Faculty Bibliography

OBJECTIVE:The objective of this study was to analyse the failure mode of adhesive interfaces by comparing OCT and scanning electron microscope (SEM) analysis of class V restoration margins located on enamel and dentin. MATERIALS AND METHODS/METHODS:Three groups were tested that differed in the application of a 3-step etch-and-rinse adhesive system (OptiBond FL) prior to cavity filling with restorative composite resin (Clearfil AP-X). After tooth restoration and polishing, the samples were loaded in a fatigue machine, and adhesive interfaces were evaluated with OCT and SEM. RESULTS:Important and complementary information could be obtained with OCT analysis in respect to how marginal defects can propagate inside the cavity, compromising the restoration's long-term performance. A self-etching effect was observed with OptiBond FL due to the presence of an acidic primer (GPDM) within its composition. Our results could show that areas of bonding and gaps coexisted within the same restoration. CONCLUSIONS:When marginal imperfections, or non-continuous margins, were detected by SEM, also imperfections beneath the surface could be observed at the tooth-restoration interface with OCT. Restoration loss occurred above the borderline of 50% of marginal gaps on enamel and dentin. CLINICAL RELEVANCE/CONCLUSIONS:Marginal discrepancies of adhesive restorations can propagate inside the cavity and lead to restoration loss.

In vivo confocal microscopy (IVCM) findings of 84 patients who had undergone conventional epithelium-off corneal collagen crosslinking (CXL) and accelerated CXL (ACXL) were retrospectively reviewed. Analysis confirmed that despite a significant decrease in the mean density of anterior keratocytes in the first 6 postoperative months, cell density after CXL and ACXL returned to baseline values at 12 months. The demarcation lines observed after treatments represent an expression of light-scattering (reflectivity changes) through different tissue densities. Temporary haze of the anterior-mid stroma after conventional CXL represents an indirect sign of CXL-induced stromal collagen compaction and remodeling. IVCM showed that treatment penetration varies to some extent, but that the endothelium is not damaged and is correlated with CXL biomechanical effects. IVCM of limbal structures shows no evidence of pathological changes. Regeneration of subepithelial and stromal nerves was complete 12 months after the operation with fully restored corneal sensitivity and no neurodystrophic occurrences. IVCM allowed detailed high magnification in vivo micromorphological analysis of corneal layers, enabling the assessment of early and late corneal modifications induced by conventional and accelerated CXL. IVCM confirms that CXL is a safe procedure, which is still undergoing development and protocol adjustments.

PURPOSE/OBJECTIVE:To establish corneal cross-linking (CXL) with riboflavin and UV-A in in the mouse cornea in vivo and to develop tools to measure the biomechanical changes observed. METHODS:A total of 55 male C57BL/6 wild-type mice (aged 5 weeks) were divided into 14 groups. Standard CXL parameters were adapted to the anatomy of the mouse cornea, and riboflavin concentration (0.1%-0.5%) and fluence series (0.09-5.4 J/cm²) were performed on the assumption of the endothelial damage thresholds. Untreated and riboflavin only corneas were used as controls. Animals were killed at 30 minutes and at 1 month after CXL. Corneas were harvested. Two-dimensional (2D) biomechanical testing was performed using a customized corneal holder in a commercially available stress-strain extensometer/indenter. Both elastic and viscoelastic analyses were performed. Statistical inference was performed using t-tests and specific mathematical models fitted to the experimental stress-strain and stress-relaxation data. Adjusted P values by the method of Benjamini and Hochberg are reported. RESULTS:For all CXL treatment groups, stress-relaxation showed significant differences (P < 0.0001) after 120 seconds of constant strain application, with cross-linked corneas maintaining a higher stress (441 ± 40 kPa) when compared with controls (337 ± 39 kPa). Stress-strain analysis confirmed these findings but was less sensitive to CXL-induced changes: at 0.5% of strain, cross-linked corneas remained at higher stress (778 ± 111 kPa) when compared with controls (659 ± 121 kPa). CONCLUSIONS:Cross-linking was induced in the mouse cornea in vivo, and its biomechanical effect successfully measured. This could create opportunities to study molecular pathways of CXL in transgenic mice.

PURPOSE/OBJECTIVE:PAX6 is a highly conserved protein essential for the control of eye development both in invertebrates and vertebrates. PAX6 expression persists in the adult inner retina, but little is known about its functions after completion of retinal differentiation. Therefore, we investigated PAX6 expression in wild-type and calcitonin receptor-like receptor transgenic (CLR(SMαA)) mice with angle-closure glaucoma. METHODS:Intraocular pressure was measured by indentation tonometry in anesthetized mice. Eyes of mice of both genotypes were enucleated at various ages and retinas were processed for morphological analysis and PAX6 immunostaining. The content of PAX6 in retinal extracts was estimated by Western blot analysis. Retinal expression of glaucoma-related genes was analyzed by reverse transcription-polymerase chain reaction. RESULTS:Control mice showed normal retinal morphology between p22 and p428 with steady PAX6 expression in the ganglion cell layer (GCL) and the inner nuclear layer (INL). CLR(SMαA) mice examined between p22 and p82 exhibited increased intraocular pressure and a progressive decrease in cell number including PAX6-expressing cells in the GCL. The INL was not affected up to postnatal day 42. Later, a significant increase in PAX6-expressing cells concomitant with an overall loss of cells was observed in the INL of CLR(SMαA) as compared with control mice. Retinal up-regulation of glaucoma-related genes was furthermore observed. CONCLUSIONS:Distinctive changes of PAX6 expression in the inner retina of CLR(SMαA) mice suggest a role in regulatory mechanisms involved in glaucoma-related retinal cell death. The selective increase of PAX6 expression in the degenerating INL of CLR(SMαA) mice may represent an attempt to preserve retinal cytoarchitecture.

