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Papers by David Diaz-Valle

Research paper thumbnail of Tratamiento de la escleritis anterior difusa refractaria con infliximab

Archivos de la Sociedad Española de Oftalmología, 2004

espanolCaso clinico: Mujer de 48 anos de edad diagnosticada de artritis reumatoide (AR) 10 anos a... more espanolCaso clinico: Mujer de 48 anos de edad diagnosticada de artritis reumatoide (AR) 10 anos antes, desarrollo una escleritis anterior severa en ojo derecho (OD) refractaria al tratamiento convencional. La paciente fue tratada mediante infusion intravenosa de 3 dosis de infliximab consiguiendo la remision completa de la inflamacion escleral en 4 semanas. Discusion: El uso del infliximab, un inhibidor del factor de necrosis tumoral a (TNFalfa), podria constituir una alternativa terapeutica en el tratamiento de la escleritis refractaria al tratamiento convencional, si bien son necesarios estudios adicionales a mas largo plazo para evaluar su seguridad y eficacia. EnglishCase report: A 48-year old woman diagnosed with rheumatoid arthritis 10 years previously, developed severe anterior scleritis in the right eye (RE) refractory to conventional treatment. The patient was treated with 3 intravenous doses of Infliximab achieving complete remission of the scleral inflammation within four weeks. Discussion: The use of Infliximab, a blocker of tumour necrosis factor ( (TNF() could be an alternative approach to the management of refractory scleritis, but further long-term investigations would be necessary to evaluate their safety and efficacy.

Research paper thumbnail of Correction to: Validation of UVEDAI: An Index for Evaluating the Level of Inflammatory Activity in Uveitis

Ophthalmology and Therapy

Research paper thumbnail of Blood-aqueous barrier permeability determination in HLA B27-positive acute anterior uveitis patients

International Ophthalmology, 1995

The blood-aqueous barrier (BAB) permeability was studied by fluorophotometry in 17 healthy contro... more The blood-aqueous barrier (BAB) permeability was studied by fluorophotometry in 17 healthy control subjects and in 27 eyes from 27 patients with HLA-B27-positive acute anterior uveitis (HLA-B27 AAU). Twenty of these patients had an associated spondyloarthropathy. BAB permeability was studied during the ocular inflammatory crisis and in the disease-free periods in the same patients. Anterior chamber fluorophotometric scans were performed before and 30 minutes after the intravenous injection of 14 mg/kg of sodium fluorescein. The diffusion coefficient (Kd) was obtained from the ratio between the fluorescein concentration in the anterior chamber and the NPBF. Data were analyzed using the Student's t test and analysis of variance. A statistically significant difference (P < 0.001) was found between the Kd of active HLA-B27 AAU (61.4 +/- 16.8 x 10(-4) min-1) and the Kd of inactive HLA-B27 AAU (4.8 +/- 1.6 x 10(-4) min-1). No statistically significant differences were found between the Kd of inactive HLA-B27 AAU and the Kd of the control subjects (4.3 +/- 1.0 x 10(-4) min-1). We also failed to detect significant differences between patients with and without spondyloarthropathy either during the acute attack or during the disease-free period. On the basis of these results we conclude that the permeability of the BAB remains intact in inactive HLA-B27-positive AAU. The parallel fluorophotometric behaviour of HLA-B27-positive AAU with spondyloarthropathy and without spondyloarthropathy suggests that both share a common pathogenetic mechanism.

Research paper thumbnail of Toxoplasmic maculopathy with bacillary layer detachment in a pediatric patient

Journal of American Association for Pediatric Ophthalmology and Strabismus

Research paper thumbnail of Face mask use and effects on the ocular surface health: A comprehensive review

Research paper thumbnail of Clinical outcomes of long-term corneas preserved frozen in Eusol-C used in emergency tectonic grafts

Cell and Tissue Banking

previous corneal graft failure (10, 22%). Mean size of grafts was 5.6 mm and 36 cases (72%) also ... more previous corneal graft failure (10, 22%). Mean size of grafts was 5.6 mm and 36 cases (72%) also received an amniotic membrane graft. Thirty-eight corneas achieved epithelization (76%), 25 (50%) were clear and 19 (38%) developed neovascularization. None of the corneas were rejected. Seventeen corneas (34%) failed: 7 (14%) due to reactivation of baseline disease and 10 (20%) due to primary graft failure. Four corneas (8%) had positive microbial cultures suggestive of contamination and 2 (4%) developed a cornea abscess non-related to a positive microbial culture. Long-term preservation of donor corneas in Eusol-C at − 78 °C is a viable technique to meet the needs of emergency grafts with minimal equipment.

