Publications by authors named "Alfonso Iovieno"

72 Publications

Effects of hormonal contraceptives on dry eye disease: a population-based study.

Eye (Lond) 2021 Apr 6. Epub 2021 Apr 6.

Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC, Canada.

Background: Hormonal contraceptives (HCs) are a known risk factor for dry eye disease (DED), yet the relationship between HCs use and DED in women of child-bearing age remains debatable. The aim of this study was to determine the association between HCs and DED in females of reproductive age.

Methods: This was a retrospective cohort study using data from IQVIA's electronic medical record (IQVIA, USA). 4,871,504 women (age 15-45) between 2008 and 2018 were followed to the first diagnosis of DED as defined by an ICD-9/10 code. DED cases also required at least two prescriptions of cyclosporine or lifitegrast topical drops within 60 days of the first code. The date of the first code was designated as the index date. Regular HCs users needed to have at least two prescriptions in both the first year and second year prior to the index date. For each case, five controls were selected and matched to cases by age and follow-up time. A conditional logistic regression model was used to adjust for confounders of DED and to calculate odds ratios (ORs).

Results: HCs users were at a higher risk for DED than non-users. Regular users of HCs were more likely to develop DED (ORs = 2.73, 95% CI [2.21-3.73]) than irregular users. Those who used a greater number of HCs were at a higher risk for DED.

Conclusions: This study indicates an increased risk of DED with HCs use in women of child-bearing age.
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http://dx.doi.org/10.1038/s41433-021-01517-xDOI Listing
April 2021

Topical Corticosteroids and Fungal Keratitis: A Review of the Literature and Case Series.

J Clin Med 2021 Mar 11;10(6). Epub 2021 Mar 11.

Cornea and Ocular Surface Unit, San Raffaele Scientific Institute, 20132 Milan, Italy.

The management of fungal keratitis is complex since signs and symptoms are subtle and ocular inflammation is minimal in the preliminary stages of infection. Initial misdiagnosis of the condition and consequent management of inflammation with corticosteroids is a frequent occurrence. Topical steroid use is considered to be a principal factor for development of fungal keratitis. In this review, we assess the studies that have reported outcomes of fungal keratitis in patients receiving steroids prior to diagnosis. We also assess the possible rebound effect present when steroids are abruptly discontinued and the clinical characteristics of three patients in this particular clinical scenario. Previous reports and the three clinical descriptions presented suggest that in fungal keratitis, discontinuing topical steroids can induce worsening of clinical signs. In these cases, we recommend to slowly taper steroids and continue or commence appropriate antifungal therapy.
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http://dx.doi.org/10.3390/jcm10061178DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8001350PMC
March 2021

Retrospective analysis of ophthalmology referrals to a tertiary academic centre during the COVID-19 pandemic in comparison to the pre-COVID-19 era.

Can J Ophthalmol 2021 Mar 5. Epub 2021 Mar 5.

Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC.

Objective: This study was conducted to analyse emergency ophthalmology referrals to a Canadian tertiary academic centre during the current coronavirus disease 2019 (COVID-19) pandemic in comparison to prepandemic referrals.

Design: This was a retrospective chart review looking at emergency referrals seen by the ophthalmology service between March 18 to April 17, 2020 (representing the COVID-19 period), and March 18 to April 17, 2019 (representing the pre-COVID-19 period).

Methods: Data gathered from referral records included patient demographics, timing and site of referral, and ophthalmic diagnosis. Referrals were categorized as urgent or nonurgent, with urgent indicating the need for ophthalmic assessment within 24 hours.

Results: The total number of referrals decreased by 54.2% in the COVID-19 period versus the pre-COVID-19 period. There was a similar bimodal age distribution in both periods, with fewer patients over 65 years of age presenting during the pandemic. Tertiary hospital referrals decreased by 62% in the pandemic period, while nontertiary emergency department referral trends varied and outpatient clinic referrals increased by 16%. Overall, there was a significant shift in the distribution of referral sites (p = 0.04). The proportion of urgent referrals increased by 14% during the pandemic; this was not statistically significant. There was no significant change in the timing of referrals or in the distribution of diagnostic segments.

Conclusions: This study offers insight into the impact of the COVID-19 pandemic on ophthalmology referral patterns in a Canadian context. Moving forward, it helps to guide resource allocation and public education on the importance of seeking necessary eye care.
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http://dx.doi.org/10.1016/j.jcjo.2021.02.034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7934690PMC
March 2021

Late-onset recurrent Acremonium fungal keratitis after therapeutic penetrating keratoplasty.

Can J Ophthalmol 2021 Mar 9. Epub 2021 Mar 9.

University of British Columbia, Vancouver, B.C.. Electronic address:

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http://dx.doi.org/10.1016/j.jcjo.2021.02.006DOI Listing
March 2021

Is There an Association between Herpetic Infections and Giant Cell Arteritis? A Population-Based Study.

J Clin Med 2020 Dec 27;10(1). Epub 2020 Dec 27.

Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC V5Z 3N9, Canada.

