impairment combined with severe visual impairment under the term "low vision". Individual with this condition, despite the visual loss, is able to plan and/or execute assignments. About 1% of the world population presents some kind of visual deficiency, and more than 90% of those are distributed in third world countries [1].

Visual loss can be either congenital or acquired. A person who had developed blindness during his life has visual memories, thus, such memories are preserved. However, those who were born blind will not have the capacity of forming visual images, but they will develop strategies in order to structure a mental representation of space. Unsighted people normally use sonorous, kinesthetic, tactile, thermal and olfactory information through reminiscent senses [2]. In those cases, moving through places requires sensor-motor-cognitive skills, including perception, codification, learning and space information recall. That assignment can be stressfull, especially for the existence of two factors that directly affects the process of space orientation: environment layout and environment quality information [2].

Even though law guarantees their rights, visually impaired people face many problems when it comes to urban mobility. Many of them are able to guide well themselves using white canes and tactile devices, but they still needs some help from others to successfully complete their journey or assignment, which reduces their autonomy or even their safety. When using public transportation, the visually impaired report lack of awareness and sensitivity of people in general and the need of help to inform bus destination, for example [2].

Absence of great urban mobility results in negative consequences not only for people's life quality, but also for economy, including factors that influence since Brazilian social security till the indexes of productivity and of competitiveness at job market [3]. Is doubtless that mobility technology facilitates the access to visual, tactile, olfactory and sonorous information through systems like Braille, conventional canes, especial boards, etc. It's concession should be considered as an integrant and an indispensable part of the rehabilitation or habilitation process [4].

Nowadays, new mobility technology is emerging such as electronic canes, which integrate the information given by the ultrasound sensor to the traditional cane characteristics, maintaining the touch technique used in independent dislocation [1]. Another example is WAYFINDR® App that uses beacons (proximity device that sends information), Bluetooth, headphones, bone conduction and the smart phone itself, permitting visually impaired people to walk on streets in a more independent way [5].

The concept of a smart city includes also an idea of urban management based on Technology of Information and Communication [3], using hardware and software as sensors, Radio Frequency Identification (RFID), beacons, and other items related to de Internet of Things concept (IoT) [6-8]. Many of the technologies applied resort to Global Positioning System (GPS) for the purpose of collecting location data. However, GPS can suffer interference from obstacles which hind satellite's signal propagation, as indoor places, where signal hardly can be captured with enough quality. Thereby, other forms to localization will be required, as well as inertial sensors or ultrasound pulses [9].

Accordingly, at smart cities will be possible monitoring, localization and geo referencing actions, traffic preventive maintenance, alternative transportation and itinerary and route information. Users also can report urban accessibility features trough their ride, describing street and sidewalk conditions, for an example [3]. The purpose of the present study is to show that the combination between concepts related to mobility of unsighted people and to smart cities results in benefits for both the visually impaired and the society.

    Discussion

A person who is blind or has low vision faces many adversities during the day. Those difficulties goes since obstacles in the way till poor infrastructure on educational and on professional fields [5]. Among the most common structural problems are bumpy sidewalks and few or none signaling, making harder and dangerous to cross streets [10]. In general, the visually impaired recur to some instruments that give space orientation on urban mobility and they are directly influenced by the city infrastructure [4].

White cane pencil tip: ideal for places still unknown. Enables different types of soil identification by vibration and sounds produced [4].

White cane roller tip: used for space recognition at places without many obstacles [4].

Walls: are used as a safety reference for the visually challenge [4].

Lowered sidewalks: offer risks when tactile floor is not present to indicate where the sidewalk starts [4].

Tactile floor: very helpful, but needs to be perfectly installed in order to preserve its information [4].

Urban furniture: benches, trashcans, street sings, bus stop, telephone cabins, etc [4].

Another aspect of a poor urban mobility is the negatives consequences for city economy, mentioning the impact on Brazilian social security when it comes to the occurrence of accidents and to the raise of governmental pensions; besides productivity reduction as the employee spends extra time and effort commuting to work [3].

Difficulties are present also on the job market. To professional qualify and to be competitive can be a great challenge for people who suffer from visual loss. Thus, assistant technology is indispensable because it provides more independency for the visually impaired and freedom to do everyday duty in a plainer way. Yet, technology incentive, especially for mobility, is extremely important and even determinant to insert this group in professional, educational and social communication spheres, making them participatory in society [11]. Some projects have already been developed, as WAYFINDR® App. That system recurs location data given by beacons via Bluetooth to define one’s location, then, audio instructions are created to guide the individual trough the space, avoiding dangerous spots, permitting people to reach their destination safer and faster [5].

