pubblicazioni e curriculum vitae
Curriculum Vitae Francesco Fasce, MD (eng)
Medico Chirurgo Specializzato in Oculistica: microchirurgia oculare della cataratta e del segmento anteriore.
Nato a Ferrara il 20 marzo 1960.
Studio privato: Viale Tunisia 37 Milano Tel +39.3341415094- Fax +39.02.70009857
Dipartimento di Oftalmologia, Università Vita e Salute, Ospedale San Raffaele, Via Olgettina, 60 - 20132 Milano (Italy). Tel +39.02.26.43.35.32
Evaluation of fixation one year after perifoveal laser treatment of subfoveal choroidal neovascularization
The natural prognosis of subfoveal neovascularization is severe visual acuity loss. Perifoveal laser photocoagulation is meant to spare a small portion of the central retina so as to possibly preserve foveal fixation. The aim of this retrospective study was to detect the persistence of central fixation and to evaluate the visual function of patients who had undergone perifoveal laser photocoagulation one year before, due to the presence of age-related macular degeneration with subfoveal neovascularization. The visual function was assessed by means of visual acuity (VA) measurement, central perimetry, scanning laser ophthalmoscope (SLO) scotometry and capability of using low- vision aids with success. Twelve eyes of 12 patients, 5 males and 7 females, with mean age 72.6 + 9.62 years, were included in the Study Group. Mean VA was 0.22 4. 0.089 before laser treatment, 0.17 4- 0.054 one week after laser treatment (p--0.0152) and 0.13 4- 0.063 one year after laser treatment (p=0.045), with a statistically significant reduction of VA overtime (initial-final p--0.0015). Mean lesion size was 2.12 4- 0.528 disc diameters on the last follow-up fluorescein angiogram. One year after laser treatment, perimetry showed the persistence of central fixation in 2 eyes, while 10 eyes seemed to have lost it. SLO scotometry revealed central dot stimulus perception in 6 eyes and no central residual in 6 eyes. The SLO fixation plot showed persistence of central fixation also in i eye in which static perimetry had not detected it. The preferential retinal locus was located on the upper or upper-right margin of the lesion in 8 of the 9 eyes with paracentral fixation. All patients achieved a useful reading VA using low-vision aids, with7.16 4- 6.1 mean magnification power. The eyes with central visual residual on SLO scotometry had a final VA slightly higher than those without central residuals (VA 0.158 4- 0.03 and 0.098 =L0.07, respectively), though the difference was not statistically significant (p=0.0977).
Incomplete extrusion of an acrylic punctum plug in a case of severe dry eye syndrome
PURPOSE: To report a case of extrusion of a new soft punctum plug with thermoexpansion property (Medennium SmartPLUG).
METHODS: A soft punctum plug was implanted in a 32-year-old woman with a severe dry eye syndrome in juvenile arthritis.
RESULTS: One week after implant the plug partially extruded outside the punctum. Despite this adverse event, all subjective dry eye symptoms increased.
CONCLUSION: The peculiarity of this case is the persistence of clinical efficacy of the soft punctum plug even if partially extruded. The patient experienced relief of symptoms that can be compared to the benefits usually obtained with a successfully implanted silicon plug.(Eur J Ophthalmol 2005; : 000)
Optomechanical eye model with imaging capabilities for objective evaluation of intraocular lenses
PURPOSE: To develop an in vitro procedure providing data on the visual performance obtainable with intraocular lenses (IOLs), for objective comparison between IOL models and direct correlation with the relative visual performance attainable in vivo.
SETTING: University Hospital San Raffaele, Milan, Italy.
METHODS: An optomechanical eye model was developed to allow simulated in vivo testing of IOLs. The experimental eye mimics the optics and geometry of the Gullstrand’s eye model, with an aspheric poly(methyl methacrylate) cornea, variable pupil, and IOL holder. Its detection system is designed to reproduce the mean resolution of the human fovea. The imaging capabilities of the model eye were measured using monofocal IOLs. The tests included qualitative information, such as appearance of op- totype chart images, and quantitative information, such as simulated visual acuity tests for far and near distance at variable contrasts.
RESULTS: Objective numerical IOL evaluation was made possible on the basis of the visual acuity recorded with the eye model. The maximum recorded far acuity for the monofocal IOLs was about 20/14 at full contrast, progressively decreasing for reduced contrast. Best corrected near acuity ranged between 20/14.7 and 20/15.4.
CONCLUSIONS: The optomechanical eye model provided objective grading of IOLs through the eval- uation of simulated visual acuity, which can be scaled usefully to human vision. The eye model also allowed the qualitative visualization of IOL imaging properties, making it potentially useful in charac- terizing and distinguishing different IOL types.
