Diffuse Corneal Edema after Uneventful Pterygium Surgery: Toxic Anterior Segment Syndrome or Toxic Keratopathy?

A 29-year-old woman was referred to our department for corneal edema after uneventful pterygium excision surgery with conjunctival autografting. She was prescribed topical dexamethasone and showed a complete response within 2 weeks of treatment. Specular microscopic examination revealed severe endothelial cell loss in the operated eye. Mild corneal haze causing a decrease in vision (20/50) was observed in long-term follow-up. This steroid-responsive complication was linked to two possible etiologies: mild toxic anterior segment syndrome or povidone-iodine (PVP-I) corneal toxicity. Surgeons should be careful during pterygium surgery to completely clear PVP-I and avoid any penetration into the anterior chamber to prevent possible serious complications. When diffuse corneal edema is encountered after pterygium surgery, intense steroid treatment should be prescribed as in the present case.

Evaluation of the Cataract Surgery 2018 Survey in Terms of Achieving Refractive Cataract Surgery Targets.

Objectives: The aim of this study was to show at what rate the technological equipment used in cataract surgery by Turkish ophthalmologists and their knowledge are reflected in practice and how up to date they are. Materials and Methods: A questionnaire conducted using SurveyMonkey was used to evaluate the answers to 17 questions from 823 members of the Turkish Ophthalmological Association. Results were evaluated in subgroups according to the participants' age, occupational status, institutions, and whether they conducted relevant academic activities, and the data were compared as inadequate, standard, and contemporary approaches according to the determined criteria. Results: Optical biometry devices were used at rates of 77.7% and 67.3% for intraocular lens (IOL) power calculations and keratometric measurements in preparation for cataract surgery, respectively. For IOL power calculation, third-generation formulas, especially the SRK-T, were used most commonly (46.2%), followed by second-generation formulas (21.9%), and fourth/fifth-generation formulas and multiple evaluations for different axial lengths (31.9%). The most common incision size was 2.8 mm (51.6%), while the percentage of 2.2 mm and shorter incisions considered to be neutral in terms of surgically induced astigmatism was 18.8%. When selecting incision location, approaches to reduce corneal astigmatism were reported by 28.9%, neutral approaches by 26.2%, and insensitive approaches by 44.9%. Additionally, 55.6% of participants never implanted toric IOLs and 50.7% did not use presbyopia-correcting IOLs. The proportion of surgeons who have experience with femtosecond laser-assisted cataract surgery was 10.3% and the rate of intracameral antibiotic injection at the end of the operation was 89.4%. Conclusion: It was seen that Turkish cataract surgeons were able to use high technology for surgical preparation and surgery at high rates, but this was not reflected in practice at same rate in terms of achieving contemporary standards of refractive cataract surgery.

In Vitro Antifungal Effect of Acrylic Corneal Glue (N-Butyl-2-Cyanoacrylate).

PURPOSE: The purpose of this study was to evaluate the in vitro antifungal effects of n-butyl-2-cyanoacrylate (nB2CA; Histoacryl Blue; B. Braun, Melsungen, Germany) against a variety of different fungal species. METHODS: Inocula taken from suspensions prepared with Aspergillus flavus, Aspergillus fumigatus, Aspergillus niger, Aspergillus ochraceus, Aspergillus oryzae, Fusarium solanii, Fusarium oxysporum, Trichoderma spp., Rhizomucor spp., Scedosporium apiospermum, Penicillium commune, Phoma glomerata, and Chrysosporium spp. molds and Candida albicans, Candida glabrata, Candida parapsilosis, Candida kruzei, Candida dubliniensis, Candida tropicalis, Candida kefyr, and Trichosporon asahii yeasts were spread on the surface of RPMI1640 agar media. Then, 50 µL of nB2CA was dropped on the surface of these media and they were incubated at 35°C. Observation of a clear zone of inhibition around the nB2CA was regarded as an indicator of the susceptibility of the fungi to nB2CA, and the absence of this zone was interpreted as an indicator of nonsusceptibility. The inhibition zone diameter was measured across the largest clear zone. RESULTS: A zone of inhibition was observed around nB2CA for all of the yeast and mold species except A. flavus, A. oryzae, and Chrysosporium spp. Among molds, the largest zone of inhibition was observed with P. glomerata (25.7 ± 0.6 mm), whereas among yeasts, the largest zone of inhibition was observed with C. kruzei (19.3 ± 1.5 mm). CONCLUSIONS: nB2CA has shown antifungal activity against 18 different mold and yeast species, but not against A. flavus, A. oryzae, and Chrysosporium spp. molds.