Recent data suggests that herpes zoster (HZ) and herpes simplex virus (HSV) may be one of the underlying immunological triggers for giant cell arteritis (GCA). However, there is limited population-based data to support this. Our goal was to determine if herpetic infections increase the likelihood of GCA in the British Columbia (BC) population. The background prevalence of GCA was compared to the prevalence of GCA in subjects with HZ and HSV using diagnostic billing code data from an online BC database (BC Data Scout). BC residents ≥30 years old at the time of diagnosis from January 2000 to January 2019 were included. The relevant International Classification of Disease codes was used to identify patients with GCA, HZ, and HSV. Comparisons were made using two-sample Z tests. There were 4315 GCA diagnoses, from a total population of 3,026,005 subjects. The prevalence of GCA was 143 per 100,000 people. In terms of herpetic infections, 850 GCA cases were identified in 249,900 subjects with HZ versus 310 diagnoses of GCA in 163,170 subjects with HSV. The prevalence of GCA in subjects with HZ (0.340%) was significantly higher than the prevalence of GCA (0.143%) in the general population ( < 0.00001). The prevalence of GCA in HSV subjects (0.190%) was also significantly higher ( < 0.00001) than the population prevalence but lower than ( < 0.00001) the GCA with HZ prevalence. The likelihood of GCA appears to increase with herpetic infections, more significantly with HZ.
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http://dx.doi.org/10.3390/jcm10010063DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7795735PMC
December 2020

Quantification of Aerosol Generation During Cataract Surgery.

J Cataract Refract Surg 2020 Nov 30. Epub 2020 Nov 30.

Department of Ophthalmology and Visual Sciences, The University of British Columbia, Vancouver, Canada.

Purpose: To determine whether phacoemulsification cataract surgery is an aerosol-generating medical procedure (AGMP) and therefore, to help determine the personal protective equipment required by healthcare providers in the era of the COVID-19 pandemic, as COVID-19 can be transmitted via aerosolization during AGMPs.

Setting: Laboratory DESIGN:: In this laboratory-based simulation, phacoemulsification cataract surgery was performed on porcine eyes. At a fixed distance, a DustTrak DRX Aerosol Monitor Model 8534 (DustTrak) was positioned to quantify particle generation during surgery. Experiments were run in triplicate for two wound sizes, 2.4 and 2.75mm. Positive controls were established by measuring particle generation from an aerosolizing spray-bottle. Negative controls were established while the phacoemulsification machine was not running.

Methods: The DustTrak was used to measure particulate matter (PM) mass fractions for each of three particle sizes, PM1, PM2.5, and PM4 (in microns), every 2 seconds during surgery and for one minute after. The main outcome measure was an increase in the mass fraction of aerosolized particles of various sizes.

Results: There was no significant aerosolization of particles during cataract surgery for both the 2.4 and 2.75mm wound sizes.

Conclusions: Phacoemulsification cataract surgery was not found to be an AGMP. In the midst of the COVID-19 pandemic, ophthalmologists can continue to use droplet precautions while performing this surgery.
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http://dx.doi.org/10.1097/j.jcrs.0000000000000530DOI Listing
November 2020

Refractive Outcomes of Descemet Membrane Endothelial Keratoplasty Combined With Cataract Surgery in Fuchs Endothelial Dystrophy.

J Refract Surg 2020 Oct;36(10):661-666

Purpose: To evaluate the refractive outcomes of Descemet membrane endothelial keratoplasty combined with cataract surgery (DMEK triple) in patients with Fuchs endothelial dystrophy.

Methods: A retrospective analysis of 68 eyes of 68 patients with Fuchs endothelial dystrophy who underwent DMEK triple between 2014 and 2018.

Results: The mean age of patients was 66.5 ± 8.6 years, and 65% (44 of 68) were female. Mean target refraction was -0.69 diopters (D) (interquartile range: -0.80 to -0.50 D). At 6 months, 47% (32 of 68) and 63% (43 of 68) of eyes were within ±0.50 and ±1.00 D of target refraction, respectively. Among eyes greater than 0.50 D from target, 78% (28 of 36) were hyperopic surprises. Mean spherical equivalent at 6 months was -0.14 ± 1.26 D, representing a mean hyperopic shift of 0.55 D from target. Preoperative pachymetry was higher in eyes with greater than 0.50 D of hyperopic surprise (648 ± 60 vs 613 ± 49 µm, P = .04). Refractive shift was greater in eyes with a preoperative central corneal thickness of 640 µm or greater versus eyes with a central corneal thickness of less than 640 µm (+1.20 ± 0.92 vs +0.40 ± 0.99 D, P = .02). None of the eyes with a preoperative central corneal thickness of 640 µm or greater shifted myopically compared to target (range: -0.09 to +2.89 D).

Conclusions: A mean hyperopic shift of 0.55 D from target refraction occurred after DMEK triple, and 47% of eyes were within 0.50 D of target refraction at 6 months postoperatively. Thicker corneas preoperatively had greater hyperopic shift. A greater myopic target refraction may be warranted in eyes with a preoperative central corneal thickness of 640 µm or greater. [J Refract Surg. 2020;36(10):661-666.].
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http://dx.doi.org/10.3928/1081597X-20200729-02DOI Listing
October 2020

Delayed-onset Bilateral Peripheral Posterior Interstitial Keratitis Associated with Epstein-Barr Virus-Induced Infectious Mononucleosis.

