The effect of transepithelial corneal collagen cross-linking treatment on optical quality of the cornea in keratoconus: 12-month clinical results.

PURPOSE: To evaluate the effect of transepithelial corneal collagen crosslinking (CXL) treatment on the optical performance of the cornea at 12-month follow-up after CXL in patients with progressive keratoconus. METHODS: One hundred and ten eyes of 67 patients were included. The following corneal optical aberrations over the 4-mm-diameter pupil were recorded via Sirius dual-scanning corneal tomography: total, anterior and posterior amount of corneal higher order aberrations [HOAs], vertical coma, horizontal coma, vertical trefoil, oblique trefoil, and spherical aberration, and Strehl ratio of point spread function (PSF). RESULTS: There were significant improvements in mean root mean square error values for corneal total HOA, total coma, anterior HOA, anterior coma, and vertical coma following CXL (P > 0.05, for all). No significant changes were found in the posterior aberometric parameters. PSF value did not change after CXL (P > 0.05). The corneal topographic measurements not revealed a change in the mean simulated keratometry-1, simulated keratometry-2, and maximum keratometry compared with the baseline measurements (P > 0.05, for all). At 12 months, there was a significant improvement in the uncorrected (UCVA) and best corrected (BCVA) visual acuity (P < 0.001, both). Most corneal aberrations correlated significantly with postoperative BCVA, but changes in HOAs were not statistically associated with improvements in visual acuity. CONCLUSIONS: Transepithelial CXL was effective in stabilizing the keratometric indices and improving the most corneal aberrations in keratoconic eyes 1 year after the procedure. While the healing effect on aberrations after CXL was in total and anterior parameters, no significant changes were observed in the posterior surface. In addition, it was observed that transepithelial CXL treatment did not cause a significant change in PSF distribution data.

In vivo confocal microscopy of corneal nerve fiber damage in early course of multiple sclerosis.

PURPOSE: To evaluate the corneal nerve fiber morphology in patients with multiple sclerosis (MS) by in vivo corneal confocal microscopy (CCM). METHODS: Retinal nerve fiber layer thickness (RNFLT), central macular thickness (CMT), corneal nerve fiber length (CNFL), corneal nerve fiber density (CNFD), corneal nerve branch density (CNBD) and corneal nerve fiber tortuosity (CNFT) were measured. Correlation of corneal nerve findings with duration and clinical severity of MS was calculated. RESULTS: CNFL (9.50 ± 0.60 vs. 11.20 ± 0.57 mm/mm2, P = 0.046) and CNBD (57.46 ± 5.04 vs. 77.65 ± 3.41 no/mm2, P = 0.001) were significantly lower with no significant difference in CNFD (21.24 ± 1.20 vs. 23.62 ± 0.95 no/mm2, P = 0.125), CNFT (2.00 ± 0.15 vs. 1.73 ± 0.12, P = 0.180), CMT (269.57 ± 12.53 vs. 271.10 ± 18.84 µm, P = 0.716) or RNFLT (102.82 ± 6.98 vs. 105.33 ± 12.70 µm, P = 0.351) between patients with RRMS compared to controls. There was no significant correlation between CCM parameters with EDSS and duration of disease in MS patients. CONCLUSION: The current study demonstrated that a decrease in CNFL, CNFD and CNBD in CCM analysis in the early course of MS.

Optical coherence tomography measurements in patients with systemic hypertension.