Efficacy of fixation of the amniotic membrane on a symblepharon ring with continuous suturing in acute ocular chemical burn patients.

PURPOSE: To describe a modified non-traumatic amniotic membrane transplantation (AMT) technique and evaluating its efficiency for the ocular surface injury after chemical burn were aimed. METHODS: Twenty eyes of 20 patients (F: 6, M: 14) with acute chemical burn for whom modified non-traumatic AMT was utilized were evaluated retrospectively. In this technique, amniotic membrane (AM) was fixated onto a symblepharon ring with continuous suturing. The healing time of the corneal epithelial defect due to ocular surface chemical injury and melting duration of AM were evaluated. Development of infection or symblepharon, recurrence or persistence of epithelial defect, corneal perforation and the ring falling out with AM were evaluated as complications. RESULTS: Mean age of the patients was 24.7 ± 11.7 years old (14 months-40 years). Mean duration of applying the non-traumatic AMT after contact with the chemical agent was 8.4 ± 6.2 days (2-21 days). The mean duration of the epithelial defect healing was 27.8 ± 8.8 days (11-40 days) in the grade II, III, and IV (n = 12) cases, while in the grade V and VI (n = 8) cases, a persistent epithelial defect developed, and the mean duration of the epithelial defect healing was 83 ± 23.1 days (42-120 days) (p = 0.0002). The mean melting duration of the AM was 22.7 ± 10 days (10-42 days). CONCLUSION: By using this modified AMT technique, AM can be utilized efficiently, easily, and non-traumatically in every center for the treatment of the ocular surface injury due to chemical burn.

Ring Keratitis From Topical Anesthetic Abuse After Laser Epithelial Keratomileusis.

A 28-year-old man underwent laser epithelial keratomileusis for the correction of myopia in both eyes. The patient subsequently had delayed corneal epithelial healing in both eyes and ring infiltrate in the left eye (LE). Corneal scrapings were obtained from the ocular surface and subjected to microscopic examination and culture. On identifying and preventing the use of topical proparacaine, the corneal epithelium healed in both eyes after the use of eye pressure patches. The ring infiltrate resolved in the patient's LE, leaving minor opacity at the inferior cornea. Refractive surgeons should consider the possibility of topical anesthetic abuse in cases of corneal ring infiltrates. The resulting prognosis can be excellent after the rapid removal of inciting agents and the application of appropriate treatments.

Corneal viscoelastic differences between pseudoexfoliative glaucoma and primary open-angle glaucoma.