Ocul Immunol Inflamm 2020 Sep 18:1-4. Epub 2020 Sep 18.

Department of Ophthalmology, Azienda USL - IRCCS , Reggio Emilia, Italy.

Introduction: Epstein-Barr Virus (EBV) has been previously reported to cause rare occurrence of mostly epithelial and nummular keratitis. We hereby report two patients developing bilateral peripheral deep interstitial keratitis following EBV-related infectious mononucleosis (IM).

Description Of Cases: Two female adolescents presented with findings of chronic relapsing posterior interstitial keratitis with neovascularisation mostly located in the superior and inferior peripheral cornea, in absence of signs of anterior uveitis. The disease presented months after the occurrence of IM. Other etiologies of interstitial keratitis were excluded. EBV DNA could not be detected in the aqueous humor of both patients. The patients responded promptly to topical corticosteroids, with multiple recurrences reported in one case.

Conclusion: EBV-induced IM can cause bilateral peripheral interstitial keratitis with delayed onset. Progressive relapsing course of the keratitis can be observed.
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http://dx.doi.org/10.1080/09273948.2020.1811351DOI Listing
September 2020

Incidence and Outcomes of Cystoid Macular Edema after Descemet Membrane Endothelial Keratoplasty (DMEK) and DMEK Combined with Cataract Surgery.

Curr Eye Res 2020 Sep 9:1-5. Epub 2020 Sep 9.

Department of Ophthalmology & Visual Sciences, University of British Columbia , Vancouver, British Columbia, Canada.

Purpose: To investigate the incidence and outcomes of cystoid macular edema (CME) after Descemet membrane endothelial keratoplasty (DMEK) alone and DMEK combined with cataract surgery (DMEK triple).

Materials And Methods: A retrospective chart review was performed for patients who underwent DMEK and DMEK triple between January 2014 and March 2018 at two tertiary hospitals. Patients with minimum of 6 months of follow-up were included. Logistic regression analysis was used to identify potential risk factors for CME including gender, age, glaucoma, uveitis, epiretinal membrane, diabetes mellitus, iridotomy, and rebubbling.

Results: 09 eyes of 193 patients who underwent DMEK (124 eyes) and DMEK triple (85 eyes) were included. The 6-month incidence of CME was 3.8% (8/209) for all cases, 2.4% (2/85) for DMEK triple, and 4.8% (6/124) for DMEK alone. CME was treated with topical prednisolone acetate 1% and nepafenac four times daily, and/or periocular triamcinolone acetonide, with resolution in all cases. On average, CME was detected 8.9 ± 2.1 weeks postoperatively, with a mean time to resolution of 4.1 ± 1.7 months. The 6-month best-corrected distance visual acuity of eyes that developed CME was not significantly different compared to eyes that did not develop CME (0.17 ± 0.15 logMAR vs. 0.23 ± 0.27 logMAR; = .76). On logistic regression analysis, no risk factors for developing CME were identified.

Conclusions: The incidence of CME after DMEK was low and not associated with decreased long-term visual acuity. Most cases of CME occurred between 1 and 3 months postoperatively. Predictive factors for CME after DMEK require further study.
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http://dx.doi.org/10.1080/02713683.2020.1818260DOI Listing
September 2020

Topical insulin for neurotrophic corneal ulcers.

Can J Ophthalmol 2020 10 13;55(5):e170-e172. Epub 2020 May 13.

University of British Columbia, Vancouver, B.C.. Electronic address:

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http://dx.doi.org/10.1016/j.jcjo.2020.04.001DOI Listing
October 2020

Candida Keratitis: Epidemiology, Management, and Clinical Outcomes.

Cornea 2020 Jul;39(7):801-805

Department of Ophthalmology & Visual Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; and.

Purpose: To examine the epidemiological characteristics, trends, risk factors, management strategies, and clinical outcomes of Candida albicans and non-albicans keratitis over a 15-year period in a tertiary Canadian eye center.

Methods: In a retrospective observational case series of Candida keratitis from 2003 to 2017, demographics, risk factors, corrected distance visual acuity (CDVA) at initial and final consultations, medical and surgical management, and follow-up duration were recorded.

Results: Twenty-one cases of Candida keratitis were identified (62.5% of total fungal keratitis; 10 C. albicans and 11 non-albicans). The most commonly associated risk factors were topical steroid use (16 patients, 76%), ocular surface disease (15 patients, 71%), contact lens use (11 patients, 52%), and previous corneal surgery (8 patients, 38%); all patients had 2 or more combined risk factors. The number of patients with a visual acuity of 20/200 or better remained the same before and after the treatment (5/21, 24%). The mean duration of the antifungal treatment was 98 ± 126 days. Sixteen patients ultimately required surgical management (76%; 12 therapeutic keratoplasties, 3 enucleation, and 1 optical keratoplasty). When comparing C. albicans with non-albicans keratitis, we found no difference in presenting visual acuity, final visual acuity, or requirement for surgical management.

Conclusions: Candida keratitis accounts for the most identified fungal keratitis cases in this temperate climate area. An exposure to multiple risk factors appears necessary. A surgical intervention is required for the resolution of most cases. Different subspecies of Candida ultimately resulted in similar clinical outcomes.
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http://dx.doi.org/10.1097/ICO.0000000000002306DOI Listing
July 2020

SJS/TEN 2019: From science to translation.

