Combat-related ocular trauma and visual outcomes during counter-terrorism urban warfare operations in Turkey.

BACKGROUND: The study was to report the clinical features and post-operative outcomes in military personnel admitted to the Ocular Trauma Center of Gülhane Training and Research Hospital after sustaining combat injuries in urban warfare. METHODS: This is a retrospective, non-comparative, interventional case series analyzing Turkish military personnel transferred to our tertiary ocular trauma center from the warfare zone and combat support hospitals. Ocular injuries were subdivided into zones and ocular trauma classification. RESULTS: There were 103 combat ocular injuries in 74 military personnel. The average age was 27.31±4.64 years (range; 21-48 years), and all were men (100%). The average follow-up was 529.34±213.98 days (288-1464 days). There were 84 open-globe and 19 closed-globe injuries. Thirty-six (34.9%) had final vision of 20/40 or better. Pars plana vitrectomy was the most common surgery (79.6%). Five eyes underwent evisceration, and seven eyes developed phthisis bulbi. The globe survival rate was 88.3%. Zone III injuries (32.2%) were the most common cause of unfavorable visual outcomes, and most injuries were caused by improvised explosive devices (IEDs) (59.2%). These devices also had the worst impact on globe survival and visual improvement. These eyes had a higher likelihood ratio of requiring globe removal surgery or developing phthisis bulbi [odds ratio: 21.5 (95% CI: 1.23-373)]. Two eyes that underwent keratoprosthesis-assisted pars plana vitrectomy followed by penetrating keratoplasty (PKP) during the same session developed PKP failure while failure was not seen in any of the cases that underwent PKP in a later session. CONCLUSION: Ocular injuries related to IEDs had the most significant impact on both visual and anatomic prognoses, and globe survival was less likely in eyes with zone III trauma, in which intraocular foreign bodies penetrated the choroid. There is a higher pos-sibility of PKP failure if this procedure is performed during the same session as other ocular surgery.

The effect of longstanding silicone oil on retina choroid and optic nerve in eyes with retinal detachment: an optical coherence tomography study.

BACKGROUND: The study aims to evaluate peripapillary retinal nerve fiber layer thickness (RNFL-T), central macular thickness (MT), choroidal thickness (CT), and thickness of each retinal layer after automatic segmentation in patients who underwent retinal detachment (RD) repair with longstanding silicone oil tamponade. METHODS: We enrolled 33 patients who underwent complicated primary rhegmatogenous RD surgery and followed up with a long-term silicone tamponade were included in this retrospective comparative (case-control) study. RNFL-T, CT, and thickness of each retinal layer after automatic segmentation analysis were measured after the longstanding silicone removal surgery. RESULTS: The mean silicone oil removal time was 15.1 ± 15.2 (7-70) months. The overall average thickness of the RNFL was 90.7 ± 13.6 µm in the operated eyes and 118.3 ± 35.6 µm in the sound eyes, with a statistically significant difference. The overall average central MT was 186.3 ± 57.7 µm and was significantly lower in the operated eyes than in the sound eyes. Inner retinal layers of the study group showed a significant thinning in the nerve fiber layer, ganglion cell layer, inner plexiform layer, and inner nuclear layer as compared to that of the sound eyes. The subfoveal CT was 213.7 ± 86.6 µm in the study eyes and 217.7 ± 115.5 µm in the control eyes. There was no significant difference between the study eyes and controls. CONCLUSION: The effects of silicone oil on the retina remain uncertain; however, morphological results in our study have shown direct or indirect silicone oil-induced toxicity, especially in the inner retinal layers.

Comparison of obstructive sleep apnea syndrome and keratoconus patients on elevation maps.

PURPOSE: This study aimed to compare the tomographic features of the cornea on elevation maps between obstructive sleep apnea syndrome (OSAS) and keratoconus (KC) patients and to investigate the presence of susceptibility to ectatic corneal diseases in OSAS patients. DESIGN: This is a comparative cross-sectional case-control study. METHODS: This study included 84 eyes of 42 patients diagnosed with severe OSAS using polysomnography (apnea/hypopnea index > 30), 84 eyes of 56 patients diagnosed with keratoconus, and 84 eyes of 42 healthy subjects as control group and evaluated in three groups. Elevation maps of all the groups were performed using Pentacam, and topometric, pachymetric, and deviation indices were recorded. RESULTS: The study included 252 eyes of 130 participants divided in three groups. Comparing all the tomographic keratometric values, a significant difference was found among the three groups. All keratometric values were found to be higher in the OSAS patients group compared to those in the control group. Also topometric indices and Belin-Ambrosio enhanced ectasia display (BAD) were observed to be higher as in subclinical keratoconus and statistically significant when compared to those in the control group. CONCLUSION: The study reveals the tomographic corneal characteristics and topometric and pachymetric indices of patients with severe OSAS at the time of diagnosis; these findings statistically significantly differ from the control group. In addition to the known association of floppy eyelid in OSAS patients, the suspicion of keratoconus should be kept in mind.