There are also some projects of the so-called smart canes [1].

E Touch cane: is known as the "speakerphone cane" .It has Global Positioning System (GPS), voice recognition and headphones, by which the visually impaired, indicates its starting point and destination by voice command [1].

«Low Cost» electronic cane: it has two sensors that warn the visually impaired when there is some obstacle within a certain distance [1].

«Smart» electronic cane: created by the Universität Konstanz, this type of electronic cane is able to trace routes and identify signs that have Quick Response codes (QR codes) to help the user cross streets or find establishments [1].

Smart Cane: developed by students at the University of Michigan, can recognize radio frequency identification tags located along the route [1].

It is important to note that with the advent of generations of communities and services that have the Web conception as a platform, possibilities of information dissemination and data sharing have increased. That fact happened due to popularization of Internet and to increased shared data flow, allowing the user to participate in creation of content. That is a great contribution for many smart cities tools [9]. The collected and processed data make possible to plan some action such as details about the path where the user travels with his smart cane, after processing references about the place. That technology should also be used at environments as school, work or home [3].

A smart city uses information and communication technology resources, providing more interactivity in order to improve its infrastructure and its public services in general, making that administration, education, health service, public security, and housing and transportation sectors even more connected and efficient. Technology is the starting point for a smart city [8].

    Conclusion

It is possible to infer that through the fusion between the concepts of Technology of Information and Communication applied in auxiliary devices for people with visual impairment and the idea of smart cities has a positive impact on these people's life quality. Therefore, the greater autonomy of the visually impaired results in greater self-esteem, better security and ensure competitiveness in job market. In addition, infrastructure is benefited with improvements generating more interactivity and development for the city.

    Acknowledgement

We are grateful to CNPq for the Technological and Industrial Initiation grant A granted by process no 180180/ 2017-7 for the project “Support magnifying glass with color change and adjustment of light intensity for visual rehabilitation” to student Caio Henrique Marques Texeira.

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A Case of Temporal Arteritis Associated with Atypical Clinical Findings- Juniper Publishers

Juniper Publishers- JOJ Ophthalmology

Introduction

Giant cell arteritis (GCA), is a systemic vasculitis, affects medium and large sized cranial arteries [1], it can cause serious morbidities. Giant cell arteritis (GCA) predominantly affects elderly females [2]. The typical symptoms of new-onset GCA are bitemporal headaches, jaw claudiacation, scalp tenderness, visual disturbances, systemic symptoms such as fever and weight loss, and polymyalgia [3]. The diagnostic assessment comprises laboratory testing (erythrocyte sedimentation rate, C-reactive protein), temporal artery biopsy and imaging studies. The most important complication is permenant and deep vision loss. Diagnosis of TA is difficult if typical symptoms other than visual loss are absent. It can be difficult to diagnose this disease in the absence of typical clinical signs and labaratuary findings. Here we report a silent and atypical temporal arteritis case (Table 1& 2).

    Case Report

63 year old hypertensive male patient applied to our hospital with complaint of vision loss in his right eye for two

weeks. His visual acquity was perception of hand movements in right eye and 8/10 according to Snellen Chart in left eye. While anterior segment evaluation revealed bilateral nuclear sclerosis, fundoscopic examination revealed papiledema in his right eye. He did not complain of any associated headache, scalp tenderness, jaw claudication or constitutional symptoms such as weight loss, fever, malaise or sweats. We consulted the patient to internal medicine, rheumotology and hematology departments. His clinical and labaratuary findings were unremarkable except thrombocytosis. Following a presumptive diagnosis of non- arteritic ischemic optic neuropathy the patient was hospitalized and treated with intravenous 1000mg methylprednisolone for 3 days. After 3 days, oral prednisolone therapy was started 60mg per day. Oral steroid therapy was tapered 10mg with 3 days interval. However at 10-days' examination visual acquity in his right eye was reduced to loss of light perception. 1 month later, patient presented with sudden vision loss in his left eye, headache and malaise. Fundus examination revealed left optic disc swelling and soft exudates near the optic disc (Figure 1). Floroscein anjiography showed delayed filling at arterial phase and late staining of the optic disc. When labaratuary tests were repeated, erythrocyte sedimentation rate (ESR) was 65mm/ h(normal range: 1-15mm/h) and creactive protein (CRP) level was 15mg/L (normal range: <5 mg/L). According to these findings, with the diagnosis of arteritic ischemic optic neuropathy, intravenous steroid therapy was initiated. Rheumatology department evaluated the patient again and a temporal artery biopsy was performed; focal chronic inflammation and elastic fiber degeneration areas were identified at histologic sections (Figure 2). At the fifth day of intravenous steroid therapy visual acquity in left eye was 7/10 according to the Snellen Chart. The Humphrey Perimetry test revealed a paracentral island in his left eye.Since the visual acquity was at the level of loss of light perception at the right eye we didn't perform the Humphrey Perimetry test for the right eye.