Sedative effect of acupuncture during cataract surgery Prospective randomized double-blind study
PURPOSE: To assess the effectiveness of acupuncture in reducing anxiety in patients having cataract surgery under topical anesthesia.
SETTING: Vita-Salute University of Milan and IRCCS H. San Raffaele, Milan, Italy.
METHODS: In a prospective randomized double-blind controlled trial, anxiety levels before and after cataract surgery in 3 groups (A Z no acupuncture, B Z true acupuncture starting 20 minutes before surgery, C Z sham acupuncture starting 20 minutes before surgery) were compared using the Visual Analog Scale (VAS). Twenty-five patients scheduled for inpatient phacoemulsification were enrolled in each group. All surgeries were performed using topical anesthesia. Exclusion criteria were refusal to provide informed consent, use of drugs with sedative properties, psychiatric disease, pregnancy, knowledge of the principles of acupuncture, anatomic alterations, or cutaneous infections precluding acupuncture at the selected acupoints.
RESULTS: Preoperative anxiety levels were significantly lower only in Group B (P Z .001). Anxiety in Group B was significantly lower than in Group A (P Z .001) and Group C (P Z .037). Regarding post- operative anxiety, the mean VAS score was 39 G 5 in Group A, 19 G 3 in Group B, and 31 G 4 in Group C. The difference was significant only between Group A and Group B (P Z .003).
CONCLUSION: Acupuncture was effective in reducing anxiety related to cataract surgery under topical anesthesia.
Comparison of BD MultiviscTM with the soft shell technique in cases with hard lens nucleus and Fuchs endothelial dystrophy
PURPOSE: To compare the efficacy of 2.5% sodium hyaluronate (BD MultiviscTM) with the soft shell technique in reducing corneal endothelial cell damage during cataract phacoemulsification in pa- tients with hard lens nucleus (3+) and cornea guttata.
METHODS: Thirty patients (37 eyes) scheduled for cataract surgery at Department of Ophthalmology and Visual Sciences, University Hospital San Raffaele, Milano, Italy. Thirty-seven eyes (randomly di- vided into Groups A and B) with hard lens nucleus (grade 3 or higher) and cornea guttata had pha- coemulsification using the soft shell technique (Group A) with Biolon® (sodium hyaluronate 1%) and Viscoat® (sodium hyaluronate 3%–chondroitin sulfate 4%) or with BD MultiviscTM alone (Group B). Patients were evaluated preoperatively and after 1, 15, 90, and 180 days, checked for best-cor- rected visual acuity (BCVA), intraocular pressure (IOP), central corneal thickness, and corneal en- dothelial density. Stop and chop phacoemulsification technique, with burst mode (Alcon Legacy 20000, Advantec), was performed.
RESULTS: There were no significant differences between the two groups at 3 and 6 months in BC- VA, IOP, corneal thickness, or endothelial cell density. The increase of central corneal thickness (preoperative: Group A 584±30 μm, Group B 573±30 μm; postoperative at 90 days: Group A 593±38 μm, Group B 577±25 μm) was not significant. Endothelial cell loss was similar in both groups.
CONCLUSIONS: The results suggest that the soft shell technique (Biolon®, Viscoat®) and 2.5% sodi- um hyaluronate (BD MultiviscTM) are both effective in protecting the corneal endothelium in Fuchs dystrophy during phacoemulsification in patients with hard lens nucleus. (Eur J Ophthalmol 2007; 17: 709-13)
Anesthesiologist intervention during cataract surgery under topical or peribulbar anesthesia: a propensity model comparison
PURPOSE: To compare the incidence and type of anesthesiologist intervention during cataract surgery under peribulbar (PA) or topical (TA) anesthesia in a day-surgery monitored anesthesia care setting (monitoring provided by nurses with the anesthesiologist available on an on-call basis).
METHODS: From a prospective database of all phacoemulsifications performed in our hospital (Janu- ary 2008-January 2009), 97 patients submitted to cataract surgery under PA were matched with 97 patients submitted to the same surgery under TA by a propensity model. The resulting groups were homogeneous as to history of antihypertensive therapy administered on the day of surgery and not administered on the day of surgery, cardiologic history, neurologic history, psychiatric history, anxi- olytic assumption, and history of diabetes mellitus. We compared the incidence of intervention of the anesthesiologist between groups and the type of adverse event triggering such interventions. results.