Research paper thumbnail of Long-Term Results of Postoperative Rescuing of Inverted DMEK Grafts: Two Case Reports

Cornea, 2022

PURPOSE The purpose of this study was to report the clinical outcomes of postoperative reposition... more PURPOSE The purpose of this study was to report the clinical outcomes of postoperative repositioning of 2 inverted Descemet membrane endothelial keratoplasty (DMEK) grafts in 2 patients with endothelial dysfunction. METHODS Two patients underwent DMEK surgery in a tertiary referral corneal clinic. Initial surgery was performed by 2 different corneal surgeons, and a third surgeon repositioned both cases. In the early postoperative period, partial and subtotal detachments were observed at slitlamp and inverted graft orientation was confirmed by anterior segment optical coherence tomography. In both cases, uneventful reposition of the inverted graft was performed by an experienced DMEK surgeon on days 2 and 9 after initial DMEK surgery. RESULTS Repositioning surgery was successful in both patients. The Moutsouris sign was used to confirm proper orientation. One patient had total graft adherence at day 1 postrepositioning. The second patient required a rebubbling procedure, despite the correct orientation confirmed by using anterior segment optical coherence tomography. Visual acuity and corneal thickness were stable in both cases (case 1: 20/30, 567 μm; case 2: 20/80, 543 μm). Both patients had clear corneas and functional cell counts 2 years after repositioning (451 cells/mm2 and 1052 cells/mm2). CONCLUSIONS Postoperative repositioning of an inverted DMEK graft may be a viable procedure to delay or prevent regrafting.

Research paper thumbnail of Peripheral Melt of Flap after Laser in situ Keratomileusis

Journal of Refractive Surgery, 1998

Laser in situ keratomileusis (LASIK) is an effective procedure to correct myopia. It may have com... more Laser in situ keratomileusis (LASIK) is an effective procedure to correct myopia. It may have complications related to the flap, such as epithelial ingrowth and stromal melt. We report on a patient who developed extensive epithelial ingrowth and partial keratolysis of the flap following LASIK. This complication was treated by lifting the flap and removing the epithelium from within the interface. Progressive keratolysis (stromal melt) can result in irregular astigmatism and loss of vision as well as photophobia and ciliary injection. The pathogenesis is not completely understood although the epithelial ingrowth in the interface is always present, and epithelial-stromal interaction with production of proteases may be involved. Epithelial ingrowth may develop in the lamellar interface after LASIK and be associated with melting of the edge of the flap. This undesirable complication can be successfully managed with early surgical removal of the epithelium and proper attachment of the flap.

Research paper thumbnail of Efficacy, safety and cost-effectiveness of methotrexate, adalimumab or their combination in non-infectious non-anterior uveitis: a protocol for a multicentre, randomised, parallel three arms, active-controlled, phase III open label with blinded outcome assessment study

BMJ Open, 2022

IntroductionNon-infectious uveitis include a heterogeneous group of sight-threatening and incapac... more IntroductionNon-infectious uveitis include a heterogeneous group of sight-threatening and incapacitating conditions. Their correct management sometimes requires the use of immunosuppressive drugs (ISDs), prescribed in monotherapy or in combination. Several observational studies showed that the use of ISDs in combination could be more effective than and as safe as their use in monotherapy. However, a direct comparison between these two treatment strategies has not been carried out yet.Methods and analysisThe Combination THerapy with mEthotrexate and adalImumAb for uveitis (CoTHEIA) study is a phase III, multicentre, prospective, randomised, single-blinded with masked outcome assessment, parallel three arms with 1:1:1 allocation, active-controlled, superiority study design, comparing the efficacy, safety and cost-effectiveness of methotrexate, adalimumab or their combination in non-infectious non-anterior uveitis. We aim to recruit 192 subjects. The duration of the treatment and follo...

Research paper thumbnail of Comparison of the efficacy of topical insulin with autologous serum eye drops in persistent epithelial defects of the cornea

Acta Ophthalmologica, 2021

PURPOSE To investigate the effect of topical insulin on epithelization in persistent epithelial d... more PURPOSE To investigate the effect of topical insulin on epithelization in persistent epithelial defects (PED) refractory to usual treatment compared to autologous serum. DESIGN Retrospective, consecutive case-control series. METHODS The charts of 61 consecutive patients with PED treated with topical insulin (case group) and 23 treated with autologous serum (control group) were reviewed. Primary efficacy end points were the percentage of patients in which epithelization was achieved, as well as the rate and time until epithelization. Secondary efficacy point was need for amniotic membrane transplantation (AMT) or other surgeries. RESULTS Mean time between PED diagnosis and start of topical insulin was 22.7 ± 18.5 days (range 13-115) and the mean area was 14.8 ± 16.2 mm2 (range 1.1-70.6). In the control group, mean time was 27.9 ± 16.8 days, mean epithelial defect area being 18.6 ± 15.0 mm2 (range 1.7-52.9). No differences in baseline characteristics were found between groups (p > 0.05). Epithelization was achieved in 51 patients (84%) on insulin and 11 patients (48%) on autologous serum (p = 0.002). In those patients, mean time until reepithelization was 32.6 ± 28.3 days (range 4-124) in the insulin group and 82.6 ± 82.4 days (range 13-231) in the autologous serum group (p = 0.011). The need for AMT was significantly lower in the insulin group (p = 0.005). PED recurrence was higher in patients treated on autologous serum (43%) compared with insulin (11%) (p = 0.002). CONCLUSIONS Topical insulin is an effective treatment and safely promotes healing of PED. In our series, topical insulin presented better epithelization outcomes than autologous serum and could thus be considered as a first-line treatment.