Fourier analysis of corneal Scheimpflug imaging: clinical use in keratoconus.

AIM: To evaluate the clinical use of Fourier analysis of videokeratography data in the diagnosis and follow-up of keratoconus (KC). METHODS: We conducted a chart review of consecutive patients presented to our cornea clinic. A team of two experienced cornea specialists divided the patients into three groups: normal cornea, forme fruste KC (FFKC), and clinical KC. The exclusion criteria were a history of previous ocular surgery, any accompanying corneal pathology other than KC, high myopia (>6.00 diopters), amblyopia, pregnancy, breastfeeding, or any current autoimmune disease. The data of Fourier series harmonic analysis were evaluated for their diagnostic capacity using the receiver operating characteristic (ROC) curve. A binary logistic regression analysis was also conducted to construct a diagnostic model. A total of 259 eyes showed progression in the clinical KC group and underwent a combination of accelerated corneal collagen cross-linking and topography-guided customized treatment with an excimer laser. RESULTS: The study included 1262 eyes (618 normal, 530 KC, and 114 FFKC) of 1262 patients. We observed that maximum decentration (MaxDec) was almost as good as maximum keratometry (Kmax) in detecting progressive KC. The area under the curve (AUC) was 0.95 for KC [95% confidence interval (CI): 0.93-0.96] and 0.84 for FFKC (95%CI: 0.79-0.88). Higher predictive accuracy was obtained using a model combining the spherical component, MaxDec, irregularity, and regular astigmatism in the center of the cornea (AUC: 0.97; sensitivity: 89%, and specificity: 96%). CONCLUSION: Decentration, Kmax, and posterior radii of curvatures from a 3.0-mm optical zone centered on the thinnest point of the cornea provide the highest accuracy with low reproducibility of Kmax.

Scheimpflug imaging of the anterior segment following simultaneous cross-linking with topography-guided custom ablation treatment for keratoconus.

PURPOSE: To report alterations in the anterior segment following accelerated corneal collagen cross-linking and topo-guided customized ablation treatment with the Nidek vision excimer laser system (Nidek Co., Ltd., Gamagori, Japan) in a single procedure. METHODS: We reviewed the medical records of patients who underwent cross-linking for progressive keratoconus. We divided patients into four groups based on the treatment protocol. Eyes were evaluated regarding uncorrected distance visual acuity, corrected distance visual acuity, keratometry (maximum [Kmax], equivalent keratometry readings, Ksteep and Kflat parameters), corneal elevations (anterior and posterior), the anterior radius of curvature, the posterior radius of curvature, anterior chamber volume, anterior chamber depth, anterior chamber angle and the pachymeter of the thinnest locale of the cornea before the surgery and at 1, 3, 6, and 12 months after the procedure. RESULTS: We included 259 eyes of 227 patients with progressive keratoconus who underwent treatment. The mean respective baseline uncorrected distance visual acuity and corrected distance visual acuity were: 0.68 ± 0.45 and 0.34 ± 0.40 in Group 1; 0.82 ± 0.44 and 0.33 ± 0.23 in Group 2; 0.61 ± 0.36 and 0.21 ± 0.17 in Group 3; and 0.65 ± 0.38 and 0.23 ± 0.18 in Group 4; logMAR did not show significant difference among the groups (p=0.14 and p=0.06, respectively). Visual improvements were better in the combined surgery groups. Mean Kmax in Groups 1, 2, 3, and 4 were 57.24 ± 7.51, 59.26 ± 6.94, 53.73 ± 4.60, and 54.31 ± 4.25 diopter (D), respectively. Group 1 demonstrated increased Kmax for 6 months. Maximum flattening by 3.38 ± 2.35 D 1 year after surgery was observed in Group 4 (p<0.05). Decreased anterior chamber angle, anterior chamber depth, and anterior chamber volume were similar, indicating the stability of the anterior chamber. CONCLUSION: Visual and anatomical improvement is better, with improved stability of the anterior segment, in combined surgery groups compared with cross-linking alone.