J Dermatol Sci 2020 Apr 7;98(1):2-12. Epub 2020 Mar 7.

Division of Translational Therapeutics, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada. Electronic address:

Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) are potentially life-threatening, immune-mediated adverse reactions characterized by widespread erythema, epidermal necrosis, and detachment of skin and mucosa. Efforts to grow and develop functional international collaborations and a multidisciplinary interactive network focusing on SJS/TEN as an uncommon but high burden disease will be necessary to improve efforts in prevention, early diagnosis and improved acute and long-term management. SJS/TEN 2019: From Science to Translation was a 1.5-day scientific program held April 26-27, 2019, in Vancouver, Canada. The meeting successfully engaged clinicians, researchers, and patients and conducted many productive discussions on research and patient care needs.
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http://dx.doi.org/10.1016/j.jdermsci.2020.02.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7261636PMC
April 2020

Concomitant herpetic keratitis and acute retinal necrosis: clinical features and outcomes.

Eye (Lond) 2020 12 24;34(12):2322-2327. Epub 2020 Feb 24.

Department of Ophthalmology, University of British Columbia, 2550 Willow Street, Vancouver, BC, V5Z 3N9, Canada.

Background/objectives: The aim of this study was to identify risk factors, prognosis, and management in patients with concomitant herpetic keratitis and acute retinal necrosis (ARN).

Subjects/methods: In this retrospective observational series, ARN patients in the Greater Vancouver area from 2004 to 2018 were identified through key words, billing codes, and dispensing data from medical records of affiliate researchers and the pharmacy at Vancouver General Hospital.

Results: Twenty-eight patients were diagnosed with ARN during this period. Five of those were also diagnosed with herpetic keratitis. Thus, the incidence of combined keratitis and ARN was 18% of patients with ARN. The two diseases occurred concomitantly in four out of five patients. Mean age at diagnosis was 55 ± 17 years. Of the five patients with both corneal and retinal involvement, three patients were immunocompromised and three had a history of herpetic diseases. Three developed disciform keratitis and two developed stromal immune keratitis. Clinical management and outcomes of these patients did not differ from patients with ARN alone, except for a lower rate of retinal detachment (p = 0.006) and a higher proportion with visual acuity ≥ 20/200 (p = 0.01).

Conclusions: Keratitis may complicate the clinical picture of one out of five to six patients with ARN. Comprehensive ophthalmic examination, including careful anterior segment exams in patients with ARN and sequential dilated fundus exams in patients with herpetic keratitis, should always be conducted to identify cases of concomitant disease.
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http://dx.doi.org/10.1038/s41433-020-0826-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7784993PMC
December 2020

Case of bilateral Wessely rings in a contact lens wearer.

Can J Ophthalmol 2019 08 14;54(4):e182-e183. Epub 2019 Jan 14.

University of British Columbia, Vancouver, B.C.. Electronic address:

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http://dx.doi.org/10.1016/j.jcjo.2018.10.023DOI Listing
August 2019

Did Collagen Cross-Linking Reduce the Requirement for Corneal Transplantation in Keratoconus? The Canadian Experience.

Cornea 2019 Nov;38(11):1390-1394

Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver General Hospital Eye Care Center, Vancouver, BC, Canada.

Purpose: To investigate the relationship between corneal collagen cross-linking (CXL) and the number of corneal transplants required for the treatment of keratoconus (KCN) in 2 major Canadian provinces.

Methods: This is a retrospective review of all corneal transplantation performed in Ontario and British Columbia over an 18-year period (1998-2016). Data were collected at the Eye Bank of Canada-Ontario/British Columbia Divisions. The primary outcome was to determine the change in proportion and absolute number of corneal transplants required for treatment of KCN since the introduction of CXL in Canada in 2008.

Results: A total of 31,943 grafts were included. Overall, the mean age of participants was 39.3 ± 2.2 years, with our cohort being composed of 28% of women and 72% of men. The results showed a significant decrease in the proportion of total transplants required for KCN between 1998 and 2016 [1998-2008 (pre-CXL), range: 14.77%-12.63%; 2009-2016 (post-CXL), range: 12.98%-5.50%, P < 0.001]. However, there was no change in the absolute number of grafts performed for KCN over this time (pre-CXL: 179 ± 26 grafts; post-CXL: 198 ± 27 grafts; P = 0.5), whereas the total number of grafts (pre-CXL: 1318 ± 183 grafts; post-CXL: 2181 ± 404; P < 0.001) and endothelial keratoplasties (pre-CXL: 59 ± 108; post-CXL: 966 ± 431 grafts; P < 0.001) increased significantly. In addition, there were no changes in penetrating keratoplasty/deep anterior lamellar keratoplasty (DALK) performed for indications other than KCN (pre-CXL: 1080 ± 157; post-CXL: 1017 ± 92; P > 0.5).

