Comparison of the efficacy of intravitreal Anti-VEGF versus intravitreal dexamethasone implant in treatment resistant diabetic Macular Edema.

PURPOSE: Comparison of the efficacy of monthly anti-VEGF versus dexamethasone (DEX) implant in patients with diabetic macular edema (DME) whose macular edema persists despite three doses of anti-VEGF therapy. MATERIALS AND METHODS: This retrospective study included 94 eyes of 94 patients with central macular thickness (CMT) > 300 µm despite previously receiving three doses of anti-VGEF (aflibercept or ranibizumab) injections between January 2014 and January 2019. The patients were divided into four groups. The first and second groups were the patients who received three more doses of initial anti-VGEF treatment after the initial anti-VGEF treatment. The third and fourth groups were patients switched to intravitreal dexamethasone implants. Patients were followed up every month for six months after the injection. The primary outcome measures were best-corrected visual acuity (BCVA), central macular thickness (CMT), and intraocular pressure (IOP) at six months. RESULTS: The mean age of the patients included in the study was 64.64 ± 7; there were 58 men (61.7%) and 36 women (38.3%). There was no statistically significant difference between the groups regarding age, stage of retinopathy, and lens status. When CMT, BCVA, and IOP were assessed among the four groups at the end of the sixth month, no statistical difference between the groups was found. There was no need for medical intervention despite the statistically significant increase in IOP at the end of the sixth month compared to the third month in the dexamethasone implanted groups. In contrast to the decrease in CMT, which was statistically significant in all four groups at the end of the sixth month compared to the third month, the increase in BCVA was not statistically significant in any of the four groups at the end of the sixth month. CONCLUSION: According to the results of our study, there is no superiority between continuing with existing anti-VEGF or switching to a dexamethasone implant after three doses of anti-VEGF.

Evaluating the effectiveness of localized sub-Tenon's anesthesia in 23-gauge vitreoretinal surgery.

PURPOSE: To evaluate the effectiveness of localized sub-Tenon's anesthesia for pain control during 23-gauge vitreoretinal surgery. METHODS: Eighty patients were randomly divided into two groups as localized sub-Tenon's (group 1, n = 41) and retrobulbar (group 2, n = 39) anesthesia groups. In group 1, a small volume of anesthetic was injected into the sub-Tenon's capsules at the trocar entry sites. The 23-gauge vitreoretinal surgery was performed in all patients. In both groups, the pain levels during the surgical steps were evaluated using the visual analog pain scale. RESULTS: Patients in group 1 experienced less pain than group 2 patients did during placement of the trocars and scleral depression (p = 0.041, p = 0.029). Pain during laser photocoagulation was higher in group 1 (p = 0.008). There was no serious complication due to anesthesia or surgery. CONCLUSION: Localized sub-Tenon's anesthesia is as effective as retrobulbar anesthesia in many steps of vitreoretinal surgery for providing pain control. It can be considered an alternative form of local anesthesia.

Objective vision screening using PlusoptiX for children aged 3-11 years in rural Turkey.

BACKGROUND: This population based cross sectional study was conducted to detect amblyopia risk factors and myopia in a rural district of Northwestern Turkey by using PlusoptiX S12R (Photoscreener PlusoptiX Inc., Nuremberg, Germany). METHODS: Children from 38 rural schools in Caycuma district of Zonguldak Turkey underwent vision screening in their school using PlusoptiX S12 photoscreener. Data were analyzed using the factory default level 5 referral criteria targeting 80% sensitivity and 95% specificity. Referral, unable readings, and positive predictive value (PPV) were reported. RESULTS: Data from 2846 children were analyzed. Mean age was 7.9 years (±0.8) (range 36 months to 11 years). Three hundred ten (11%) were referred of whom 32% were read as 'unable'. 150 children (48% of the referred) received a gold standard examination. Positive predictive value of PlusoptiX was 69%. PPV was 83% when unable readings were excluded. 93 children with amblyopia risk factors were identified. Only 26% (n = 25) had received glasses priorly. 49 children had amblyopia of whom 33 were newly diagnosed. CONCLUSIONS: PlusoptiX showed a reasonable level of positive predictive value in community setting and the device could be a useful tool for vision screening in preschoolers and schoolers. We found most of the amblyogenic refractive errors were underdiagnosed in rural school children leading to a call for action on vision screening.