RESULTS:The anesthesiologist was called in 37 (38.14%) cases in the PA group and in 27 (27.84%) cas- es in the TA group (37 [38.14%]) (p=0.123). Only the occurrence of agitation differed significantly be- tween groups (9 [9.28%] patients in the TA group vs 24 [24.74%] patients in the PA group; p=0.004).
CONCLUSIONS: Monitored anesthesia care is feasible for cataract surgery both under PA or TA. PA still remains an appealing alternative to TA during cataract surgery for patients incapable of keeping the operating eye in the primary position or with incoercible blinking, photophobia, or phacodonesis. A greater incidence of agitation is to be expected and adequate premedication with anxiolytics should be considered if PA is chosen. (Eur J Ophthalmol 2010; 20: 687-93)
Sinsintomatologia e obiettività precoce delle infezioni nella chirurgia oftalmica tomatologia e obiettività precoce delle infezioni nella chirurgia oftalmica
L’endoftalmite è una grave complicanza infettiva intraoculare nella chirurgia oftal- mica, seppur rara. Il 90% delle endoftalmiti è riconducibi- le all’estrazione della cataratta, per l’alta frequenza di questa procedura chirurgica e indipendentemente dalla tecnica ese- guita (1-3). Ogni occhio che presenti un’infiamma- zione non proporzionata al trauma chirurgi- co o una sintomatologia algica esagerata rispetto a un decorso postoperatorio nor- male, deve essere valutato con attenzione per escludere questa complicanza (2). L’endoftalmite infettiva può essere clas- sificata in tre forme differenti (4):
1. Forma acuta immediata (o fulminante): si manifesta entro 2-4 giorni dalla pro- cedura chirurgica.
2. Forma acuta (ritardata): si manifesta dopo 5-7 giorni dall’intervento.
3. Forma cronica: si presenta non prima di 1 mese dallo stesso. dal punto di vista microbiologico sipossono identificare tre fasi successive dell’infezione: l’incubazione, la fase di accelerazione e quella distruttiva. La pri- ma fase dura circa 14 ore ed è influenzata principalmente dal tipo di patogeno re- sponsabile e dalla sua capacità di produrre tossine. La fase di accelerazione è caratterizzata dall’inizio della sintomatologia soggettiva e delle prime manifestazioni cliniche; l’ulti- ma fase è espressione del danno tissutale (5,6).
Epidemiologia e batteriologia delle infezioni nella chirurgia della cataratta
L’intervento di estrazione di cataratta rappresenta a tutt’oggi una delle proce- dure chirurgiche più eseguite al mondo. nonostante i notevoli sviluppi nella tec- nologia e nelle tecniche chirurgiche, la possibilità di comparsa di endoftalmite postoperatoria (POe) rimane sempre fonte di preoccupazione per il chirurgo. L’endoftalmite postoperatoria è un’in- fezione intraoculare non frequente ma grave che spesso è responsabile di grave riduzione dell’acuità visiva o anche di perdita del bulbo oculare fino all’enucle- azione. L’endoftalmite acuta si manifesta a breve distanza dall’intervento, nella prima settimana dopo l’intervento; talvolta però, può svilupparsi a distanza di mesi (forma cronica), come nel caso del P. acnes. La necessità di un elevato standard di monitoraggio dell’incidenza, della ge- stione e dell’esito della POe è sempre più importante in considerazione dell’elevato numero di interventi di estrazione di cata- ratta eseguiti al mondo e dell’aspetto re- frattivo della chirurgia della cataratta, con l’avvento delle lenti premium. Pertanto la prevenzione delle POe rimane essenziale. All’inizio dello scorso decennio, l’unica misura preventiva nei confronti delle infe- zioni era l’utilizzo di iodopovidone (1); in seguito, è stata introdotta nella routine pre e postoperatoria la profilassi con antibiotici topici, per cui però vi è un’evidenza talvolta controversa (1,2).
The Bigaussian Nature of Ocular Biometry
PURPOSE: Tostudyhowtheleptokurticshapeoftherefractivedistributioncanbederivedfromocularbiometrybymeansof a multivariate Gaussian model.
METHODS: Autorefraction and optical biometry data (Scheimpflug and partial coherence interferometry) were obtained for 1136 right eyes of healthy white subjects recruited by various European ophthalmological centers participating in Project Gullstrand. These biometric data were fitted with linear combinations of multivariate Gaussians to create a Monte Carlo simulation of the biometry, from which the corresponding refraction was calculated. These simulated data were then compared with the original data by histogram analysis.