Conclusions: Although there has been a significant decrease in the proportion of corneal graft rates for KCN since the introduction of CXL as a factor of all transplants performed for all indications, this result is most likely because of an increase in endothelial keratoplasties rather than decreased transplants performed for definitive treatment.
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http://dx.doi.org/10.1097/ICO.0000000000002085DOI Listing
November 2019

Oral Miltefosine as Adjunctive Treatment for Recalcitrant Acanthamoeba Keratitis.

Cornea 2019 Jul;38(7):914-917

Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC, Canada.

Purpose: Acanthamoeba keratitis is a rare, vision-threatening disease. Commercially available antiamoebics are poorly cysticidal and highly toxic, and therapeutic keratoplasties can be complicated by recurrence or graft failure. We aimed to discuss the use of oral miltefosine for treatment of recalcitrant Acanthamoeba keratitis.

Methods: A 44-year-old contact lens wearer presented with a 2-week history of red painful eye and decreasing vision. After poorly responding to topical corticosteroid on the presumptive diagnosis of anterior uveitis, she developed radial keratoneuritis. Corneal scraping was positive for Acanthamoeba. No clinical response to treatment was observed with topical chlorhexidine 0.02%, polyhexamethylene biguanide 0.02%, and oral voriconazole. She then underwent 2 therapeutic keratoplasties with prompt recurrence of the disease in the keratoplasty graft.

Results: Oral miltefosine was added to the treatment. She underwent a third penetrating keratoplasty 8 months later. The excised button was negative for amoeba. She continued miltefosine for 3 more months. No recurrence was observed after 30 months.

Conclusions: This case shows resolution of recalcitrant Acanthamoeba keratitis with oral miltefosine in an immunocompetent patient. Further clinical evidence would be needed to possibly incorporate this medication in the antiamoebic armamentarium.
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http://dx.doi.org/10.1097/ICO.0000000000001968DOI Listing
July 2019

Management of Descemet Membrane's Folds After Deep Anterior Lamellar Keratoplasty: Descemet Membrane-Tucking Technique.

Cornea 2019 Jun;38(6):772-774

Ophthalmology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy.

Purpose: To describe a surgical maneuver that allows for correction of central Descemet membrane (DM) folds at the end of a deep anterior lamellar keratoplasty (DALK) procedure. We term the present technique "DM tucking."

Methods: A blunt tip spatula is introduced vertically into the trephination cut, 90 degrees away from the main direction of the DM folds, and advanced until it touches the host layer. Gentle pressure is applied, resulting in tucking of the redundant host layer toward the periphery. The tucking maneuver is repeated at different clock hours until a regular graft-host interface is obtained.

Results: We applied the present technique to several DALK procedures performed for keratoconus, and found it to be safe and effective.

Conclusions: DALK is the procedure of choice for the surgical treatment of corneal stromal diseases with a healthy endothelium, such as keratoconus. DM folds are a possible complication after DALK in patients with advanced corneal ectasia, arising from the compression of the redundant host DM by the donor graft, once it is sutured to the recipient. DM folds after DALK, when they involve the visual axis, cause permanent visual disturbances DM tucking allows the displacement of the central DM folds toward the graft margin, where they do not affect the patient's quality of vision.
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http://dx.doi.org/10.1097/ICO.0000000000001910DOI Listing
June 2019

Interface infectious keratitis after anterior and posterior lamellar keratoplasty. Clinical features and treatment strategies. A review.

Br J Ophthalmol 2019 03 24;103(3):307-314. Epub 2018 Oct 24.

Ophthalmology Unit, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy.

Interface infectious keratitis (IIK) is a novel corneal infection that may develop after any type of lamellar keratoplasty. Onset of infection occurs in the virtual space between the graft and the host where it may remain localised until spreading with possible risk of endophthalmitis. A literature review identified 42 cases of IIK. Thirty-one of them occurred after endothelial keratoplasty and 12 after deep anterior lamellar keratoplasty. Fungi in the form of species were the most common microorganisms involved, with donor to host transmission of infection documented in the majority of cases. Donor rim cultures were useful to address the infectious microorganisms within few days after surgery. Due to the sequestered site of infection, medical treatment, using both topical and systemic antimicrobials drugs, was ineffective on halting the progression of the infection. Injection of antifungals, right at the graft-host interface, was reported successful in some cases. Spreading of the infection with development of endophthalmitis occurred in five cases after Descemet stripping automated endothelial keratoplasty with severe sight loss in three cases. Early excisional penetrating keratoplasty showed to be the treatment with the highest therapeutic efficacy, lowest rate of complications and greater visual outcomes.
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http://dx.doi.org/10.1136/bjophthalmol-2018-312938DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6579547PMC
March 2019

Epidemiology of bacterial corneal ulcers at tertiary centres in Vancouver, B.C.

Can J Ophthalmol 2018 08 3;53(4):330-336. Epub 2018 Feb 3.

Eye Care Center, Cornea Unit, Department of Ophthalmology, University of British Columbia, Vancouver, B.C.

Objective: To report the epidemiology of culture-positive bacterial corneal ulcers in Vancouver, B.C., Canada.

Design: Retrospective, observational case series.

Methods: Predetermined search terms were entered into the hospitals' electronic microbiology databases to create a cohort of patients who had undergone corneal scrapings for ulcers from April 2006 to March 2011. All specimens were plated on culture media. Cultured species were identified, and antimicrobial sensitivities were obtained. Clinical charts were then reviewed to identify associated risk factors.