PURPOSE: The aims of this study were to assess the biomechanical properties of corneas with pseudoexfoliative glaucoma (PEXG) and to compare them with those of patients with primary open-angle glaucoma (POAG). METHODS: This prospective, comparative case series consisted of 73 eyes of 73 patients, 35 eyes with PEXG (PEXG group) and 38 eyes with POAG (POAG group). Corneal hysteresis (CH), corneal resistance factor (CRF), corneal-compensated intraocular pressure (IOPCC), and Goldmann-correlated intraocular pressure (IOPG) were determined by using ocular response analyzer (ORA). IOP using Goldmann applanation tonometer (GAT) and ultrasonic central corneal thickness (CCT) were also measured for each eye. Exclusion criteria included refractive error/astigmatism of >3.00 D, history of intraocular surgery, corneal disease, angle-closure glaucoma, and secondary glaucoma other than PEXG. In cases where both eyes were eligible, the right eye was preferred for analysis. The main outcome measures were CH, CRF, IOPCC, IOPG, and GAT. The results were statistically analyzed by using t test, general linear model, and the Pearson correlation test. RESULTS: The mean CH was found to be significantly lower in patients with PEXG (8.8 ± 1.4 mm Hg) than those with primary open-angle glaucoma (9.9 ± 1.2 mm Hg; P=0.0007). The mean CRF was found to be significantly lower in patients with PEXG (9.5 ± 1.8 mm Hg) than those with POAG (11.1 ± 1.3 mm Hg; P<0.0001). IOPCC was not significantly different between the groups (PEXG, 16.7 ± 2.5 mm Hg; POAG, 16.9 ± 2.4 mm Hg; P=0.72). IOPG was significantly lower in PEXG group (14.7 ± 2.7 mm Hg) compared with the POAG group (16.5 ± 2.5 mm Hg; P=0.004). GAT was significantly lower in the PEXG group (14.6 ± 2.7 mm Hg) compared with the POAG group (16.4 ± 2.8 mm Hg; P=0.007). There was no significant difference between the groups regarding mean CCT (PEXG, 546.1 ± 34.9 µ; POAG, 549.1 ± 25 µ; P=0.66) and mean age (PEXG, 70.3 ± 8.2; POAG, 67.6 ± 8.8; P=0.17). The difference between the IOPCC and the GAT was 2.1 and 0.5 mm Hg in both PEXG and POAG groups, respectively. CONCLUSIONS: Patients with PEXG had lower CH and CRF values than those with POAG. These findings require further investigation to assess the role of differing corneal biomechanical properties between the 2 groups and its association with poor prognosis among patients with PEXG.

Intraocular lens optic capture in eyes with zonular weakness in cataract patients.

We desribe a technique for managing cataracts in eyes with zonular weakness. The technique is a combination of microhook iris retractors to fixate the capsulorhexis, a capsular tension ring, and intraocular lens optic capture. Results of this technique in 70 eyes after a 13-month mean follow-up are reported.

A case of medication-resistant acanthamoeba keratitis treated by corneal crosslinking in Turkey.

Purpose. To report a case of medication-resistant acanthamoeba keratitis (AK) treated successfully by corneal crosslinking (CXL). Methods. A 26-year-old male with medication-resistant AK underwent a standard CXL procedure with local anesthesia, followed by central corneal epithelial debridement, application of riboflavin 0.1%, and UV-A irradiation. Results. The patient experienced a dramatic symptomatic improvement within 24 hours. At two months, keratitis was healed with a semitransparent paracentral scar that did not affect visual acuity. Conclusions. Our experience, considered in the context of recent studies, suggests that CXL may be an option for selected patients with medication-resistant AK and corneal melting. CXL allows patients to avoid emergency keratoplasty and experience rapid symptomatic relief.

Bioadhesive sulfacetamide sodium microspheres: evaluation of their effectiveness in the treatment of bacterial keratitis caused by Staphylococcus aureus and Pseudomonas aeruginosa in a rabbit model.

The aim of this study was to prepare bioadhesive sulfacetamide sodium (SA) microspheres to increase their residence time on the ocular surface and to enhance their treatment efficacy on ocular keratitis. Microspheres were fabricated by spray drying method using mixture of polymers such as pectin, polycarbophil and hydroxypropylmethyl cellulose (HPMC) at different ratios. The particle size and distribution, morphological characteristics, thermal behavior, encapsulation efficiency, mucoadhesion and in vitro drug release studies on formulations have been investigated. After optimisation studies, SA-loaded polycarbophil microsphere formulation with polymer:drug ratio of 2:1 was found to be the most suitable for ocular application and used in in vivo studies. In vivo studies were carried out on New Zealand male rabbit eyes with keratitis caused by Pseudomonas aeruginosa and Staphylococcus aureus. Sterile microsphere suspension in light mineral oil was applied to infected eyes twice a day. Plain SA suspension was used as a positive control. On 3rd and 6th days of the antimicrobial therapy, the eyes were examined in respect to clinical signs of infection (blepharitis, conjunctivitis, iritis, corneal oedema and corneal infiltrates) which are the main symptoms of bacterial keratitis and then cornea samples were counted microbiologically. The rabbit eyes treated with microspheres demonstrated significantly lower clinical scores than those treated with SA alone. A significant decrease in the number of viable bacteria in eyes treated with microspheres was observed in both infection models when compared to those treated with SA alone. In conclusion, in vitro and in vivo studies showed that SA-loaded microspheres were proven to be highly effective in the treatment of ocular keratitis.