Research paper thumbnail of Comment on

Research paper thumbnail of Management and Treatment of Central Steep Islands after Excimer Laser Photorefractive Keratectomy

Journal of Refractive Surgery, 1996

Permanent central steep islands are an undesirable phenomenon that cause distorted images and a s... more Permanent central steep islands are an undesirable phenomenon that cause distorted images and a significant reduction in visual acuity. We describe treatment of central steep islands with repeat excimer laser photoablation in the central cornea. Three patients with preoperative refractions of -7.50 -2.50 x 170 degrees D (right eye), -8.00 -2.25 x 10 degrees D (right eye) and -6.00 -1.50 x 90 degrees (right eye) developed central steep islands which persisted more than 12 months. All patients lost more than two lines of spectacle-corrected visual acuity and complained of visual disturbances. We retreated the central steep islands with a VISX 20/20 excimer laser PRK ablation that matched the size of the central island measured on videokeratography. Symptomatic glare and distortion were significantly reduced and the central steep islands were resolved. Several weeks after reablation, spectacle-corrected visual acuity improved to the preoperative level. Central steep island, an infrequent complication of excimer laser photorefractive keratectomy, can be safely removed with a repeat laser ablation that matches the central circular steep area.

Research paper thumbnail of Concentric rings after femtosecond laser-assisted phacoemulsification with Descemet's membrane endothelial keratoplasty

Indian Journal of Ophthalmology - Case Reports, 2021

Research paper thumbnail of Spontaneous resolution of inflammatory epiretinal membrane: Case series and review of the literature

Epiretinal membrane (ERM) represents a common complication of uveitis that may contribute indepen... more Epiretinal membrane (ERM) represents a common complication of uveitis that may contribute independently to vision loss in patients with uveitis. Although spontaneous idiopathic ERM separation has been previously reported, to the best of our knowledge there are only two case reports in the scientific literature that depicts spontaneous regression of an inflammation-associated ERM. Spontaneous ERM separation is a rare but possible event, which occurs most often subsequent to posterior vitreous detachment. We present a case series of three patients with uveitis that exhibit the formation and subsequent spontaneous resolution of an inflammatory ERM.

Research paper thumbnail of Topical insulin for refractory persistent corneal epithelial defects

European Journal of Ophthalmology

Purpose: To evaluate insulin eye drops for persistent epithelial defects (PEDs) that are refracto... more Purpose: To evaluate insulin eye drops for persistent epithelial defects (PEDs) that are refractory to usual treatment in clinical practice and to analyze how it may improve epithelization. Methods: A prospective non-randomized hospital-based study was performed. Patients with PEDs that were refractory to conventional treatment were treated with insulin eye drops four times a day. Patients’ demographics, PED etiology, concomitant treatments, and comorbidities were reviewed. The rate of PED closure and epithelial healing time were considered the primary outcome measures. Results: 21 patients were treated with insulin drops (12 females and 9 males; mean age 72.2 years). Mean PED area before treatment was 17.6 ± 16.5 mm2 (median 13.2; range 3.9–70.6). PED comorbidities included seven eyes with infectious keratitis (33%), five eyes with calcium keratopathy (24%), ocular surgery on three eyes (14%), three eyes with lagophthalmos (14%), two eyes with bullous keratopathy (10%), and one pat...

Research paper thumbnail of Multicentre study: reliability and repeatability of Scheimpflug system measurement in keratoconus

British Journal of Ophthalmology

PurposeTo assess the repeatability and reliability of the most important tomographic parameters f... more PurposeTo assess the repeatability and reliability of the most important tomographic parameters for characterising keratoconus measured with a Pentacam HR (high resolution).MethodsOverall, 230 eyes in 158 patients with keratoconus were analysed. We performed five consecutive corneal tomography examinations for each eye with a Pentacam HR in patients with keratoconus. Study eyes were classified into three groups depending on the maximum posterior elevation (max_BFS_post): grade 1 for cases of keratoconus with a max_BFS_post of 40 µm; grade 2 for those with a max_BFS_post of between 41 and 75 µm and grade 3 for those with a max_BFS_post of over 75 µm. We calculated the intraclass correlation coefficients (ICCs) and repeatability limits of parameters from tomography and aberrometry.ResultsAll the parameters were found to have excellent ICCs (0.9). The repeatability limits for the key parameters were higher than 0.5D for the power parameters, 20° for the axis of corneal astigmatism and ...