AIM: To evaluate the effect of systemic arterial hypertension (SAH) on retinal optical coherence tomography (OCT) parameters and investigate whether a correlation exists between ambulatory blood pressure monitoring (ABPM) and OCT measurements.Material-methods: 115 SAH patients (225 eyes) and 123 healthy control cases (234 eyes) were included. ABPM was performed on 89 of 115 SAH patients. All patients underwent detailed ophthalmologic examination including imaging with OCT. SAH patients were divided into two groups (dippers, non-dippers) according to their nocturnal blood pressure (BP) reduction, and OCT measurements were compared. RESULTS: Average and superior retinal nerve fiber layer (RNFL) quadrants were significantly thin in hypertensive cases (p:0.002, p < 0.001, respectively). Cup area, cup/disk (c/d) area, and c/d horizontal ratios were wider; the rim area was smaller in hypertensive cases (respectively: p:0.024, p:0.017, p:0.003, p < 0.001). Total macular volume (TMV), the thicknesses in 1-3 and 1-6 mm of the macula were less in hypertensives (p < 0.001). There was no significant difference between dippers and non-dippers in RNFL thickness, macula and optic nerve head (ONH) parameters. CONCLUSION: There were statistically significant differences between healthy cases and patients with SAH in terms of RNFL, macula thicknesses and ONH parameters.

Comparative proteome analysis of the tear samples in patients with low-grade keratoconus.

PURPOSE: To elucidate the metabolic processes playing roles in the formation of keratoconus (KC). METHODS: Tears samples were collected using capillary glass tubes without stimulation and without prior anesthesia from 17 patients and 16 controls. Proteomic analysis by fluorescent 2D gel electrophoresis (DIGE) coupled with MALDI-TOF/TOF was performed. The identified proteins that were differentially regulated were subjected to Ingenuity Pathway Analysis (IPA). Corneal topography analyses with Sirius topography system (Costruzioni Strumenti Oftalmici, Florence, Italy) were performed on all participants. The steepest keratometry index was lower than 50 diopters in all keratoconus patients. RESULTS: DIGE analysis showed changes in abundance of nine proteins. Six of these proteins, namely serum albumin, Keratin Type II Cytoskeletal 1, IgG gamma chain-1, GAPDH, alpha-1 antitrypsin and ApoA-I, were down-regulated in the KC samples in comparison with the controls. In addition, we detected up-regulation of lysozyme C, keratin type I cytoskeletal 10 and lipocalin. The subsequent IPA predicted that NADH repair pathway is activated in the KC patients. This pathway involves generation of NADHX as a by-product via catalysis by GAPDH. NADHX is an inhibitor of several dehydrogenases and must be removed. CONCLUSION: The involvement of NADHX repair pathway in KC should be investigated, since preliminary clues obtained in this study point to that direction. In particular, showing the presence of ATP-dependent NAD(P)H-hydrate dehydratase that eliminates NADHX would strengthen our findings and would be a major step toward understanding KC.

Comparative proteomic analysis of amnion membrane transplantation and cross-linking treatments in an experimental alkali injury model.

PURPOSE: In this study, by using a two-dimensional (2D) electrophoresis-based experimental approach, we aimed at understanding the nature of alkali injuries and the underlying mechanisms. A secondary aim was to compare the effects of cross-linking (CXL) and amnion membrane transplantation (AMT) on corneal protein compositions at the end of the early repair phase after injured with alkali. METHOD: The right corneas of 24 rabbits were injured with a 1 N solution of NaOH. Groups were formed based on the adjuvant therapies as (1) healthy group, (2) control group, (3) CXL group, (4) AMT group. In addition to the therapies, a conventional medical treatment was applied to all groups. Left eyes were used as within-subject healthy corneas (1). The corneas were excised at day 21, and a comparative proteomic analysis was performed using 2D gel electrophoresis coupled with MALDI-TOF/TOF. RESULT: 2D gel electrophoresis revealed the presence seven protein spots whose abundance changed among the groups. Those proteins were SH3 domain-binding protein, plant homeodomain finger protein 23, S100 calcium binding protein A-11(S100 A11), keratin type 2 cytoskeletal 1 and 2, transketolase and glyceraldehyde 3-phosphate dehydrogenase. Ingenuity pathway analysis predicted that the observed changes may be linked to a central metabolic pathway, transforming growth factor beta 1. Canonical pathway analysis focused our attention to two different pathways, namely nicotinamide adenine dinucleotide repair pathway and non-oxidative branch of pentose phosphate pathway. CONCLUSION: Our results shed some light onto the molecular mechanisms affected by alkali injury and adjuvant treatments. Further research is needed to propose medically significant target molecules that may be used for novel drug developments for alkali injury.