Results: In total 281 corneal scrapings were included, with a positive culture recovery rate of 75%. Bacterial keratitis accounted for 84.8% of culture-positive ulcers, followed by fungi (10%) and finally Acanthamoeba (5.2%); 73% of ulcers were monomicrobial in origin and 28% polymicrobial. We found an increase in Gram-negative micro-organisms over time. General sensitivity to antibiotics did not change over time. A major risk factor for Gram-positive involvement was ocular surface disease, whereas contact lens wear was a major risk factor for Gram-negative involvement.

Conclusions: Bacterial keratitis was found to be the major cause of infectious keratitis in Vancouver, B.C. The majority of bacterial ulcers were caused by Gram-positive bacteria. However, we found an increase in Gram-negative involvement over time. Contact lens wear was identified as the major risk factor for development of Gram-negative ulcers. Pre-existing ocular disease was associated with Gram-positive infection. Susceptibility of Gram-negative bacteria to common broad-spectrum antibiotics was high, but susceptibility of Gram-positive bacteria to these antibiotics was lower and more variable.
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http://dx.doi.org/10.1016/j.jcjo.2017.11.001DOI Listing
August 2018

Lamellar macular holes: surgical outcome of 106 patients with long-term follow-up.

Graefes Arch Clin Exp Ophthalmol 2018 Jul 21;256(7):1265-1273. Epub 2018 May 21.

Ophthalmology, Santa Maria Nuova Hospital IRCCS, Reggio Emilia, Italy.

Purpose: To determine long-term results of vitrectomy for lamellar macular holes (LMH). To evaluate how the type of lamellar macular hole (tractional vs. degenerative) and the crystalline lens status might influence visual outcomes.

Methods: We collected data from 106 patients with symptomatic lamellar macular hole that underwent pars plana vitrectomy with membranectomy and internal limiting membrane peeling. Best-corrected visual acuity (BCVA) and optical coherence tomography appearance were determined preoperatively and postoperatively.

Results: Most of the lamellar holes were of tractional type (65%). Mean follow-up after surgery was 36 months. Mean BCVA increased from 20/50 to 20/43 at 6 months and 20/33 at last follow-up visit (p < 0.001). Vision improved in 74 (70%), remained stable in 11 (10%), and decreased in 21 (20%) eyes. Subgroup analysis showed that visual acuity significantly increased in the tractional but not in the degenerative forms of LMH. Thirteen eyes lost two or more ETDRS lines after surgery. Preoperative phakic/pseudophakic status influenced the functional outcomes.

Conclusions: Surgery may be effective in some subsets of patients with lamellar macular hole, but postoperative visual loss is not uncommon and prospective controlled studies are warranted.
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http://dx.doi.org/10.1007/s00417-018-3989-6DOI Listing
July 2018

Reply.

Cornea 2018 04;37(4):e21-e22

Department of Ophthalmology and Visual Science, The University of Chicago, Chicago, IL.

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http://dx.doi.org/10.1097/ICO.0000000000001529DOI Listing
April 2018

Cataract surgery in patients with pseudoex-foliation syndrome: current updates.

Clin Ophthalmol 2017 31;11:1377-1383. Epub 2017 Jul 31.

Ophthalmology Unit, Arcispedale Santa Maria Nuova - IRCCS, Reggio Emilia, Italy.

Pseudoexfoliation is a ubiquitous syndrome of multifactorial origin affecting elderly people by increasing the risk of cataract and secondary glaucoma development. Despite modern techniques and technologies for cataract surgery, pseudoexfoliation syndrome represents a challenge for surgeons because of the increased weakness of the zonular apparatus and limited pupil dilation. Due to the inherent difficulties during surgery, the risk of vitreous loss in these patients is several times higher than in cataract patients without pseudoexfoliation. Using currently available surgical devices (ophthalmic viscosurgical device, iris retractors and ring dilators, capsular tension ring, etc.), the risk of intraoperative complications may be much reduced, allowing the surgeon to handle difficult cases with greater confidence and safety. This review analyzes the methodologic approach to the patient with zonular laxity with the aim of providing useful advices to limit the risks of intraoperative and postoperative complications. From the preoperative planning, to the intraoperative management of the small pupil and phacodonesis, and to the postoperative correction of capsule phimosis and intraocular lens dislocation, a step approach to the surgical management of pseudoexfoliation patients is illustrated.
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http://dx.doi.org/10.2147/OPTH.S142870DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5546806PMC
July 2017

Human papillomavirus (HPV)-associated trilateral squamous neoplasia in immunocompetent individual.

Int Ophthalmol 2018 Jun 6;38(3):1347-1350. Epub 2017 Jun 6.

Department of Ophthalmology, Arcispedale Santa Maria Nuova - IRCCS, Viale Risorgimento, 80, 42121, Reggio Emilia, Italy.

Purpose: To describe a case of bilateral conjunctival and cervical human papillomavirus (HPV)-related squamous neoplasia.