Efficiency and safety of phenylephrine and tropicamide used in premature retinopathy: a prospective observational study.

BACKGROUND: To determine effects and side effects of topical application of phenylephrine 2.5% and tropicamide 0.5% combination in preterm infants. METHODS: In this prospective observational study, 60 infants undergoing retinopathy of prematurity (ROP) screening were prospectively observed. Pupillary diameter, blood pressure, heart rate, and oxygen saturation were monitored before and after up to 24 h during ROP screening examinations. RESULTS: The mean pupillary diameter 1 h after the instillation of drops was 5.58 ± 0.75 mm for both eyes. The mean systolic and diastolic pressure and oxygen saturation of infants did not change statistically until the end of the study. The average heart rate decreased by a mean of 4.96 beats/minute from the baseline following eye drops instillation. General condition deterioration, fall in oxygen saturation and bradycardia were observed in 4 infants that already had respiratory distress syndrome. CONCLUSION: The phenylephrine 2.5% plus tropicamide 0.5% drop is effective and safe as mydriatic combination for retinopathy of prematurity screening. In infants with an additional systemic disease such as respiratory distress syndrome, the side effects of mydriatic drops may be more common. Such babies should be kept under close observation. TRIAL REGISTRATION: The trial was retrospectively registered on 28 February 2018. The ClinicalTrials.gov Identifier is NCT03448640.

The role of patient's systemic characteristics and plateletcrit in developing toxic anterior segment syndrome after uneventful phaco surgery: A case-control study.

PURPOSE: To compare the systemic and ocular characteristics and laboratory findings of patients developing toxic anterior segment syndrome (TASS) after uneventful phaco surgery with unaffected subjects undergoing the same surgery in the same session. DESIGN: A retrospective case-control study. METHODS: The study group consisted of 26 eyes of 26 patients who underwent uneventful phaco surgery and who went on to develop TASS, while the control group included 39 subjects who had routine phaco surgery in the same session by the same surgeon. The sterilization stages of reusable instruments, disposable instruments, and compositions were recorded. The preoperative systemic diseases, complete blood count parameters, glycosylated hemoglobin (HbA1c), biochemical parameters, thyroid hormone profiles, and the surgical features were compared between the two groups. RESULTS: Type 2 diabetes mellitus (DM), systemic hypertension (HT), hyperlipidemia, chronic ischaemic heart disease, and chronic renal failure were significantly more common in the TASS group (p < 0.05). Proliferative diabetic retinopathy was also more frequent in the TASS group (p = 0.003). Mean HbA1c% values, white blood cell count, neutrophil/lymphocyte ratio, platelet counts, platelet distribution width, and plateletcrit parameters were significantly higher in the TASS group (p < 0.05). Multivariate logistic regression analysis revealed that a high plateletcrit level (p = 0.001, odds ratio [95% CI]; 22.27 [3.36-147.76]) and systemic HT (p = 0.044, odds ratio [95% CI]; 7.13 [1.05-48.12]) are independently associated with the development of TASS. CONCLUSION: Although TASS may arise as a result of insufficient sterilization of instruments or intraocular solutions, patient factors may also contribute to its development. Systemic vascular disorders such as uncontrolled type 2 DM, systemic hypertension, and hyperlipidemia may increase the risk of TASS after uneventful phaco surgery. Abnormal parameters associated with systemic inflammation, such as higher plateletcrit level, may facilitate the development of TASS. These findings may be a predicting factor of TASS development for uneventful cataract surgeries.

Color Doppler Evaluation of the Retrobulbar Hemodynamic Changes in Chronic Obstructive Pulmonary Disease: COPD and Retrobulbar Hemodynamic Changes.