Effect of eye trauma on mental health and quality of life in children and adolescents.

The purpose of this study is to evaluate the effects of eye traumas on mental health and quality of life of children, adolescents, and their parents. Medical records of 20 children and adolescents presented with blunt and open eye injuries between June 2009 and May 2014 were reviewed. Demographics of patients, timing and type of trauma, findings of initial examination, and medical and surgical interventions applied were recorded. To detect mental health, "Affect disorders and schizophrenia interview chart for school children, now and lifelong" (AFSIC-NL) and "Child Post-Traumatic Stress Reaction Index (CPTSD-RI)" were used. "Pediatric scale of quality of life" (PedsQL) was used to assess quality of life for both parents and children. According to AFSIC-NL, 9 patients were diagnosed with mental disorders including posttraumatic stress disorder (n = 3, 15 % patients), generalized anxiety disorder (n = 3, 15 % patients), and major depression (n = 3, 15 % patients). The PedsQL values of both children's and parents' were at their lowest in school and physical health domains for children and in physical health domain for parents. A reverse correlation was detected between the number of surgeries and PedsQL-child physical functionality, school functionality, psychosocial functionality, and total scale point. There was a statistically significant relationship between initial visual acuity or lens damage and PedsQL-parent emotional functionality scale. Regarding CPTSD-RI, the parents of these patients have a mild posttraumatic stress disorder. Eye injuries can lead development of psychopathology in children. Therefore, psychiatric support must be provided in follow-up period for these patients.

Correlation of the measurements of optical coherence tomography and diffuse tension imaging of optic pathways in amblyopia.

The aim of this study was to investigate whether a correlation exists between optical coherence tomography (OCT) of retina and diffusion tensor imaging (DTI) of the optic pathway measurements. All subjects underwent OCT measurements of optic nerve head, retinal nerve fiber layer, and macula. Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values of optic pathways were analyzed using DTI. Prechiasmatic FA values were significantly decreased in unilateral amblyopic group in both affected and sound fellow eyes (p = 0.019 and 0.013), but not in bilateral amblyopic group (p = 0.221) when compared with the control group. ADC values were significantly greater in sound eye in unilateral amblyopic group in prechiasmatic and postchiasmatic regions (p = 0.001 and 0.049). ADC values were also significantly greater in bilateral amblyopic group in postchiasmatic region (p = 0.037). There were no significant differences between the affected eye and sound eye side DTI measurements. There was no significant correlation between prechiasmatic DTI and OCT measurements in affected and sound eyes of unilateral amblyopia group. DTI results demonstrated that there is a functional underdevelopment of the anterior and posterior visual pathways in both affected and sound eye of unilateral amblyopic patients. Significantly reduced FA values in prechiasmatic region where OCT values of retina were normal can be explained by possible micro-structural changes.

Quantitative Assessment of Optic Nerve With Diffusion Tensor Imaging in Patients With Thyroid Orbitopathy.

PURPOSE: To detect abnormalities of the optic nerve in patients with thyroid orbitopathy using diffusion tensor MRI. METHODS: Twenty-eight patients with Graves orbitopathy prospectively underwent diffusion tensor imaging scanning. A full ophthalmic examination including visual acuity, intraocular pressure, fundoscopy, and visual field analysis was performed. Clinical activity scores were also calculated. Fractional anisotropy (FA) and mean diffusivity values of the patients were compared with age and sex-matched healthy control subjects. RESULTS: The mean FA values were decreased and mean diffusivity values were increased significantly in patients with Graves orbitopathy compared with the control subjects (p < 0.001). There was a strong reverse correlation between the FA levels and the visual fields in 4 quadrants of the optic nerve. In addition, there was a strong correlation between the degree of proptosis and the FA values in both eyes. The mean diffusivity levels were also correlated with changes in the visual field and the degree of proptosis. CONCLUSION: FA and mean diffusivity levels measured with the diffusion tensor imaging of the thyroid orbitopathy patients were affected. The changes in diffusion tensor imaging were also correlated with the ophthalmologic tests of the patients.