    Discussion

Patients with GCA typically present headache, jaw claudication, fever, weight loss, myalgia, arthralgia or malaise. Conversely, patients with occult GCA, first described by Simmons & Cogan [5], present with sudden visual loss without systemic symptoms and signs. Thus, due to the lack of symptoms, diagnosis and treatment of silent GCA may be considerably delayed when compared to typical GCA. Occult GCA , a potential cause of blindness, is defined as ocular involvement of GCA without any systemic symptoms and signs [6]. Ocular symptoms include visual loss, amaurosis fugax, diplopia and eye pain Hayreh et al. [6], described cotton wool spots in up to one third of eyes with visual loss dring the early stages of occult GCA [6]. Scalp abcess, chronic earache, bilateral central retinal artery occlusion, mydriaitic pupil, dry cough, aort anevrism , bilateral submandibular lymphadenopathy, hepatosplenomegaly are some atypic symptoms of GCA. The occult GCA group had higher C-reactive protein levels, a higher platelet count , and lower serum albumin levels [7]. Ophthalmic involvement can occur in up to 50% to 70% of the GCA patients, and this represents an ocular emergency. Arteritic anterior ischemic optic neuropathy (AAION) is the most common type of ophthalmic involvement in GCA and can cause permanent visual loss. Therefore, prompt diagnosis and treatment with a high dose of steroids is essential for these patients. In our patient at the first presentation labaratuary findings were unremarkable and there were no systemic symptoms; therefore at the beginning, our presumptive diagnosis was non-arteritic ischemic optic neuropathy of right eye. 1 month later, sudden vision loss appeared at left eye and he was complaining from headache, scalp tenderness ; ESR and CRP levels were elevated on labaratuary examination at that time. Hayreh et al. [6] found that ESR and CRP levels were relatively lower in patients with occult GCA compared to cranial GCA. On the other hand, Hamidou et al. [7] found higher CRP levels, a higher platelet count, and lower serum albumin levels in occult GCA group. In our patient's first presentation, ESR and CRP levels were within the normal limits. One month later when the other eye was effected ESR and CRP levels were remarkably high (Figure 3].

Although Liozon et al. [8] describes occult GCA as a protracted inflammatory response and a relatively benign short term outcome, in our case despite the long term corticosteroid and immunsupresive treatment, visual acquity was loss of light perception level in the right eye. Tan et al. [9] reported a case of GCA involving only the occipital artery which was revealed by magnetic resonance angiography. Chomlak et al. [10] reported a case of GCA with vertebral artery involvement, which was refractory to immunosuppressives. Hocevar et al. [11] claimed that, even early diagnosis and a prompt initiation of steroid did not prevent relapses in GCA. In our case after first attack despite the prompt intravenous steroid therapy one month later the patient consulted with visual loss at his other eye this verified Hocevar’s hypothesis. Cullen et al. [12] reported an occult GCA case in Singapore. Papakostas et al. [13] reported a case of GCA that presented with cotton wool spots and retinal vasculitis affecting small-size retinal arterioles. Shambhu et al. [14] reported an atypical case of GCA presenting as mild upper abdominal pain and generalized weakness in the context of hyponatremia as the presenting manifestation of vasculitis that was subsequently diagnosed by MRI scanning. Cheema et al. [15] described a case had the signs and symptoms consistent with GCA but who had an ESR within the normal limits, 27mm/h. In our case ESR at the first presenting ESR was within the normal limits,too. Labarca et al. [16] reported that patients with hypertension or diabetes at GCA diagnosis have more relapses during follow-up. Kermani et al. [17] reported seven patients with a positive temporal arteritis for GCA had a normal ESR and CRP at diagnosis (Figure 4].