Comparison of optical coherence biometry and applanation ultrasound biometry in high-myopic eyes with posterior pole staphyloma.

We compared the refractive outcomes of optical coherence biometry and applanation ultrasound biometry in 17 high-myopic eyes with posterior pole staphyloma. The optical coherence biometry provided more accurate IOL power calculations than applanation ultrasound biometry in patients with high myopia and posterior pole staphyloma.

A case of herpetic keratitis after intravitreal triamcinolone injection.

PURPOSE: We report a case of herpetic epithelial keratitis that developed after intravitreal triamcinolone acetonide injection. METHODS: An 81-year-old man with diabetes with severe nonproliferative diabetic retinopathy and diffuse macular edema in both eyes received bilateral intravitreal injections of 0.4 mg/0.1 mL of triamcinolone acetonide. RESULTS: Eighteen days after the injections, the patient presented with redness, tearing, foreign body sensation, and decreased visual acuity in the right eye. The cornea showed dendriform ulcers that exhibited positive fluorescein staining. Diagnosis for herpes simplex epithelial keratitis was made, and topical acyclovir ointment therapy was initiated. The epithelial lesions healed after 7 days of therapy. CONCLUSIONS: Herpes simplex epithelial keratitis can be a possible complication of intravitreal triamcinolone acetonide injection. The course and response to conventional therapy was no different from that of the classical course of the disease.

Flap dimensions created with the Hansatome microkeratome: correlation with Orbscan-derived anterior segment data.

PURPOSE: To investigate the flap dimensions created by Hansatome microkeratome (Bausch & Lomb Surgical) and their correlation with anterior segment biometric data measured by the Orbscan II (Bausch & Lomb). SETTING: Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey. METHODS: Forty-four myopic eyes of 22 patients (mean age 29 years +/- 7 [SD]) that had laser in situ keratomileusis surgery using the Hansatome microkeratome were enrolled in the study. Intraoperative images taken from video recordings of procedures were analyzed with image analysis software to determine flap size and hinge size. White-to-white corneal diameter, corneal curvatures (K(max), K(min)), corneal thickness, and anterior chamber depth were deducted from Orbscan measurement. Correlation analyses between flap dimensions and Orbscan-derived anterior segment biometric data were done. RESULTS: The mean corneal flap diameter was 9.56 +/- 0.28 mm in the right eye and 9.62 +/- 0.28 mm in the left eye. There was no difference in flap size between the right and left eyes (P=.43). The mean hinge size was 4.98 +/- 0.37 mm in the right eye and 5.07 +/- 0.41 mm in the left eye. There was no difference in hinge size between the right and left eyes (P=.46). There was a significant correlation between flap size and preoperative corneal thickness (P<.001, r=0.487), but there was no correlation between flap size and corneal curvature (P=.40, r=-0.12), white-to-white corneal diameter (P=.11, r=0.47), or anterior chamber depth (P=.52, r=0.09). There was also no correlation between hinge size and preoperative anterior segment biometric data. CONCLUSION: The Hansatome microkeratome produced a flap whose diameter is close to the intended flap diameter, and preoperative corneal thickness seems to be the important factor in determining flap size.

Failure to detect hepatitis B virus in vitreous by polymerase chain reaction.