Alterations in the Retinal Nerve Fiber Layer Thickness Color Map in Non-Glaucomatous Eyes with Myopia.

Objectives: To determine the normal values for retinal nerve fiber layer thickness (RNFLT) in myopic patients without glaucoma and analyze the changes in their color map. Materials and Methods: A total of 245 eyes without glaucoma were included in the study. According to the degree of myopia, the cases were divided into 4 groups: control group (+1.00/-1.00 D; n=70), Group 1 (-1.00/-3.00 D; n=50), Group 2 (-3.00/-6.00 D; n=75), and Group 3 (>-6.00 D; n=50). Intra-group comparisons were performed in terms of superotemporal, superonasal, nasal, inferonasal, inferotemporal, temporal, and global RNFLT (Heidelberg Spectralis, Optic Coherence Tomography, Germany) and the color coding of these quadrants (green: within normal limits, yellow: borderline, red: outside normal limits). Results: All groups were similar in age and gender (p>0.05). As the degree of myopia increased, RNFLT became thinner in the upper and lower temporal and upper and lower nasal quadrants (p<0.01). The rate of measurements considered borderline and outside normal limit in at least 1 quadrant was higher in groups with higher myopia for all quadrants (p<0.05). This rate was found to be 8/70 (11.4%) for the control group, 9/50 (18.0%) for Group 1, 21/75 (28.0%) for Group 2, and 33/50 (66.0%) for Group 3 (p<0.01). Conclusion: The high rate of RNFLT classified as borderline or outside normal limits in myopic patients is a finding to which clinicians should pay attention in order not to make a misdiagnosis, especially in cases of suspected glaucoma.

Pars plana vitrectomy timing in deadly weapon-related open-globe injuries.

OBJECTIVES: The objective of this study is to evaluate the effect of vitrectomy timing on anatomical and functional outcomes in cases with open-globe injuries caused by improvised explosive devices (IEDs). METHODS: A retrospective review of ocular injuries caused by IEDs was undertaken. The eyes were classified into four groups based on the timing of vitrectomy: early (Group-1; 2-4 days), delayed (Group-2; 5-7 days), late (Group-3; 8-14 days) and very late (Group-4; >14 days). RESULTS: The medical records of 351 patients were reviewed, and 212 patients were excluded. A total of 189 eyes of the remaining 139 patients were analysed. Visual improvements were statistically significant compared to the baseline values in all groups (p < 0.001). The early group showed better functional and structural outcomes when compared to the other groups. There was also no proliferative vitreoretinopathy (PVR) in the early group, while PVR was at the highest rate (25%) in the very late group and constituted the most significant reason for recurrent retinal detachment. CONCLUSION: Both functional and anatomical outcomes were better in the early group. Delayed surgery may be indicated for some cases, but 1-week interval seems to be an optimal time-frame in open globe injuries due to IEDs.

Surgical Outcomes of Idiopathic Epiretinal Membrane: the Gülhane Experience.

OBJECTIVES: We aimed to report our experiences and outcomes of vitreoretinal surgery in idiopathic epiretinal membrane. MATERIALS AND METHODS: We retrospectively reviewed patients who underwent vitreoretinal surgery for idiopathic epiretinal membrane between January 2012 and 2014. The patients' pre- and postoperative visual acuity, slit-lamp examination findings, and optical coherence tomography (OCT) images were evaluated. RESULTS: Forty-five eyes of 45 patients (36% male, 64% female) were included (mean age, 69±8.2 years). Mean postoperative follow-up time was 7±4 (1-12) months. The mean preoperative logMAR best corrected visual acuity was 0.58±0.32 and postoperatively 0.40±0.31, 0.33±0.33, 0.28±0.34 respectively at 3, 6, and 12 months. All OCT parameters showed statistically significant anatomical improvement at 1, 3, 6, and 12 months. Correlation analysis showed that central macular thickness (r=0.69, p<0.05) and central macular volume (r=0.69, p<0.05) were the only parameters that had strong positive correlations with visual improvement. CONCLUSION: Epiretinal membrane causes heterogeneous anatomical changes in the macula for every patient. Therefore, a correlation between visual gain and changes in central macular thickness could not yet be demonstrated. We believe that central macular volume may be a better parameter for following these patients.