Case Description: A healthy immunocompetent 55-year-old lady came to our attention for prosecution of care of a right recurrent conjunctival squamous cell carcinoma. Upon examination, she was found disease-free in the right eye but displayed a left conjunctival intraepithelial neoplasia (CIN grade I) and low-grade cervical squamous dysplasia. HPV infection with genotypes 16 (right eye), 11 and 39 (left eye) and 39 (uterine cervix) was also detected.

Conclusion: Simultaneous uterine and conjunctival HPV-related squamous neoplasia can occur in immunocompetent individuals. Auto-inoculation and repeated exposure to HPV could explain coexistence of different genotypes.
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http://dx.doi.org/10.1007/s10792-017-0573-8DOI Listing
June 2018

Descemetorhexis Without Graft Placement for the Treatment of Fuchs Endothelial Dystrophy: Preliminary Results and Review of the Literature.

Cornea 2017 Jun;36(6):637-641

Department of Ophthalmology, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy.

Purpose: To report our preliminary experience with a central descemetorhexis without graft placement in Fuchs endothelial corneal dystrophy (FECD) and to review the existing literature on the topic.

Methods: A 4-mm central descemetorhexis was performed in 5 patients (4 women, 1 man; mean age: 69.8 ± 8.6 yrs; range: 57-78 yrs) with FECD. All patients had central confluent guttae, undetectable central endothelial cell count, healthy peripheral corneal endothelium, no clinically evident bullous keratopathy, and no ocular comorbidities. In 3 patients, the procedure was combined with phacoemulsification and intraocular lens implantation.

Results: All patients completed at least 6 months of postoperative follow-up (mean follow-up 9 ± 2.5 mo; 7-13 mo). Endothelial repopulation of the central stroma was completed in all patients by the third month. Corneal clarity was achieved in 4 of 5 patients. The patient with persistent edema and haze had the highest preoperative central pachymetry. A final improvement in corrected visual acuity was achieved in 4/5 patients. A reduction in preoperative central pachymetry was observed in all cases. All patients developed deep stromal opacities around the margin of the descemetorhexis, which did not resolve over the follow-up time. Abnormal corneal topography and irregular astigmatism developed in 3 of 5 patients; these patients achieved 20/20 corrected distance visual acuity with rigid gas-permeable contact lens fitting.

Conclusions: In partial concordance with previous studies, preliminary outcomes of a central descemetorhexis in FECD performed without endothelial graft placement seemed rather unpredictable. Baring of central stroma may trigger a variable wound-healing response with subsequent posterior stromal scarring and topographical irregularity.
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http://dx.doi.org/10.1097/ICO.0000000000001202DOI Listing
June 2017

Accelerated Corneal Collagen Cross-Linking Using Topography-Guided UV-A Energy Emission: Preliminary Clinical and Morphological Outcomes.

J Ophthalmol 2016 28;2016:2031031. Epub 2016 Nov 28.

Ophthalmology Unit, Arcispedale Santa Maria Nuova Hospital-IRCCS, Reggio Emilia, Italy.

. To assess the clinical and morphological outcomes of topography-guided accelerated corneal cross-linking. . Retrospective case series. . 21 eyes of 20 patients with progressive keratoconus were enrolled. All patients underwent accelerated cross-linking using an ultraviolet-A (UVA) exposure with an energy release varying from 7.2 J/cm up to 15 J/cm, according to the topographic corneal curvature. Uncorrected (UDVA) and corrected (CDVA) distance visual acuity, topography, in vivo confocal microscopy (IVCM), and anterior segment optic coherence tomography (AS-OCT) were evaluated preoperatively and at the 1, 3, 6, and 12 months postoperatively. . 12 months after surgery UDVA and CDVA did not significantly vary from preoperative values. The average topographic astigmatism decreased from -4.61 ± 0.74 diopters (D) to -3.20 ± 0.81 D and coma aberration improved from 0.95 ± 0.03 m to 0.88 ± 0.04 m after surgery. AS-OCT and IVCM documented differential effects on the treated areas using different energies doses. The depths of demarcation line and keratocyte apoptosis were assessed. . Preliminary results show correspondence between the energy dose applied and the microstructural stromal changes induced by the cross-linking at various depths in different areas of treated cornea. One year after surgery a significant reduction in the topographic astigmatism and comatic aberration was detected. None of the patients developed significant complications.
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http://dx.doi.org/10.1155/2016/2031031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5149693PMC
November 2016

Outcomes of photorefractive keratectomy following laser in situ keratomileusis: a cohort study.

Can J Ophthalmol 2016 Dec 30;51(6):417-422. Epub 2016 Sep 30.

Department of Ophthalmology, University Health Network, Toronto, Ont.

Objective: To analyze the outcomes of photorefractive keratectomy (PRK) on residual myopia and hyperopia post-laser in situ keratomileusis (LASIK) and to compare these results with PRK on eyes without previous laser refractive surgery.

Design: Retrospective comparative cohort study.

Participants: Patients undergoing PRK between 2006 and 2010 were reviewed.

Methods: Patients were divided into 4 groups, myopic or hyperopic PRK post-LASIK (mPRK-PL and hPRK-PL, respectively) and myopic or hyperopic PRK on corneas without previous laser refractive surgery (mPRK and hPRK, respectively). Uncorrected and corrected distance visual acuity, mean refractive spherical equivalent (MRSE), and mean keratometry and aberrations (total, higher order [HOA], coma, trefoil, and spherical aberration) were recorded at months 3 and 6 postoperatively, as were complications and attempted versus achieved MRSE.