Research paper thumbnail of Predictors for functional and anatomic outcomes in macular edema secondary to non-infectious uveitis

PLOS ONE

We aimed to investigate predictive factors for visual and anatomic outcomes in patients with macu... more We aimed to investigate predictive factors for visual and anatomic outcomes in patients with macular edema secondary to non-infectious uveitis. Material and methods We conducted a multicenter, prospective, observational, 12-month follow-up study. Participants included in the study were adults with non-infectious uveitic macular edema (UME), defined as central subfoveal thickness (CST) of >300 μm as measured by spectral domain optical coherence tomography (SD-OCT) and fluid in the macula. Demographic, clinical and tomographic data was recorded at baseline, 1, 3, 6 and 12 months. Foveal-centered SD-OCT exploration was set as the gold-standard determination of UME using a standard Macular Cube 512x128 A-scan, within a 6 x 6 mm 2 area, and the Enhanced High Definition Single-Line Raster. To assess favorable prognosis, the main outcomes analyzed were the best-corrected visual acuity (BCVA) and the CST. Favorable prognosis was defined as sustained improvement of BCVA (2 lines of gain of the Snellen scale) and CST (decrease of 20% of the initial value or <300 μm) within a 12 month period. Results Fifty-six eyes were analyzed. The number of eyes with sustained improvement in the CST was 48 (86.2%), against 23 (41.1%) eyes with sustained improvement in BCVA. Favorable prognosis, as defined above, was observed in 18 (32.1%) eyes. UME prognosis was negatively correlated with baseline foveal thickening, alteration in the vitreo-macular interface and cystoid macular edema. In contrast, bilaterally, systemic disease and the presence of anterior chamber cells were predictive of favorable prognosis.

Research paper thumbnail of Guidance on Noncorticosteroid Systemic Immunomodulatory Therapy in Noninfectious Uveitis: Fundamentals Of Care for UveitiS (FOCUS) Initiative

Ophthalmology, Jan 6, 2018

An international, expert-led consensus initiative to develop systematic, evidence-based recommend... more An international, expert-led consensus initiative to develop systematic, evidence-based recommendations for the treatment of noninfectious uveitis in the era of biologics. The availability of biologic agents for the treatment of human eye disease has altered practice patterns for the management of noninfectious uveitis. Current guidelines are insufficient to assure optimal use of noncorticosteroid systemic immunomodulatory agents. An international expert steering committee comprising 9 uveitis specialists (including both ophthalmologists and rheumatologists) identified clinical questions and, together with 6 bibliographic fellows trained in uveitis, conducted a Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol systematic review of the literature (English language studies from January 1996 through June 2016; Medline [OVID], the Central Cochrane library, EMBASE, CINAHL, SCOPUS, BIOSIS, and Web of Science). Publications included randomized controlled trials, p...

Research paper thumbnail of Glaukos® trabecular stent used to treat steroid-induced glaucoma

European Journal of Ophthalmology, 2012

Purpose This case report illustrates the efficacy of the Glaukos trabecular bypass (Glaukos i-ste... more Purpose This case report illustrates the efficacy of the Glaukos trabecular bypass (Glaukos i-stent, Glaukos Corporation, Laguna Hills, California, USA) used for intraocular pressure (IOP) control in a patient with glaucoma induced by the steroid treatment of post–laser-assisted in situ keratomileusis (LASIK) bilateral anterior uveitis. Methods A 35-year-old woman who had undergone LASIK 5 months previously presented with blurred vision in both eyes. Examination revealed bilateral anterior uveitis and diffuse lamellar keratitis (DLK) requiring steroid treatment. In response to treatment, inflammation improved but the patient had increased IOP that was difficult to control. The course of pressure elevation was more aggressive in the left eye despite the gradual discontinuation of steroids. We therefore decided to place 2 trabecular i-stents in the left eye. Results This solution achieved good pressure control with no associated complications after 1 year follow-up. Conclusions This t...

Research paper thumbnail of Charles Bonnet plus syndrome: apropos of a case

European Journal of Ophthalmology, 2012

Charles Bonnet syndrome plus is an exceedingly rare variant of this disorder. The variant has bee... more Charles Bonnet syndrome plus is an exceedingly rare variant of this disorder. The variant has been described in patients with sight impairment and severe hypoacusis, and is usually characterized by complex visual and auditory--musical--hallucinations that the patients recognize as unreal. Case report. A 75-year-old woman diagnosed with Usher syndrome presented with visual acuity of light perception in both eyes, which did not improve with the use of a pinhole occluder. She also had coptosis in right ear and severe hypoacusis in left ear, confirmed through audiometry. Audiometric tests were normal once the implant and the hearing aid were connected. The patient was referred to the Neuro-Ophthalmology Unit after recounting experiencing complex visual hallucinations, as well as auditory (musical) ones at night after disconnecting the hearing aid. She described the latter as a nightly occurrence of hearing &amp;amp;amp;amp;amp;amp;quot;cabaret music.&amp;amp;amp;amp;amp;amp;quot; Nevertheless, she was aware of reality and of her sensory impairments. The patient was diagnosed at the interdisciplinary Neuro-Ophthalmology Unit, and began pharmacologic treatment with clear improvement. Knowledge of Charles Bonnet syndrome and in particular of Charles Bonnet syndrome plus--due to its infrequency--on the part of ophthalmologists is fundamental to adequately diagnose and treat this rare disorder.