PURPOSE/OBJECTIVE:Retinitis pigmentosa (RP) is a group of inherited retinal degenerations leading to blindness due to photoreceptor loss. Retinitis pigmentosa is a rare disease, affecting only approximately 100 000 people in the United States. There is no cure and no approved medical therapy to slow or reverse RP. The purpose of this clinical trial was to evaluate the safety, reliability, and benefit of the Argus II Retinal Prosthesis System (Second Sight Medical Products, Inc, Sylmar, CA) in restoring some visual function to subjects completely blind from RP. We report clinical trial results at 1 and 3 years after implantation. DESIGN/METHODS:The study is a multicenter, single-arm, prospective clinical trial. PARTICIPANTS/METHODS:There were 30 subjects in 10 centers in the United States and Europe. Subjects served as their own controls, that is, implanted eye versus fellow eye, and system on versus system off (native residual vision). METHODS:The Argus II System was implanted on and in a single eye (typically the worse-seeing eye) of blind subjects. Subjects wore glasses mounted with a small camera and a video processor that converted images into stimulation patterns sent to the electrode array on the retina. MAIN OUTCOME MEASURES/METHODS:The primary outcome measures were safety (the number, seriousness, and relatedness of adverse events) and visual function, as measured by 3 computer-based, objective tests. RESULTS:A total of 29 of 30 subjects had functioning Argus II Systems implants 3 years after implantation. Eleven subjects experienced a total of 23 serious device- or surgery-related adverse events. All were treated with standard ophthalmic care. As a group, subjects performed significantly better with the system on than off on all visual function tests and functional vision assessments. CONCLUSIONS:The 3-year results of the Argus II trial support the long-term safety profile and benefit of the Argus II System for patients blind from RP. Earlier results from this trial were used to gain approval of the Argus II by the Food and Drug Administration and a CE mark in Europe. The Argus II System is the first and only retinal implant to have both approvals.

BACKGROUND:Despite extensive knowledge regarding the diagnosis and management of keratoconus and ectatic corneal diseases, many controversies still exist. For that reason, there is a need for current guidelines for the diagnosis and management of these conditions. PURPOSE/OBJECTIVE:This project aimed to reach consensus of ophthalmology experts from around the world regarding keratoconus and ectatic diseases, focusing on their definition, concepts, clinical management, and surgical treatments. METHODS:The Delphi method was followed with 3 questionnaire rounds and was complemented with a face-to-face meeting. Thirty-six panelists were involved and allocated to 1 of 3 panels: definition/diagnosis, nonsurgical management, or surgical treatment. The level of agreement considered for consensus was two thirds. RESULTS:Numerous agreements were generated in definitions, methods of diagnosing, and management of keratoconus and other ectatic diseases. Nonsurgical and surgical treatments for these conditions, including the use of corneal cross-linking and corneal transplantations, were presented in a stepwise approach. A flowchart describing a logical management sequence for keratoconus was created. CONCLUSIONS:This project resulted in definitions, statements, and recommendations for the diagnosis and management of keratoconus and other ectatic diseases. It also provides an insight into the current worldwide treatment of these conditions.

OBJECTIVE:Corneal collagen cross-linking with riboflavin and UV-A (CXL) decreases corneal oedema and increases visual acuity in human patients with bullous keratopathy. Presumed mechanisms are an increase in collagen packing density and a reduction in stromal swelling pressure. We present two cases in which CXL was used to treat bullous keratopathy in dogs. PROCEDURES/METHODS:Four eyes of two dogs with painful bullous keratopathy-induced corneal erosions that were resistant to prior therapy were treated with CXL. Both corneas of the second patient were dehydrated to ± 400 μm corneal thickness using topical 70% glycerol solution immediately prior to CXL. Follow-up included slit-lamp examination, fluorescein staining and photographic documentation in both cases and high-resolution ultrasound examination in the second patient. RESULTS:All four eyes were comfortable and fluorescein negative at 1-week post-CXL and remained so for the rest of the follow-up period (17.5 months for case 1 and 6 months for case 2). The owner of the first patient reported a less oedematous cornea and improvement in vision that lasted for 6 months. Despite a reported lack of improvement in vision in the second patient, corneal thickness initially decreased, but was back at baseline thickness at the 4-month recheck. CONCLUSIONS:Similar to humans, CXL might become a useful treatment option for bullous keratopathy-induced therapy-resistant corneal erosions in dogs. Patient comfort was greatly improved, but corneal thickness decrease was not as long-lasting as reported for humans. The presently used protocols might need modification to fit the dog cornea.