PURPOSE: To assay the vitreous of asymptomatic hepatitis B virus (HBV) carriers for the presence of HBV DNA using polymerase chain reaction (PCR). METHODS: Vitreous and serum specimens were collected from 13 carriers of HBV. The presence of HBV DNA was investigated by using PCR and Digene's Hybrid Capture System. The presence of hepatitis B surface antigen (HBsAg) in vitreous was also investigated by using the enzyme immunoassay (EIA). RESULTS: The serum was positive for HBV DNA in3 of the 13 asymptomatic carriers using PCR. Vitreous samples of all the patients, including 3 patients who were positive for HBV DNA in serum, were negative for HBV DNA with PCR and were negative for HBsAg with EIA. CONCLUSION: There is no evidence of HBV in the vitreous of asymptomatic HBV carriers.

Visual field changes after laser in situ keratomileusis in myopic eyes.

PURPOSE: To evaluate the effect of acute elevation of intraocular pressure (IOP) during laser in situ keratomileusis (LASIK) on the visual field in myopic eyes. SETTING: Istanbul University, Cerrahpassa Medical Faculty, Istanbul, Turkey. METHODS: Thirty-seven eyes of 37 patients were included in the study. The LASIK procedure was performed using the Hansatome microkeratome (Bausch & Lomb) and the Summit SVS Apex Plus 193 nm argon-fluoride excimer laser. Visual field testing was performed twice before LASIK and 1 day and 24 months after LASIK. Seventy-six points, 6 degrees apart, in the central visual field (Central 30-2) were tested for threshold sensitivity (Humphrey). The mean threshold sensitivity of baseline and post-LASIK visual field examinations was calculated in each patient. Seventy-six points of the Central 30-2 test were divided into 21 clusters corresponding to perimetric nerve-fiber bundles derived from Peridata software version 6.2a (Interzaag AG). The mean threshold sensitivity of each cluster and the visual field indices (mean deviation [MD] and corrected pattern standard deviation [CPSD]) in baseline and follow-up visual fields were compared using analysis of variance. RESULTS: The mean age of the 23 men and 14 women was 31.04 years +/- 6.55 (SD). The mean spherical equivalent refraction was -4.21 +/- 1.66 diopters (D) (range -2.25 to -6.75 D). The mean duration of suction was 42.29 +/- 29.06 seconds. The mean visual field sensitivity at baseline and the 2 follow-up examinations was 25.97 +/- 2.04 dB, 25.70 +/- 1.99 dB, and 27.17 +/- 1.68 dB, respectively (P =.181). There was no difference between preoperative and postoperative visual field clusters except in area 13. In area 13, threshold sensitivity was decreased at 1 day (P =.039) and at the preoperative level at 24 months. The MD of the visual fields was -3.53 +/- 1.67 dB, -3.61 +/- 2.91 dB, and -2.61 +/- 1.66 dB at the preoperative and 2 postoperative examinations, respectively (P =.495). The mean CPSD of the visual fields was 1.76 +/- 1.24 dB, 1.42 +/- 0.85 dB, and 1.74 +/- 0.86 dB, respectively (P =.680). CONCLUSION: Laser in situ keratomileusis did not cause visual field defects in mild to moderate myopic patients who had no risk factors that might render the optic nerve more vulnerable to damage.

Optic nerve head blood flow using scanning laser Doppler flowmetry after laser in situ keratomileusis.

PURPOSE: To investigate ocular blood flow changes following laser in situ keratomileusis (LASIK) in myopic eyes. METHODS: Seventeen eyes of ten myopic patients were included in the study. Mean age of the seven men and three women was 29.1+/-2.5 years. Mean spherical equivalent refraction was -7.70+/-2.52 D. LASIK was performed with the Hansatome microkeratome and Summit SVS Apex excimer laser. Optic nerve head blood flow was measured by using the Heidelberg Retinal Flowmeter preoperatively and postoperatively at 1 day, 1 week, and 1 month. Preoperative ocular blood flow data (blood flow, volume, velocity) were compared with postoperative data using variance analysis. Correlation analysis was performed for age of patients, suction time, and ocular blood flow data. RESULTS: Mean suction time was 19+/-7 seconds. There was no significant correlation between suction time, age, and ocular blood flow. We found an increase in blood flow at the lamina cribrosa taken 1 day postoperatively (P=.04). Blood flow returned to preoperative values at the 1-week and 1-month measurements in the lamina cribrosa region. There was no significant change in ocular blood flow data in the neuroretinal rim except an increase in velocity at the lower nasal quadrant on postoperative day 1 (P=.03). CONCLUSIONS: LASIK caused a temporary increase in blood flow at the lamina cribrosa region of the optical nerve head in healthy myopic eyes. The increase in blood flow may suggest a compensatory change for maintaining blood flow in the ocular nerve head following LASIK-induced ischemia.