Research paper thumbnail of Tratamiento de la escleritis anterior difusa refractaria con infliximab

Archivos de la Sociedad Española de Oftalmología, 2004

espanolCaso clinico: Mujer de 48 anos de edad diagnosticada de artritis reumatoide (AR) 10 anos a... more espanolCaso clinico: Mujer de 48 anos de edad diagnosticada de artritis reumatoide (AR) 10 anos antes, desarrollo una escleritis anterior severa en ojo derecho (OD) refractaria al tratamiento convencional. La paciente fue tratada mediante infusion intravenosa de 3 dosis de infliximab consiguiendo la remision completa de la inflamacion escleral en 4 semanas. Discusion: El uso del infliximab, un inhibidor del factor de necrosis tumoral a (TNFalfa), podria constituir una alternativa terapeutica en el tratamiento de la escleritis refractaria al tratamiento convencional, si bien son necesarios estudios adicionales a mas largo plazo para evaluar su seguridad y eficacia. EnglishCase report: A 48-year old woman diagnosed with rheumatoid arthritis 10 years previously, developed severe anterior scleritis in the right eye (RE) refractory to conventional treatment. The patient was treated with 3 intravenous doses of Infliximab achieving complete remission of the scleral inflammation within four weeks. Discussion: The use of Infliximab, a blocker of tumour necrosis factor ( (TNF() could be an alternative approach to the management of refractory scleritis, but further long-term investigations would be necessary to evaluate their safety and efficacy.

Research paper thumbnail of Correction to: Validation of UVEDAI: An Index for Evaluating the Level of Inflammatory Activity in Uveitis

Ophthalmology and Therapy

Research paper thumbnail of Blood-aqueous barrier permeability determination in HLA B27-positive acute anterior uveitis patients

International Ophthalmology, 1995

The blood-aqueous barrier (BAB) permeability was studied by fluorophotometry in 17 healthy contro... more The blood-aqueous barrier (BAB) permeability was studied by fluorophotometry in 17 healthy control subjects and in 27 eyes from 27 patients with HLA-B27-positive acute anterior uveitis (HLA-B27 AAU). Twenty of these patients had an associated spondyloarthropathy. BAB permeability was studied during the ocular inflammatory crisis and in the disease-free periods in the same patients. Anterior chamber fluorophotometric scans were performed before and 30 minutes after the intravenous injection of 14 mg/kg of sodium fluorescein. The diffusion coefficient (Kd) was obtained from the ratio between the fluorescein concentration in the anterior chamber and the NPBF. Data were analyzed using the Student&amp;amp;#39;s t test and analysis of variance. A statistically significant difference (P &amp;amp;lt; 0.001) was found between the Kd of active HLA-B27 AAU (61.4 +/- 16.8 x 10(-4) min-1) and the Kd of inactive HLA-B27 AAU (4.8 +/- 1.6 x 10(-4) min-1). No statistically significant differences were found between the Kd of inactive HLA-B27 AAU and the Kd of the control subjects (4.3 +/- 1.0 x 10(-4) min-1). We also failed to detect significant differences between patients with and without spondyloarthropathy either during the acute attack or during the disease-free period. On the basis of these results we conclude that the permeability of the BAB remains intact in inactive HLA-B27-positive AAU. The parallel fluorophotometric behaviour of HLA-B27-positive AAU with spondyloarthropathy and without spondyloarthropathy suggests that both share a common pathogenetic mechanism.

Research paper thumbnail of Toxoplasmic maculopathy with bacillary layer detachment in a pediatric patient

Journal of American Association for Pediatric Ophthalmology and Strabismus

Research paper thumbnail of Face mask use and effects on the ocular surface health: A comprehensive review

Research paper thumbnail of Clinical outcomes of long-term corneas preserved frozen in Eusol-C used in emergency tectonic grafts

Cell and Tissue Banking

previous corneal graft failure (10, 22%). Mean size of grafts was 5.6 mm and 36 cases (72%) also ... more previous corneal graft failure (10, 22%). Mean size of grafts was 5.6 mm and 36 cases (72%) also received an amniotic membrane graft. Thirty-eight corneas achieved epithelization (76%), 25 (50%) were clear and 19 (38%) developed neovascularization. None of the corneas were rejected. Seventeen corneas (34%) failed: 7 (14%) due to reactivation of baseline disease and 10 (20%) due to primary graft failure. Four corneas (8%) had positive microbial cultures suggestive of contamination and 2 (4%) developed a cornea abscess non-related to a positive microbial culture. Long-term preservation of donor corneas in Eusol-C at − 78 °C is a viable technique to meet the needs of emergency grafts with minimal equipment.