Outcomes of Intravitreal Dexamethasone Implant in the Treatment of Recalcitrant Diabetic Macular Edema.

OBJECTIVES: To investigate the efficacy and safety of intravitreal dexamethasone (OZURDEX®) implantation in patients with recalcitrant diabetic macular edema. MATERIALS AND METHODS: This is a retrospective non-randomized study of patients who underwent intravitreal dexamethasone implantation for recalcitrant diabetic macular edema. Main outcome measures included changes in best corrected visual acuity (BCVA), central macular thickness (CMT), and incidence of ocular side effects. RESULTS: Fifty-seven eyes of thirty-eight patients (20 females, 18 males; mean age 65±7 years) were included in the study. The mean hemoglobin A1c level was 7.9±1.7%. Before entering the study, patients had undergone 5.71±3.40 anti-vascular endothelial growth factor (anti-VEGF) and 3.44±2.46 intravitreal triamcinolone acetonide injections. The mean duration of diabetes and diabetic macular edema was 17.2±6.4 years and 60.2±17.6 months, respectively. At baseline, mean CMT was 506.76±166.74 µm, and the mean BCVA was 0.68±0.38 LogMAR. Mean CMT significantly decreased to 341.36±146.26 µm (p<0.001), 324.41±114.58 µm (p<0.001), and 384.82±151 µm (p<0.001) at 1, 3, and 4 months of follow-up and increased again to 462.29±152.87 µm at 5 months. Sixteen eyes (28%) received second injections after mean of 7.4±2.3 months and mean CMT was again significantly decreased at 7, 8, and 9 months. Significant improvement in mean BCVA (0.54±0.41 LogMAR; p<0.001) occurred only at 1 month after implantation. However, subgroup analysis revealed significant BCVA improvement in the pseudophakic group at 1, 3, and 4 months. Among phakic patients, 50% showed cataract progression and 28% had elevated intraocular pressure increase which was managed medically. CONCLUSION: Intravitreal dexamethasone implantation was effective for the first 4 months in eyes with recalcitrant diabetic macular edema. However, it is hard to displace anti-VEGF agents as first-line therapy due to steroid-related complications.

Fixation Characteristics of Severe Amblyopia Subtypes: Which One is Worse?

PURPOSE: To determine differences in macular sensitivity and fixation patterns in different subtypes of severe amblyopia. METHODS: This case-control study enrolled a total of 73 male adults, including 18 with pure strabismic severe amblyopia, 19 with pure anisometropic severe amblyopia, 18 with mixed (strabismic plus anizometropic) severe amblyopia, and 18 healthy controls. MP-1 microperimetry was used to evaluate macular sensitivity, location of fixation, and stability of fixation. RESULTS: Mean macular sensitivity, stability of fixation, and location of fixation were significantly worse in all amblyopia subtypes when compared with healthy controls. Intergroup comparisons between amblyopia subtypes revealed that mean macular sensitivity, stability of fixation, and location of fixation were significantly worse in pure strabismic and mixed amblyopic eyes when compared with pure anisometropic amblyopic eyes. CONCLUSIONS: Strabismus seems to be a worse prognostic factor in severe amblyopia than anisometropia in terms of fixation characteristics and retinal sensitivity.

Objective Determination of Retinal Function in Bietti Crystalline Retinopathy.

A 44-year-old female patient without any known systemic or ocular disease presented with progressive visual loss and night vision disturbance. Visual acuity was 0.6 in the right eye and 0.2 in the left eye. Tiny, yellow crystalline deposits were seen on fundus examination. In addition, areas of retinal pigment epithelium and choriocapillaris atrophy were detected. Rod and cone responses were depressed in full-field flash electroretinogram. Multifocal electroretinogram testing showed severe foveal function disturbance with less severe but still depressed responses toward the periphery. Multiple hyperreflective lesions were detected in the retina in optical coherence tomography. We aimed to present the role of ocular electrophysiology by comparing the patient's signs and symptoms with her ocular electrophysiological test results.

Ophthalmic pathologies in female subjects with bilateralcongenital sensorineural hearing loss.