The aim of this study was to evaluate the hemodynamic changes in the extraocular orbital vessels of the patients with chronic obstructive pulmonary disease (COPD), using color Doppler ultrasonography, and to compare the results with those of healthy control subjects. The control group consisted of 35 healthy subjects who had no systemic problems, while the study group consisted of 60 patients with the diagnosis of COPD. Patients with COPD were grouped according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Twenty patients of stage 1 COPD (mild airflow limitation), stage 2 COPD (moderate airflow limitation), or stage 3 COPD (severe airflow limitation) were included in the groups 1, 2, and 3, respectively. Measurements were performed in both eyes of each participant. Peak systolic velocity (PSV), end-diastolic velocity (EDV), resistance index (RI), and pulsatility index (PI) were measured in the ophthalmic artery (OA), central retinal artery (CRA), and posterior ciliary artery (PCA). The RI and PI measurements of the OA, CRA, and PCA were significantly higher in group 3 when compared to the control group and groups 1 and 2. These significances were not observed when PSV and EDV values were compared. There were also no significant differences between groups 1, 2, and control patients, when mean PSV, EDV, RI, and PI values of all arteries were compared. None of the above parameters showed statistical significance when mean RI, PI, PSV, and EDV were compared between left and right eyes. Severe (stage 3) COPD is associated with impaired retrobulbar hemodynamics. Increased hypoxia and vascular mediators may be suggested in etiology.

Comparison of retinal nerve fibre layer thickness with visual evoked potential and visual field in patients with multiple sclerosis.

BACKGROUND: To evaluate retinal nerve fibre layer thickness and to compare results with visual evoked potentials and visual field in patients with multiple sclerosis. DESIGN: A prospective, case-control study, university hospital setting. PARTICIPANTS: Seventy-three eyes of 37 multiple sclerosis patients and 74 eyes of 37 healthy subjects. METHODS: All patients underwent a complete neurological and ophthalmological examination and peri-papillary retinal nerve fibre layer thickness was evaluated using scanning laser polarimetry (GDx). Furthermore, visual evoked potential and visual field testing were performed. MAIN OUTCOME MEASURES: The χ(2) test, Student's t-test, Mann-Whitney U-test and Pearson's correlation coefficient analysis of the GDx, visual evoked potential and visual field testing parameters. RESULTS: GDx measurements showed significantly more retinal nerve fibre layer damage in the patients than in the control groups. Comparison of the GDx parameters between patients with optic neuritis and non-optic neuritis demonstrated a statistically significant difference in symmetry (P = 0.046) and superior/nasal parameters (P = 0.009). A correlation was found between the number, superior and inferior ratio parameters, and P100 amplitude obtained with visual evoked potential in patients with non-optic neuritis. Additionally, there was a correlation between the number, inferior ratio and superior/nasal parameters, and the mean deviation of visual field in the non-optic neuritis group. CONCLUSIONS: For retinal nerve fibre layer thickness measurements in multiple sclerosis patients, the GDx, along with other techniques, such as visual evoked potential, can be used as a diagnostic and follow-up criterion, particularly in patients without optic neuritis.

Incidence and risk factors for retinopathy of prematurity in the West Black Sea region, Turkey.

The objective of this study was to determine the incidence, risk factors and severity of retinopathy of prematurity (ROP) and to establish screening criteria for our region. Data on 330 infants with gestational age at birth < or = 34 weeks were analyzed retrospectively for a ROP diagnosis and risk factors. Infants with type 1 ROP were treated with argon laser photocoagulation. ROP was detected in 106 of 330 infants; 18 infants had type 1 ROP and were treated. Two infants with ROP that progressed to stage 4 disease required surgery. No treatment was needed in infants born after 32 weeks of gestation. Respiratory distress syndrome and low gestational age were the most important risk factors for type 1 ROP. In the West Black Sea region of Turkey, screening all premature infants with a gestational age < or = 32 weeks or a birth weight < or = 1900 g appears to be appropriate.

Effects of a new hemostatic agent Ankaferd Blood Stopper(®)on the intraocular tissues in rat model.