RESULTS: The distribution of the ocular refraction more closely resembled a bigaussian than a single Gaussian function (F test, p G 0.001). This also applied to the axial length, which caused the combined biometry data to be better represented by a linear combination of two multivariate Gaussians rather than by a single one (F test, p G 0.001). Corneal curvature, anterior chamber depth, and lens power, on the other hand, displayed a normal distribution. All distributions were found to gradually change with age. The statistical descriptors of these two subgroups were compared and found to differ signif- icantly in average and SD for the refraction, axial length, and anterior chamber depth. All distributions were also found to change significantly with age.
CONCLUSIONS: The bigaussian model provides a more accurate description of the data from the original refractive distribution and suggests that the general population may be composed of two separate subgroups with different biometric properties. (Optom Vis Sci 2014;91:713Y722)
Distribuiton of the Crystalline Lens Power in Vivo as a Function Age
PURPOSE: To observe the age-related changes in crystalline lens power in vivo in anoncataractous European population.
METHODS: Data were obtained though Project Gullstrand, a multicenter population study with data from healthy phakic subjects between 20 and 85 years old. One randomly selected eye per subject was used. Lens power was calculated using the modified Bennett-Rabbetts method, using biometry data from an autorefractometer, Oculus Pentacam, and Haag-Streit Lenstar.
RESULTS: The study included 1069 Caucasian subjects (490 men, 579 women) with a mean age of 44.2 6 14.2 years and mean lens power of 24.96 6 2.18 diopters (D). The average lens power showed a statistically significant decrease as a function of age, with a steeper rate of decrease after the age of 55. The highest crystalline lens power was found in emmetropic eyes and eyes with a short axial length. The correlation of lens power with different refractive components was statistically significant for axial length (r 1/4 _0.523, P < 0.01) and anterior chamber depth (r 1/4 _0.161, P < 0.01), but not for spherical equivalent and corneal power (P > 0.05).
CONCLUSIONS: This in vivo study showed a monotonous decrease in crystalline lens power with age, with a steeper decline after 55 years. While this finding fundamentally concurs with previous in vivo studies, it is at odds with studies performed on donor eyes that reported lens power increases after the age of 55.
Dome-sheped macula associated with Best vitelliform macular dystrphy
PURPOSE: Dome-shaped macula (DSM) has been described recently as an inward convexity of the macula typical of myopic eyes detectable on spectral-domain optical coherence tomography (SD-OCT). The authors describe a case of monolateral DSM associated with Best vitelliform macular dystrophy (VMD).
METHODS: A 60-year-old man already diagnosed with VMD in vitelliruptive stage underwent SD-OCT that revealed the typical vitelliform material accumulation associated in the left eye with a convex elevation of the macula. No change was registered over a 1-year follow-up.
CONCLUSIONS: This is the first report describing a monolateral DSM associated with VMD. Dome-shaped macula could be considered as a nonspecific scleral alteration, probably due to increased scleral thickness, which can accompany many retinal disorders.
Evaluation of the efficacy and safety of a standardised intracameral combination of mydriatics and anesthetics for cataract surgery
Background/aims To compare the efficacy and safety of intracameral (IC) administration at the beginning of cataract surgery, of Mydrane, a standardised ophthalmic combination of tropicamide 0.02%, phenylephrine 0.31% and lidocaine 1%, to a standard topical regimen. Methods In this international phase III, prospective, randomised study, the selected eye of 555 patients undergoing phacoemulsification with intraocular lens (IOL) implantation received 200 μL of Mydrane (Mydrane group) just after the first incision or a topical regimen of one drop each of tropicamide 0.5% and phenylephrine 10% repeated three times (reference group). The primary efficacy variable was achievement of capsulorhexis without additional mydriatics. The non-inferiority of Mydrane to the topical regimen was tested. The main outcome measures were pupil size, patient perception of ocular discomfort and safety.
Results Capsulorhexis without additional mydriatics was performed in 98.9% of patients and 94.7% in the Mydrane and reference groups, respectively. Both groups achieved adequate mydriasis (>7 mm) during capsulorhexis, phacoemulsification and IOL insertion. IOL insertion was classified as ‘routine’ in a statistically greater number of eyes in the Mydrane group compared with the reference group ( p=0.047). Patients in the Mydrane group reported statistically greater comfort than the reference group before IOL insertion ( p=0.034). Safety data were similar between groups. Conclusions Mydrane is an effective and safe alternative to standard eye drops for initiating and maintaining intraoperative mydriasis and analgesia. Patients who received IC Mydrane were significantly more comfortable before IOL insertion than the reference group. Surgeons found IOL insertion less technically challenging with IC Mydrane.