BACKGROUND/AIM: The high prevalence of ophthalmologic pathologies in hearing-disabled subjects necessitates early screening of other sensory deficits, especially visual function. The aim of this study is to determine the frequency and clinical characteristics of ophthalmic pathologies in patients with congenital bilateral sensorineural hearing loss (SNHL). MATERIALS AND METHODS: This descriptive study is a prospective analysis of 78 young female SNHL subjects who were examined at a tertiary care university hospital with a detailed ophthalmic examination, including electroretinography (ERG) and visual field tests as needed. RESULTS: The mean age was 19.00 ± 1.69 years (range: 15 to 24 years). A total of 39 cases (50%) had at least one ocular pathology. Refractive errors were the leading problem, found in 35 patients (44.9%). Anterior segment examination revealed heterochromia iridis or Waardenburg syndrome in 2 cases (2.56%). Dilated fundus examination revealed retinal pathologies in 15 cases (19.23%), including retinitis pigmentosa or Usher's syndrome in 8 cases (10.25%). Most of the Usher's syndrome cases (87.5%) had consanguinity. CONCLUSION: Screening for congenital SNHL in the early years of life and routine yearly follow-ups are essential for maximizing the rehabilitation of this disabled group. The high rate of visually debilitating syndromic ocular pathologies associated with high frequency of consanguinity doubles the importance.

Retina nerve fiber layer and choroidal thickness changes in obstructive sleep apnea syndrome.

OBJECTIVES: The purpose of this study was to determine the effects of obstructive sleep apnea syndrome (OSAS) on the submacular and peripapillary retinal nerve fiber layer (RNFL) and choroidal thickness (ChT). METHODS: Eighty-four eyes of 42 male patients with OSAS and 112 eyes of 56 aged-matched and body mass index-matched healthy male subjects were enrolled in this case-control study. The ChT and peripapillary RNFL thickness was measured using enhanced depth imaging optical coherence tomography. The ChT and RNFL thickness measurements of the groups were compared, and correlations among the Apnea Hypopnea Index (AHI) values and these measurements were calculated. Right and left eyes were separately evaluated. RESULTS: There were no significant differences in the subfoveal and temporal ChT between the groups (p > 0.05). The OSAS group had significantly thicker ChT at 0.5 and 1.5 mm nasal to the fovea in both eyes than the control group (p < 0.05). The peripapillary ChT were significantly thicker in the OSAS group at all segments except for the temporal and superotemporal segments when compared with the control group (p < 0.05 for all quadrants except temporal and superotemporal). When compared with controls, the OSAS group had significantly thinner nasal RNFL thickness in the right eye (p = 0.01) and thinner mean RNFL thickness in both eyes (p < 0.001). Other RNFL thickness measurements were similar between groups (p > 0.05). Between AHI and mean RNFL thickness showed a median negative correlation (r = - 0.411, p = 0.001). CONCLUSION: The choroidal thickening in patients with OSAS may be associated with the pathophysiology of the neurodegeneration process of the disease.

Indications for eye removal surgeries. A 15-year experience at a tertiary military hospital.

OBJECTIVES: To analyze the indications and types of eye removals at a military tertiary care hospital in Turkey. METHODS: The medical records (age, gender, affected eye, type of surgical procedure, indications of surgery) of 123 patients who underwent evisceration and enucleation in the course of a 15-year period (January 2000 to December 2014) at Gulhane Military Medical Academy, Ankara, Turkey were reviewed retrospectively. RESULTS: The mean age was 35.61±18.52 (range 3-80 years). The number of male in the patient group was 92 (74.8%) and female was 31 (25.2%). Patients who underwent evisceration were 95 (77.2%), whereas 28 (22.8%) of them underwent enucleation. The mean age of the eviscerated patients was 30.63±13.08, whereas the mean age of the enucleated patients was 52.50±23.92 (p less than 0.001). The leading indications for eye amputations were trauma (n=62, 50.4%), malignancy (n=20, 16.3%), painful blind eye and absolute glaucoma (n=20, 16.3%), endophthalmitis (n=12, 9.7%), and phthisis bulbi, and cosmetic reasons (n=9, 7.3%). CONCLUSION: Trauma was the most common etiology for evisceration, and malignancy was the most common etiology for enucleation. Using protective eyewear and early detection of intraocular malignancy and glaucoma through routine ophthalmic examinations are essential for providing non-invasive treatment modalities instead of eye removal.