PURPOSE: To investigate the histopathological changes due to administration of Ankaferd Blood Stopper(®) (ABS) into intraocular tissues by an anterior chamber and intravitreal injections. METHODS: Twenty Wistar albino rats were divided into four equal groups. Group 1 was injected 0.01 mL ABS into anterior chamber. Group 2 was injected intravitreal 0.02 mL ABS. Groups 3 and 4, which were used as controls, were injected into the anterior chamber and intravitreal 0.01 mL and 0.02 mL balanced salt solution (BSS), respectively. At 2, 5, 10, 15 and 20 days after injection, the eyes were examined under an operating microscope and were subsequently enucleated for histopathological examination. RESULTS: Ophthalmic examination of the rats prior to enucleation revealed ocular complications ranging from conjunctival hyperemia to corneal perforation in group 1 and increased conjunctival hyperemia and discharge in group 2. No physical and histopathological anomalies were detected in groups 3 and 4. All eyes in group 1 showed mixed type inflammatory cell reaction, foreign-body reaction, stromal congestion, disintegration of the collagen fibers and loss of the epithelium of the posterior wall in the iris and ciliary body were observed histopathologically. All eyes in group 2 showed disintegration and separation of the retina, brown pigment accumulation and mixed type inflammatory cell reaction. CONCLUSION: Our results indicate that the commercially available form of ABS solution exerts a toxic effect on intraocular tissues. We consider that the intraocular use of different concentrations, rather than multiple time point of ABS should be investigated.

[Eye injuries at a tertiary health center in the west Black Sea region, Turkey]. / Bati karadeniz bölgesinde uçüncü basamak bir saglik merkezindeki göz yaralanmalari.

BACKGROUND: We aimed to investigate the clinical aspects and visual prognosis in eye injury and to constitute data in the west Black Sea region in Turkey for national statistics. METHODS: A retrospective analysis of 281 eye trauma cases admitted to the Emergency Department of Zonguldak Karaelmas University Hospital between 2005 and 2010 was performed. RESULTS: A majority of eye injuries (42.7%) affected individuals aged 30 to 50 years. The most frequent cause of injury in the rural areas was wooden objects. The most frequent cause of injury in males aged 30 to 50 years was work-site injuries. Corneal-scleral lacerations were found to be the most serious injuries with regard to initial and final visual acuities. CONCLUSION: Eye injuries are still the most common and preventable cause of blindness. Simple precautions and public education might prevent this health problem, which causes economic and labor force loss and psychological problems. One of the basic precautions would be raising public awareness on wearing a seat belt inside the car and protective eyeglasses at the work site and while working in rural areas.

Use of a novel haemostatic agent: ankaferd blood stopper in conjunctival incisions.

BACKGROUND: To investigate the haemostatic efficacy and histopathological effects of a new haemostatic agent, ankaferd blood stopper, in a rat conjunctival incision model. METHODS: Twenty Wistar albino rats were divided into two equal groups (A, B). Limbal incisions of 90-120° were performed in both eyes of all rats. In group A, bleeding at the site of incision was controlled by the administration of ankaferd blood stopper to the right eyes and balanced salt solution to the left eyes. In group B, bleeding was controlled by the application of ankaferd blood stopper to the right eyes and cautery to the left eyes. Time to haemostasis was recorded. After a 4-week period, conjunctival vascularity and postoperative adhesion between Tenon's capsule and sclera were assessed. Additionally, eyes were enucleated and evaluated histopathologically. RESULTS: In group A, the mean bleeding times were 15.2 and 66.7 s for right and left eyes, respectively (P = 0.002). In group B, the mean bleeding times were 17.6 and 17.5 s for right and left eyes, respectively (P = 0.939). Cautery was found to cause significantly more adhesion (P = 0.04). Histopathological examination of the conjunctiva and scleral revealed no statistically significant difference between the samples. CONCLUSIONS: Given the ease of use and lack of histopathological side-effects in the conjunctival incision model, ankaferd blood stopper is promising for use in ophthalmic surgery. Ankaferd blood stopper is a potent haemostatic agent. Its use in ophthalmic surgery should be investigated further in a larger cohort of patients and tested in clinical and experimental models.

Effects of the folk medicinal plant extract Ankaferd Blood Stopper® on the ocular surface.

PURPOSE: To investigate the effects of Ankaferd Blood Stopper(®) (ABS) on the ocular surface. METHODS: Twenty adult male Wistar albino rats, weighing 390-530 g, were used in this prospective, controlled trial. One drop of ABS and one drop of balanced salt solution (BSS) were instilled into the lower conjunctival sac of the right and left eyes, respectively. After the rats were anesthetized, the ocular surface was evaluated based on the Draize criteria, and fluorescein tests were performed at 1, 2, 4, 18, 24, and 48 h. Subsequently, the rats were killed and all eyes were enucleated for histopathological examination. RESULTS: The outcome of the Draize and fluorescein tests revealed that ABS caused more irritation of the ocular surface than BSS (P < 0.001). The highest mean ABS score was 4.9 for the Draize test and 0.4 for the fluorescein test, and ABS was considered to be a slight irritant. Histopathological examinations of the cornea and the conjunctiva revealed no significant difference between the eyes instilled with BSS and those instilled with ABS. CONCLUSIONS: ABS is a hemostatic drug that exerts a slight toxic effect on the ocular surface. Given its ease of use and antibacterial activity, as well as its efficiency in stopping bleeding, the use of ABS during ocular surgery should be further investigated in experimental and clinical studies.