In people older than 55 years, amaurosis fugax or visual loss, development of an acute ocular ischemic lesion with or without elevated erythrocyte sedimentation rate and systemic symptoms, should raise suspicion for giant cell arteritis. The diagnosis of temporal arteritis is easily made when sudden loss is contemporary with other symptoms and raised inflammatory markers. In the absence of known symptoms, in a patient diagnosed as ischemic optic neuropathy, occult temporal arteritis shouldn’t be out of mind. Despite the early diagnosis and treatment final visual acquity may not be satisfactory.

    Conflict of Interest

Asfuroglu declares that he has no conflict of interest. Author Koz declares that she has no conflict of interest. Author Ozbalkan declares that she has no conflict of interest. Author Sandikci declares that she has no conflict of interest. Author Ciftci declares that she has no conflict of interest. Author Ozdemir declares that she has no conflict of interest.

This article does not contain any studies with human participant performed by any of the authors.

Informed consent was obtained from all individual participants included in the study.

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Efficacy of Amniotic Membrane Transplantation in Refractory Infective Keratitis Leading to Stromal Thinning, Descematocele and Perforations- Juniper Publishers

Juniper Publishers- JOJ Ophthalmology

Introduction

Diseases affecting the cornea are a major cause of blindness all over the world, second only to cataract in overall importance [1]. One of the commonest corneal causes is Infectious Keratitis. The prevalence of blindness directly resulting from complications of Infective Keratitis is estimated to be 5% [2]. Cases refractory to the medical therapy requires urgent surgical intervention to retrieve the vision and most importantly to salvage eye. Available surgical management in refractory keratitis cases include tissue adhesives, Bandage Contact Lenses (BCL), penetrating or lamellar keratoplasty [3] patch grafts, or conjunctival flaps. Unfortunately, these therapies are associated with a considerable number of complications and address only the tectonic problem, without solving the ongoing infection and inflammation. BCL and conjunctival flaps being a temporary measure does not provide with new collagen to improve corneal thickness and stabilize the cornea. For such situations Penetrating Keratoplasty (PK), Lamellar Keratoplasty (LK) or patch grafts was the only option and is still being used widely. PK and patch grafts performed to seal a corneal perforation may be complicated with synechiae, glaucoma, uveitis, and graft failure in the setting of an inflamed or infected eye [4]. Recurrence of infection in corneal grafts is also challenged. LK being difficult to perform may result in a double chamber between the donor and recipient cornea in some cases. Tissue adhesives may dislodge and are used as a temporary measure, obviating the need for a PK within a few days [5,6].

Preserved human amnion has been successfully used as a biological bandage, promoter of epithelialization, inhibitor of inflammation and angiogenesis, as well as a carrier for ex vivo cultured limbal stem cells [7]. Amniotic Membrane Transplant (AMT) offers the advantage of avoiding potential allograft rejection. Even if corneal transplantation is needed, the success rate is improved if performed on an eye that underwent AMT reducing inflammation [8,9]. Amniotic Membrane (AM) integrates in cornea and thus can be used as a treatment for corneal perforation by restoring corneal stromal thickness so that emergency PK can be avoided, as suitable donor corneal button availability is difficult in every place. Therefore, an alternative management for various stages of infectious keratitis including deep refractory stromal ulcers, descematocele and corneal perforations is reconstruction of the surface with AMT adjuvant with appropriate antimicrobials and supportive medications. In this prospective study AMT in various gravities refractory infective keratitis has been attempted to understand the efficiencies and limitations associated with it.

    Methods

A prospective, interventional study was done on 150 eyes of 150 patients. All patients with refractory (unresponsive to conventional treatments significantly for more than 2 weeks) infective keratitis, advanced infectious keratitis with descematocele and corneal perforation requiring urgent concealment to salvage the eye, were treated with single or multi layered AMT. Patients with non-infective ulcers and perforations were excluded from the study. Corneal ulcer was graded 1-5 according to the depth of corneal involvement on slit lamp biomicroscopy (Table 1). Microbial investigations (staining for bacteria and fungus with culture-sensitivity) were done and antimicrobials started accordingly. B-scan ultra sonography was done in hazy media to rule out involvement of posterior segment. Any systemic (diabetes) or ocular (dacryocystitis) conditions hindering the healing of ulcer or triggering the infection were investigated and managed.