Research paper thumbnail of Long-Term Results of Postoperative Rescuing of Inverted DMEK Grafts: Two Case Reports

Cornea, 2022

PURPOSE The purpose of this study was to report the clinical outcomes of postoperative reposition... more PURPOSE The purpose of this study was to report the clinical outcomes of postoperative repositioning of 2 inverted Descemet membrane endothelial keratoplasty (DMEK) grafts in 2 patients with endothelial dysfunction. METHODS Two patients underwent DMEK surgery in a tertiary referral corneal clinic. Initial surgery was performed by 2 different corneal surgeons, and a third surgeon repositioned both cases. In the early postoperative period, partial and subtotal detachments were observed at slitlamp and inverted graft orientation was confirmed by anterior segment optical coherence tomography. In both cases, uneventful reposition of the inverted graft was performed by an experienced DMEK surgeon on days 2 and 9 after initial DMEK surgery. RESULTS Repositioning surgery was successful in both patients. The Moutsouris sign was used to confirm proper orientation. One patient had total graft adherence at day 1 postrepositioning. The second patient required a rebubbling procedure, despite the correct orientation confirmed by using anterior segment optical coherence tomography. Visual acuity and corneal thickness were stable in both cases (case 1: 20/30, 567 μm; case 2: 20/80, 543 μm). Both patients had clear corneas and functional cell counts 2 years after repositioning (451 cells/mm2 and 1052 cells/mm2). CONCLUSIONS Postoperative repositioning of an inverted DMEK graft may be a viable procedure to delay or prevent regrafting.

Research paper thumbnail of Peripheral Melt of Flap after Laser in situ Keratomileusis

Journal of Refractive Surgery, 1998

Laser in situ keratomileusis (LASIK) is an effective procedure to correct myopia. It may have com... more Laser in situ keratomileusis (LASIK) is an effective procedure to correct myopia. It may have complications related to the flap, such as epithelial ingrowth and stromal melt. We report on a patient who developed extensive epithelial ingrowth and partial keratolysis of the flap following LASIK. This complication was treated by lifting the flap and removing the epithelium from within the interface. Progressive keratolysis (stromal melt) can result in irregular astigmatism and loss of vision as well as photophobia and ciliary injection. The pathogenesis is not completely understood although the epithelial ingrowth in the interface is always present, and epithelial-stromal interaction with production of proteases may be involved. Epithelial ingrowth may develop in the lamellar interface after LASIK and be associated with melting of the edge of the flap. This undesirable complication can be successfully managed with early surgical removal of the epithelium and proper attachment of the flap.

Research paper thumbnail of Efficacy, safety and cost-effectiveness of methotrexate, adalimumab or their combination in non-infectious non-anterior uveitis: a protocol for a multicentre, randomised, parallel three arms, active-controlled, phase III open label with blinded outcome assessment study

BMJ Open, 2022

IntroductionNon-infectious uveitis include a heterogeneous group of sight-threatening and incapac... more IntroductionNon-infectious uveitis include a heterogeneous group of sight-threatening and incapacitating conditions. Their correct management sometimes requires the use of immunosuppressive drugs (ISDs), prescribed in monotherapy or in combination. Several observational studies showed that the use of ISDs in combination could be more effective than and as safe as their use in monotherapy. However, a direct comparison between these two treatment strategies has not been carried out yet.Methods and analysisThe Combination THerapy with mEthotrexate and adalImumAb for uveitis (CoTHEIA) study is a phase III, multicentre, prospective, randomised, single-blinded with masked outcome assessment, parallel three arms with 1:1:1 allocation, active-controlled, superiority study design, comparing the efficacy, safety and cost-effectiveness of methotrexate, adalimumab or their combination in non-infectious non-anterior uveitis. We aim to recruit 192 subjects. The duration of the treatment and follo...

Research paper thumbnail of Comparison of the efficacy of topical insulin with autologous serum eye drops in persistent epithelial defects of the cornea

Acta Ophthalmologica, 2021

PURPOSE To investigate the effect of topical insulin on epithelization in persistent epithelial d... more PURPOSE To investigate the effect of topical insulin on epithelization in persistent epithelial defects (PED) refractory to usual treatment compared to autologous serum. DESIGN Retrospective, consecutive case-control series. METHODS The charts of 61 consecutive patients with PED treated with topical insulin (case group) and 23 treated with autologous serum (control group) were reviewed. Primary efficacy end points were the percentage of patients in which epithelization was achieved, as well as the rate and time until epithelization. Secondary efficacy point was need for amniotic membrane transplantation (AMT) or other surgeries. RESULTS Mean time between PED diagnosis and start of topical insulin was 22.7 ± 18.5 days (range 13-115) and the mean area was 14.8 ± 16.2 mm2 (range 1.1-70.6). In the control group, mean time was 27.9 ± 16.8 days, mean epithelial defect area being 18.6 ± 15.0 mm2 (range 1.7-52.9). No differences in baseline characteristics were found between groups (p > 0.05). Epithelization was achieved in 51 patients (84%) on insulin and 11 patients (48%) on autologous serum (p = 0.002). In those patients, mean time until reepithelization was 32.6 ± 28.3 days (range 4-124) in the insulin group and 82.6 ± 82.4 days (range 13-231) in the autologous serum group (p = 0.011). The need for AMT was significantly lower in the insulin group (p = 0.005). PED recurrence was higher in patients treated on autologous serum (43%) compared with insulin (11%) (p = 0.002). CONCLUSIONS Topical insulin is an effective treatment and safely promotes healing of PED. In our series, topical insulin presented better epithelization outcomes than autologous serum and could thus be considered as a first-line treatment.