The local vasoconstriction of infant's skin following instillation of mydriatic eye drops.

BACKGROUND: Systemic absorption of eye drops is known to occur via the nasal mucosa, cornea, and conjunctiva. Diffusion of eye drops through the skin is previously unrecognized. Here, two cases are presented in which we observed skin pallor around the eyes after instillation of phenylephrine 2.5% drops. CASE 1: A 32-week gestational age premature infant had mydriatic eye drops instilled as part of retinopathy of prematurity screening. CASE 2: A term newborn dysmorphic infant underwent fundus examination to rule out ocular pathology. In both cases, discoloration of periorbital skin was observed 45 min following administration of drops. CONCLUSION: The risks of percutaneous toxicity must always be considered in children, especially in premature neonates, in whom the epidermal permeability barrier is frequently incompetent. Application of smaller drop size or wiping of overflowed drop from the skin may be useful to decrease the risk of systemic side effects.

Posterior vitreous detachment rate following intravitreal dexamethasone injection.

AIM: To determine whether intravitreal dexamethasone (DEX) implant induces posterior vitreous detachment or not. METHODS: We retrospectively reviewed 810 eyes of 405 patients who underwent intravitreal DEX implantation due to macular edema caused by diabetic and retinal venous occlusion in our clinic. The eyes having no injection were determined as the control group. The examination findings of the patients before the injection and 3mo after the injection and optical coherence tomography (OCT) images were scanned. The pre-injection OCT findings and OCT findings of the patients having no posterior vitreous detachment (PVD) and determined to have partial PVD were compared. RESULTS: The separation in vitreoretinal adhesion and total PVD development of DEX-injected 56/208 (26.9%) eyes were statistically greater in comparison with the 12/129 (9.3%) eyes that had not been injected (P=0.001). PVD development was observed more in the patients that were younger, had larger macula thickness and lower visual acuity. CONCLUSION: It can be stated that intravitreal DEX implant induces PVD development. Prospective, controlled studies are required in order to determine prognosis of vitreoretinal disease in PVD-developed patients and in non-PVD-developed patients.

Unnoticed dysautonomic syndrome of the face: Harlequin syndrome.

Harlequin sign and harlequin syndrome, which are used interchangeably in the literature, are characterized by sudden onset of hemifacial sweating and flushing, induced by exercise and heat. Hemifacial sweating and flushing with normal ocular sympathetic innervation, known as harlequin syndrome, is rarely associated with tonic pupils, parasympathetic oculomotor lesion and pre- or postganglionic sudomotor sympathetic deficit. In the literature, hemifacial sweating and flushing in patients with apparently abnormal ocular sympathetic innervation has been defined as harlequin sign. To date, a few reports of excessive hemifacial sweating and flushing in structural lesion have been documented. Herein, we report five patients with excessive hemifacial sweating and flushing, two of whom had a syrinx. In presenting the patients, we have attempted to distinguish harlequin syndrome from harlequin sign. With this in mind, Case 1 can be described as harlequin syndrome resembling Ross syndrome, Case 2 as harlequin syndrome with normal ocular sympathetic innervation, Case 3 as harlequin sign with congenital Horner syndrome, Case 4 as harlequin sign with sympathetic and parasympathetic denervation sensitivity, and Case 5 as harlequin syndrome associated with occult sympathetic denervation sensitivity. These cases are discussed together with a review of the literature.

The Effect of Dexamethasone Intravitreal Implant on Retinal Nerve Fiber Layer in Patients Diagnosed with Branch Retinal Vein Occlusion.