On basis of slit lamp examination at the site of most impact.

    Technique

Surgery was performed preferably under sub conjunctival or peribulbar anesthesia. In children or uncooperative patients general anesthesia was used. Debridement of the necrotic tissue was done from and around the ulcer bed. Care was taken to remove the pseudo cornea over the perforation at the end of debridement to prevent leaking of aqueous and thus allowing proper keratectomy. Single layer preserved AM was used in cases of deep stromal ulcer. AM with epithelial side up was spread over the ulcer and trimmed to fit the ulcer. It was secured with continuous or interrupted 10-0 monofilament nylon suture. Descematocele and small corneal perforations up to 4mm were treated with multilayer AMT owing to deep corneal involvement. A sheet of AM, folded over it-self with epithelial side out, filled the ulcer crater and anchored to the healthy ulcer margin with interrupted 10-0 nylon suture. It was covered with a single sheet of AM similarly as in cases of deep stromal ulcers. In large corneal perforations of 4-6mm with extensive surrounding stromal necrosis, margins were not sturdy to hold the suture and there was a risk of cutting-off a corneal bite. In such cases single layer was sutured at limbus to at least provide tectonic support to the eyeball and delaying the need for PK. Side port or paracentasis was made in cases hypopyon and corneal perforation to reform the anterior chamber with air and reposit the prolapsed iris with help of spatula. Anterior synechiae if present were broken to prevent formation of adherent leucoma and thereby secondary glaucoma. Hypopyon if present was washed through the side port and intracameral antibiotic or antifungal was also injected according to sensitivity. At the end a BCL was placed over the cornea to prevent irritation from corneal sutures and maintaining AM in place. Antimicrobial, cycloplegics, ocular hypotensive and lubricating drops were continued along with systemic supportive therapy. Frequent follow-ups were done weekly for 1 month, biweekly till 3 months and monthly till 6 months. Efficacy was monitored on basis of improvement in symptoms and visual acuity, healing of the ulcer by re-epithelization and formation of anterior chamber, achievement of corneal transparency and corneal thickness. Accordingly patient's outcome was described as satisfactory, intermediate and failure (Table 2).

    Observation and Results

Keratitis was classified (Table 1) according to the depth of the cornea involved into 5 grades. Grades 1 and 2 responded well with medical management, therefore did not require AMT. Grades 3-5 with deeper corneal penetration of infection did not heal merely with medical management, there was an apprehension of corneal thinning and progression of infection, which required AMT. Of the 150 patients who underwent AMT, 55 (36.67%) were deep stromal ulcers, 25 (16.66%) were descematocele and maximum 70 (46.67%) patients were of corneal perforation ranging from 1-6mm. There was no age group or gender preponderance. Symptoms of redness, pain, watering and foreign body sensation (FBS) were collectively present in all the cases. Lid oedema and photophobia were also present in majority of the cases (70.6% and 90% respectively).Presence of discharge was seen in moderately less cases (30%). ranging between 1-2mm and 10 cases (20%) had hypopyon of Hypopyon was present in total 50 (33.3 %) cases where 10 cases >2mm (Table 3).

Single layer AMT was done in total 85 cases, all 55 cases of deep stromal ulcer and 30 cases of corneal perforation >4mm with extensive necrosis to provide tectonic support to maintain integrity to eyeball. Roofing with multilayer technique was done in 65 cases, all 25 cases of descematocele and 40 cases of corneal perforation >4mm in largest dimension where neighboring corneal tissue was healthy to hold the corneal sutures (Table 3). Patients were observed in repeated postoperative days. Rapid descent of symptoms was observed after the AMT. There was drastic improvement in pain, lid oedema, FBS and discharge in the first week. Symptoms were barely present in few cases by 1 month, which totally recovered by 3 months in all the cases (Figure 1).