Suprachoroidal seton implantation in refractory glaucoma: a novel surgical technique.

PURPOSE: To describe a new surgical technique in which aqueous humor is diverted from the anterior chamber to the suprachoroidal space for the augmentation of uveoscleral outflow in the management of refractory glaucoma. METHODS: Four painful-blind eyes of four consecutive patients were included in the study. Mean age of patients was 54.7+/- 9.2 years. Preoperative diagnosis was neovascular glaucoma complicating diabetic retinopathy in three cases and chronic angle-closure glaucoma in one case. Mean preoperative intraocular pressure of the patients receiving two medications was 58.5 +/- 9.2 mm Hg. A modified Krupin eye valve with disk was implanted into the suprachoroidal space. The anterior tube part of the Seton device was placed into the anterior chamber through the long scleral tunnel for draining the aqueous humor from the anterior chamber to the suprachoroidal space. RESULTS: The placement of modified Krupin eye valve with disk to the suprachoroidal space was achieved in all cases. While mean preoperative intraocular pressure was 58.5 +/- 9.2 mm Hg, it was 14.2 +/- 4.7 mm Hg at postoperative one week. It was 13.5 +/- 4.6 mm Hg and 15 +/- 4.9 mm Hg at one and three months respectively. At the last follow-up visit, mean intraocular pressure was 17.25 +/- 5.37 mm Hg ranging from 12 to 24 mm Hg. Choroidal detachment was developed in one case and regressed in six weeks. Rubeosis irides regressed at third month in three cases. None of the eyes developed suprachoroidal hemorrhage, retinal detachment, or phthisis bulbi. CONCLUSION: The drainage of aqueous humor from the anterior chamber to the suprachoroidal space with the implantation of the glaucoma Seton device is effective in lowering intraocular pressure in refractory glaucoma.

Intravitreal penetration of cefepime after systemic administration to humans.

PURPOSE: To investigate the penetration of cefepime (a fourth-generation cephalosporin) into the vitreous after single-dose intravenous administration to human subjects. METHODS: Thirty phakic patients about to undergo vitreous surgery received 1 g (group 1, 15 patients) or 2 g cefepime (group 2, 15 patients) in a single intravenous injection before surgery. The indications for vitreous surgery were retinal detachment with proliferative vitreoretinopathy (24 patients), retinal detachment associated with giant retinal tear (4 patients), macular hole (1 patient) and intraocular foreign body (1 patient). Samples of vitreous and serum were obtained at 0.5, 1, 2, 4 and 12 h after injection. Three patients were used for each sampling time and for 1 g and 2 g of cefepime. Samples were assayed for cefepime concentrations with high-performance liquid chromatography (HPLC). RESULTS: All the patients had detectable cefepime in their vitreous and serum measurable by HPLC. The level of cefepime in the vitreous peaked at 2 h and reached a minimum at 12 h after intravenous injection in both groups. A mean peak vitreous level of cefepime was 1.91 +/- 0.13 microg/ml in group 1 and 2.86 +/- 0.37 microg/ml in group 2. The level of cefepime in the vitreous at 12 h after injection was 0.89 +/- 0.14 microg/ml in group 1 and 0.97 +/- 0.30 microg/ml in group 2. CONCLUSION: The vitreous level of cefepime after intravenous injection was below the minimum inhibitory concentration (MIC(90)) against Staphylococcus aureus, Staphylococcus epidermidis and Pseudomonas aeruginosa, but was over the MIC(90) against Proteus mirabilis, Klebsiella spp., Haemophilus influenzae, Streptococcus pneumoniae, Streptococcus pyogenes and Enterobacter spp.