PURPOSE: To evaluate the effect of a single dose of intravitreal dexamethasone (DEX) implant on retinal nerve fiber layer (RNFL) thickness in patients with branch retinal vein occlusion (BRVO) in a 6-month period. MATERIALS AND METHODS: This retrospective observational study included the patients with BRVO who received intravitreal DEX implant and whose assessment included the baseline RNFL thickness measurements. The data of 26 eyes of 24 patients were retrospectively analyzed. Spectral domain optic coherence tomography was used to measure peripapillary RNFL thickness in six regional subfields. Intraocular pressure (IOP) values at each visit were recorded. The data of single dose DEX implant during 6 months were assessed. RESULTS: The mean preoperative and postoperative 6th month nasal RNFL values were 85.4 ± 23.0 µm and 82.1 ± 17.6 µm, respectively, and the difference between the measurements was not statistically significant (p = 0.372). There was a slight decrease in the mean RNFL values postoperatively compared to the baseline values in all quadrants except supero-temporal quadrant; however, none of them reached statistically significant level (p > 0.05). The mean IOP values before and 6 months after implantation were 15.7 ± 2.9 mmHg and 16.5 ± 4.2 mmHg, respectively. The difference between the 6th month IOP values and baseline IOP values was not statistically significant (p = 0.236). CONCLUSION: Intravitreal DEX implant seems to have no adverse effect on RNFL thickness in BRVO patients in a 6-month period.

Changes in the Choroidal Thickness and Axial Length Upon Mannitol Infusion in Patients With Asymmetric Intraocular Pressure.

BACKGROUND/AIMS: To evaluate the changes in the choroidal thickness (CT) and axial length (AL) upon systemic mannitol infusion in glaucoma patients with asymmetric intraocular pressure (IOP). MATERIALS AND METHODS: Forty glaucoma patients with asymmetric IOP, with the IOP of 1 eye ≥40 mm Hg and the fellow eye <25 mm Hg, were administered 150 mL of a 20% mannitol infusion to reduce the IOP. The CT and AL were measured before and an hour after the infusion. The relationship between the IOP reduction and the changes in the CT and AL were investigated. RESULTS: The mean decrease in the IOP was -14.23 mm Hg (32.15%) and -4.13 mm Hg (21.40%) in the eyes with higher IOP and their fellow eyes, respectively. The mean changes in the subfoveal CT were 19.28 µm (9.20%; P<0.001) and 2.60 µm (1.93%; P=0.452) in the eyes with higher IOP and their fellow eyes, respectively. The mean changes in the AL were -0.10 µm (0.42%; P<0.001) and -0.33 mm (0.14%; P=0.008) in the eyes with higher IOP and their fellow eyes, respectively. Stepwise analysis revealed that the percent IOP change is the most influential factor on the percent change of the subfoveal CT (P<0.0001; R=0.3). CONCLUSIONS: These results suggest that large IOP changes upon mannitol infusion cause the shortening of the AL in both the eyes and the thickening of the choroid only in the eyes with a higher IOP.

Acquired retraction of the eye as the first sign of myositis.

The authors report a patient who was diagnosed with idiopathic orbital myositis based on the findings of diplopia, worse on right gaze, globe retraction on adduction and injection at the lateral muscle tendon insertion of the left eye. Although orbital myositis as a cause of acquired retraction of the eye is rare, they wish to emphasize the importance of globe retraction with injection over the recti as an important clue for the diagnosis of orbital myositis.

Ophthalmologic abnormalities in children from a Turkish school for the deaf.

The aim of this study was to determine the nature and prevalence of ophthalmologic abnormalities in deaf children. Complete ophthalmologic examinations were performed on 104 children aged 7 to 20 years from a Turkish school for the deaf. Of 104 children, 42 children (40.4%) had some form of ophthalmologic abnormality, with the vast majority (31 patients, 29.8%) being refractive errors. The prevalence of hypermetropia, myopia and astigmatism was found to be higher over the general population. Of 104 children, 19 (18.2%) had ocular motility disturbances and one had external adnexal anomaly. Two (1.8%) children had anterior segment and nine (8.6%) children had posterior segment pathologies. Routine ophthalmologic examinations should be carried out in this population because deaf children use sight to compensate for hearing problems. Ophthalmologists play an important role in the diagnosis and correction of ophthalmologic abnormalities.