Results: Thirty-three eyes of 25 patients who underwent PRK post-LASIK (21 eyes of 14 patients for hPRK-PL and 12 eyes of 11 patients for mPRK-PL) and 35 eyes of 21 patients who underwent PRK on virgin eyes (11 eyes of 8 patients for hPRK and 24 eyes of 13 patients for mPRK) were included in the study. The only significant differences in outcomes were found to be HOA at 3 months for hPRK-PL as compared with both hPRK and mPRK. Achieved MRSE was significantly different from expected MRSE for hPRK-PL at 3 months postoperatively. No haze- or flap-related complications were observed.

Conclusion: Outcomes of PRK were not different in myopic and hyperopic corrections post-LASIK by 6 months or when compared with PRK in virgin eyes. HOA may render hPRK-PL results less predictable early in the postoperative period.
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http://dx.doi.org/10.1016/j.jcjo.2016.02.024DOI Listing
December 2016

Bromfenac ophthalmic solution 0.09% as an adjunctive therapy to topical steroids after cataract surgery in pseudoexfoliation syndrome.

J Cataract Refract Surg 2016 08;42(8):1119-25

From the Ophthalmology Unit (Coassin, Iovieno, Soldani, Cimino, Sartori, Fontana) and Clinical Trials and Statistics Unit (Cavuto, Formisano), Istituto di Ricerca e Cura a Carattere Scientifico-Arcispedale Santa Maria Nuova, Reggio Emilia, Italy. Electronic address:

Purpose: To study with laser flare photometry the antiinflammatory effect of bromfenac added to a topical steroid versus a topical steroid alone in patients with pseudoexfoliation (PXF) syndrome after cataract surgery.

Setting: Ophthalmology Unit, Santa Maria Nuova Hospital, Reggio Emilia, Italy.

Design: Randomized clinical trial.

Methods: Patients with cataract and clinical signs of PXF were randomized to dexamethasone 0.1% and tobramycin 0.3% ophthalmic solution (Group 1) or with the adjunct of bromfenac ophthalmic solution 0.09% (Group 2). All patients were examined on the day of surgery (baseline) and postoperatively at 1, 3, 7, and 30 days. Laser flare photometry was used to quantify anterior chamber inflammation and optical coherence tomography to measure macular thickness.

Results: Sixty-two patients were included. Postoperatively, the mean flare was 31% lower in Group 2 than in Group 1 at 3 days (11.92 ph/msec ± 8.14 [SD] versus 17.13 ± 9.03 ph/msec; P = .025) and 43% lower at 7 days (10.77 ± 6.17 ph/msec versus 18.72 ± 12.37 ph/msec; P = .003). There were no significant differences in postoperative visual acuity, symptoms, or ocular pain between groups. The mean macular thickness 1 month after surgery was increased in Group 1 but not Group 2; the difference between groups was significant at 4 weeks (P = .03). The incidence of intraretinal cysts was higher in Group 1 (n = 4) than in Group 2 (n = 0).

Conclusion: The addition of bromfenac to topical steroids after cataract surgery in eyes with PXF was associated with greater reductions in inflammation than steroids alone.

Financial Disclosure: None of the authors has a financial or proprietary interest in any material or method mentioned.
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http://dx.doi.org/10.1016/j.jcrs.2016.04.031DOI Listing
August 2016

Vitreoretinal lymphomas misdiagnosed as uveitis: Lessons learned from a case series.

Indian J Ophthalmol 2016 May;64(5):369-75

Department of Ophthalmology, Santa Maria Nuova Hospital-IRCCS, Reggio Emilia, Italy.

Purpose: To present challenging cases of vitreoretinal lymphoma (VRL) that was misdiagnosed as uveitis because of the apparent intraocular inflammation. At the light of the new classification of intraocular lymphomas, we detail the characteristics that masqueraded the tumors and the clinical aspects that guided us to the correct diagnosis.

Materials And Methods: We retrospectively reviewed the patients referred to our uveitis service between January 2006 and December 2014.

Results: Seven patients referred with a presumptive diagnosis of idiopathic uveitis received a final diagnosis of VRL. The median time between the onset of symptoms and definitive diagnosis was 25 months for these complex cases. The median time from presentation at our clinic to final diagnosis was 1 month. The described clinical features including dense vitreous cells and subretinal infiltrates were characteristic and tend to be present in all these chronically ill patients. Vitreous samples were collected, and all demonstrated the pathognomonic tumor cells, the specific immunoglobulin heavy chain gene rearrangements, and an interleukin (IL)-10 to IL-6 ratio >1.

Conclusion: VRLs are severe diseases with a poor prognosis that may be misdiagnosed as idiopathic inflammatory conditions of the eye. Treatment with steroids may occult the tumors and delay the correct diagnosis. Appropriate evaluation may prompt to a timely vitreous sampling and therefore to a faster diagnosis in these peculiar cases where the correct diagnosis was delayed by several months.
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http://dx.doi.org/10.4103/0301-4738.185600DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4966374PMC
May 2016