Corneal transparency graded from 0 (leucomatous opacity) to +4 (clear cornea, with no haze) was measured objectively at the site of most impact on slit lamp (Table 4). Improvement was seen in 105 of 150 cases and was statistically significant (p=0.016). However none of the cases improved to +4 transparency that is totally clear cornea (Table 5). Visual acuity was recorded before and after 6 months of treatment in 145 of 150 cases as 5 cases of fungal ulcer failed to heal with AMT (Table 6). Improvement in BCVA when taken collaborate, was extremely significant (p >0.0001). Mild to moderate complications were faced during the entire course of treatment. They were shallow anterior chamber in 5 cases in perforation which was tackled with air injection in anterior chamber and breaking anterior synechiae. Hemorrhage beneath AM in five cases which resolved spontaneously. Graft retraction was seen in five cases for which repeat AMT was done. Hypopyon developed in 10 cases and did not resolve with topical therapy was managed with anterior chamber wash and intracameral moxifloxacin and amphotericin-B respectively (Table 7). Hypopyon did not redevelop in these cases. All the complications were successfully managed with appropriate treatment with no recurrence and good results. Also no re-infection was noted. Graft melting and corneal perforation was seen in 5 cases of fulminant fungal ulcer and required urgent therapeutic PK.

Satisfactory results were seen in 100 of 150 eyes (66.67%), intermediate results seen in 45 cases (23.33%). Failure was noted in 5 cases (3.33%) of fulminant fungal ulcers that showed subsequent corneal perforation requiring Therapeutic PK (Table 8). All the cases in intermediate category which also required subsequent intervention, healed with stable cornea. Thus, successful results were seen in 145 of 150 cases (96.67%) of which in 30 cases subsequent penetrating keratoplasty was done for leucomatous corneal opacity obscuring the visual axis left after healed ulcer (Figure 2).

    Discussion

Approximately one-third of cases of infective keratitis require surgical interventions at the acute stage to prevent perforation or spreading of infection [10-14]. Keratoplasty being majorly followed in such situation faces a limitation of availability of good quality donor corneas, mainly in developing countries, recurrence of infection, difficulty in technique and graft rejection. Moreover, for fungal keratitis PK is technique dependent and may also carry a risk of recurrent infection [15].

Thus AMT is sought as an alternative, which has been extensively reported in ophthalmology literature [16-19]. AMT offers the advantage of stimulating re-epithelization, preventing neovascularization and scar formation and avoiding potential allograft rejection. Even if corneal transplantation is needed, the success rate is improved if performed on an eye with reduce infection and inflammation, this can be achieved with AMT [8,9]. In present study complete epithelization was noted in 145 of 150 cases, that is 96.67% success rate. Similar to our study, Chen et al. [20], showed 82.61% success rate, 4 of 23 cases in there study faced AM melting and graft failure requiring therapeutic PK in 3 and delayed healing with vascularization in the other. Kim et al. [21] used multilayer AM in cases of descematocele and corneal perforation. Corneal surface was healed successfully in all cases, and no recurrence of infection or rejection was experienced. Hanada et al. [22] used multiple layers of AM for deeper stromal ulcers down to descemetocele, to restore the normal corneal thickness as well as in corneal perforations from 0.5 to 3mm with or without additional tissue adhesive with high success rates (73-93%). In present study corneal perforations in cases of infectious keratitis up to 6mm have been treated successfully with AMT alone, and 100% corneal epithelization with more than 50% corneal thickness have been achieved in all 70 cases of perforation. In a series by Heiligenhaus et al. [23]. Seven patients with herpes simplex virus or varicella zoster- induced severe ulcerative keratitis, 5 of 7 eyes healed after first AMT [23]. In another study, stromal defect was filled up with multilayer technique proved to be better than monolayer procedure [22,24,25].

In present study 70% showed significant improvement in corneal transparency and increasing corneal transparency improves the best-corrected visual acuity further emphasizing the healing properties of AMT. Chen et al. [20], preserved useful vision after AMT in cases of fungal keratitis in 52.2% eyes. Kim et al. [21], reported 21 cases of successful AMT in infectious keratitis, in which visual acuity increased except for 5 cases because of irreversible corneal opacity. AMT has come up as a very effective managing technique for refractory ulcers. It aids in permanent healing of the refractory infective keratitis and prepares the cornea for definitive reconstructive procedure if required (Figure 3).

    Conclusion

We have found that AMT represents a viable method of treatment to promote healing and prevent progressive melting of refractory infectious keratitis. Besides being cost-effective it’s easy to perform, with a short learning curve. Thus, it might be considered a first-line surgical technique when maximal medical treatment has failed.

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