Research paper thumbnail of Comment on

Research paper thumbnail of Management and Treatment of Central Steep Islands after Excimer Laser Photorefractive Keratectomy

Journal of Refractive Surgery, 1996

Permanent central steep islands are an undesirable phenomenon that cause distorted images and a s... more Permanent central steep islands are an undesirable phenomenon that cause distorted images and a significant reduction in visual acuity. We describe treatment of central steep islands with repeat excimer laser photoablation in the central cornea. Three patients with preoperative refractions of -7.50 -2.50 x 170 degrees D (right eye), -8.00 -2.25 x 10 degrees D (right eye) and -6.00 -1.50 x 90 degrees (right eye) developed central steep islands which persisted more than 12 months. All patients lost more than two lines of spectacle-corrected visual acuity and complained of visual disturbances. We retreated the central steep islands with a VISX 20/20 excimer laser PRK ablation that matched the size of the central island measured on videokeratography. Symptomatic glare and distortion were significantly reduced and the central steep islands were resolved. Several weeks after reablation, spectacle-corrected visual acuity improved to the preoperative level. Central steep island, an infrequent complication of excimer laser photorefractive keratectomy, can be safely removed with a repeat laser ablation that matches the central circular steep area.

Research paper thumbnail of Concentric rings after femtosecond laser-assisted phacoemulsification with Descemet's membrane endothelial keratoplasty

Indian Journal of Ophthalmology - Case Reports, 2021

Research paper thumbnail of Spontaneous resolution of inflammatory epiretinal membrane: Case series and review of the literature

Epiretinal membrane (ERM) represents a common complication of uveitis that may contribute indepen... more Epiretinal membrane (ERM) represents a common complication of uveitis that may contribute independently to vision loss in patients with uveitis. Although spontaneous idiopathic ERM separation has been previously reported, to the best of our knowledge there are only two case reports in the scientific literature that depicts spontaneous regression of an inflammation-associated ERM. Spontaneous ERM separation is a rare but possible event, which occurs most often subsequent to posterior vitreous detachment. We present a case series of three patients with uveitis that exhibit the formation and subsequent spontaneous resolution of an inflammatory ERM.

Research paper thumbnail of Topical insulin for refractory persistent corneal epithelial defects

European Journal of Ophthalmology

Purpose: To evaluate insulin eye drops for persistent epithelial defects (PEDs) that are refracto... more Purpose: To evaluate insulin eye drops for persistent epithelial defects (PEDs) that are refractory to usual treatment in clinical practice and to analyze how it may improve epithelization. Methods: A prospective non-randomized hospital-based study was performed. Patients with PEDs that were refractory to conventional treatment were treated with insulin eye drops four times a day. Patients’ demographics, PED etiology, concomitant treatments, and comorbidities were reviewed. The rate of PED closure and epithelial healing time were considered the primary outcome measures. Results: 21 patients were treated with insulin drops (12 females and 9 males; mean age 72.2 years). Mean PED area before treatment was 17.6 ± 16.5 mm2 (median 13.2; range 3.9–70.6). PED comorbidities included seven eyes with infectious keratitis (33%), five eyes with calcium keratopathy (24%), ocular surgery on three eyes (14%), three eyes with lagophthalmos (14%), two eyes with bullous keratopathy (10%), and one pat...

Research paper thumbnail of Multicentre study: reliability and repeatability of Scheimpflug system measurement in keratoconus

British Journal of Ophthalmology

PurposeTo assess the repeatability and reliability of the most important tomographic parameters f... more PurposeTo assess the repeatability and reliability of the most important tomographic parameters for characterising keratoconus measured with a Pentacam HR (high resolution).MethodsOverall, 230 eyes in 158 patients with keratoconus were analysed. We performed five consecutive corneal tomography examinations for each eye with a Pentacam HR in patients with keratoconus. Study eyes were classified into three groups depending on the maximum posterior elevation (max_BFS_post): grade 1 for cases of keratoconus with a max_BFS_post of 40 µm; grade 2 for those with a max_BFS_post of between 41 and 75 µm and grade 3 for those with a max_BFS_post of over 75 µm. We calculated the intraclass correlation coefficients (ICCs) and repeatability limits of parameters from tomography and aberrometry.ResultsAll the parameters were found to have excellent ICCs (0.9). The repeatability limits for the key parameters were higher than 0.5D for the power parameters, 20° for the axis of corneal astigmatism and ...

Research paper thumbnail of Predictors for functional and anatomic outcomes in macular edema secondary to non-infectious uveitis

PLOS ONE

We aimed to investigate predictive factors for visual and anatomic outcomes in patients with macu... more We aimed to investigate predictive factors for visual and anatomic outcomes in patients with macular edema secondary to non-infectious uveitis. Material and methods We conducted a multicenter, prospective, observational, 12-month follow-up study. Participants included in the study were adults with non-infectious uveitic macular edema (UME), defined as central subfoveal thickness (CST) of >300 μm as measured by spectral domain optical coherence tomography (SD-OCT) and fluid in the macula. Demographic, clinical and tomographic data was recorded at baseline, 1, 3, 6 and 12 months. Foveal-centered SD-OCT exploration was set as the gold-standard determination of UME using a standard Macular Cube 512x128 A-scan, within a 6 x 6 mm 2 area, and the Enhanced High Definition Single-Line Raster. To assess favorable prognosis, the main outcomes analyzed were the best-corrected visual acuity (BCVA) and the CST. Favorable prognosis was defined as sustained improvement of BCVA (2 lines of gain of the Snellen scale) and CST (decrease of 20% of the initial value or <300 μm) within a 12 month period. Results Fifty-six eyes were analyzed. The number of eyes with sustained improvement in the CST was 48 (86.2%), against 23 (41.1%) eyes with sustained improvement in BCVA. Favorable prognosis, as defined above, was observed in 18 (32.1%) eyes. UME prognosis was negatively correlated with baseline foveal thickening, alteration in the vitreo-macular interface and cystoid macular edema. In contrast, bilaterally, systemic disease and the presence of anterior chamber cells were predictive of favorable prognosis.

Research paper thumbnail of Guidance on Noncorticosteroid Systemic Immunomodulatory Therapy in Noninfectious Uveitis: Fundamentals Of Care for UveitiS (FOCUS) Initiative

Ophthalmology, Jan 6, 2018

An international, expert-led consensus initiative to develop systematic, evidence-based recommend... more An international, expert-led consensus initiative to develop systematic, evidence-based recommendations for the treatment of noninfectious uveitis in the era of biologics. The availability of biologic agents for the treatment of human eye disease has altered practice patterns for the management of noninfectious uveitis. Current guidelines are insufficient to assure optimal use of noncorticosteroid systemic immunomodulatory agents. An international expert steering committee comprising 9 uveitis specialists (including both ophthalmologists and rheumatologists) identified clinical questions and, together with 6 bibliographic fellows trained in uveitis, conducted a Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol systematic review of the literature (English language studies from January 1996 through June 2016; Medline [OVID], the Central Cochrane library, EMBASE, CINAHL, SCOPUS, BIOSIS, and Web of Science). Publications included randomized controlled trials, p...

Research paper thumbnail of Glaukos® trabecular stent used to treat steroid-induced glaucoma

European Journal of Ophthalmology, 2012

Purpose This case report illustrates the efficacy of the Glaukos trabecular bypass (Glaukos i-ste... more Purpose This case report illustrates the efficacy of the Glaukos trabecular bypass (Glaukos i-stent, Glaukos Corporation, Laguna Hills, California, USA) used for intraocular pressure (IOP) control in a patient with glaucoma induced by the steroid treatment of post–laser-assisted in situ keratomileusis (LASIK) bilateral anterior uveitis. Methods A 35-year-old woman who had undergone LASIK 5 months previously presented with blurred vision in both eyes. Examination revealed bilateral anterior uveitis and diffuse lamellar keratitis (DLK) requiring steroid treatment. In response to treatment, inflammation improved but the patient had increased IOP that was difficult to control. The course of pressure elevation was more aggressive in the left eye despite the gradual discontinuation of steroids. We therefore decided to place 2 trabecular i-stents in the left eye. Results This solution achieved good pressure control with no associated complications after 1 year follow-up. Conclusions This t...

Research paper thumbnail of Charles Bonnet plus syndrome: apropos of a case

European Journal of Ophthalmology, 2012

Charles Bonnet syndrome plus is an exceedingly rare variant of this disorder. The variant has bee... more Charles Bonnet syndrome plus is an exceedingly rare variant of this disorder. The variant has been described in patients with sight impairment and severe hypoacusis, and is usually characterized by complex visual and auditory--musical--hallucinations that the patients recognize as unreal. Case report. A 75-year-old woman diagnosed with Usher syndrome presented with visual acuity of light perception in both eyes, which did not improve with the use of a pinhole occluder. She also had coptosis in right ear and severe hypoacusis in left ear, confirmed through audiometry. Audiometric tests were normal once the implant and the hearing aid were connected. The patient was referred to the Neuro-Ophthalmology Unit after recounting experiencing complex visual hallucinations, as well as auditory (musical) ones at night after disconnecting the hearing aid. She described the latter as a nightly occurrence of hearing &amp;amp;amp;amp;amp;amp;quot;cabaret music.&amp;amp;amp;amp;amp;amp;quot; Nevertheless, she was aware of reality and of her sensory impairments. The patient was diagnosed at the interdisciplinary Neuro-Ophthalmology Unit, and began pharmacologic treatment with clear improvement. Knowledge of Charles Bonnet syndrome and in particular of Charles Bonnet syndrome plus--due to its infrequency--on the part of ophthalmologists is fundamental to adequately diagnose and treat this rare disorder.