Modified use of team-based learning in an ophthalmology course for fifth-year medical students.

Team-based learning (TBL) is an interactive and analytic teaching strategy. TBL is a learner-centered strategy that uses a very structured individual and group accountability process and requires small groups to work together to solve problems. This study served to investigate whether the TBL concept could be modified and adopted to the fifth-year cornea module of an ophthalmology course. Questionnaires (using a Likert scale of 1-5) were distributed to 169 fifth-year medical students attending the cornea module applied as TBL in an ophthalmology course. The questionnaire consisted of two categories: the TBL format (7 items) and an open-ended question about the class (1 item). Feedback was then evaluated. The majority of students felt that modified TBL sessions were better at fulfilling learning objectives (121 students, 71.59%), enabled better understanding (134 students, 79.28%), were more interesting (146 students, 86.39%), ensured greater student participation (123 students, 72.78%), and involved greater effort on the part of students (148 students, 87.57%) compared with traditional teaching methods. Most of the students (129 students, 76.33%) agreed that more such sessions should be organized in the future. In conclusion, after adjustments to improve weaknesses, such as the short time allocation and students' lack of prior background, the outcomes of this modified TBL approach on the cornea module of an ophthalmology course provide a good basis for its continuation.

Decrease of over-elevation in adduction after surgery of medial rectus muscles in partially refractive accommodative esotropia.

SIGNIFICANCE: The course of over-elevation in adduction after strabismus surgery has been evaluated in a small number of research in the literature, we believe our study is the first to report the results in a specific group of esotropia (ET) patients. AIM: To report the course of postoperative over-elevation in adduction in patients who underwent surgery for horizontal deviation on the medial recti in partially accommodative ET. METHODS: The medical charts of patients who had partially accommodative ET with over-elevation in adduction were reviewed retrospectively. A scale from -4 to +4 was used to grade the oblique muscle function. Among these, 17 patients who were operated solely on the horizontal rectus muscles were identified. The primary outcome measure was the degree of improvement in over-elevation in adduction after medial rectus surgery. RESULTS: Nine (52.9%) of the 17 patients (mean age: 5.18 ± 2.24 months) were males and 8 (47.1%) were females. The mean follow-up period was 17.06 ± 15.32 months. Overall, 15 patients (88.2%) achieved surgical success. The mean inferior oblique overaction was found 1.44 ± 0.56 preoperatively and the final postoperative mean inferior oblique overaction was 0.53 ± 0.51 (P = 0.001). Postoperative over-elevation in adduction after 3 months was significantly decreased compared to the preoperative value (P = 0.003, P = 0.001, P = 0.001 at 3rd and 6th months and final visits respectively). CONCLUSION: Over-elevation in adduction accompanying partially refractive accommodative ET seems to regress after medial rectus weakening surgery. This finding should be considered in the presurgical evaluation of these patients.

Evaluation of early visual recovery in pituitary macroadenomas after endoscopic endonasal transphenoidal surgery: Quantitative assessment with diffusion tensor imaging (DTI).

BACKGROUND: Visual field analyses reflect the degree of the compression to the optic nerve that results the structural damage of the nerve. These structural damages can be evaluated by diffusion tensor imaging (DTI), which assesses the structural integrity of white matter tracts. Thus, we evaluated the quantitative assessment of early visual recovery in patients with pituitary macroadenomas, corresponding DTI with visual field analyses. METHODS: Seventy-two patients who had pituitary macroadenomas with visual field defects were included in the study retrospectively. All patients were operated on by pure endoscopic transphenoidal approach. Visual field assessment using Humphrey field analyzer and DTI with 3T magnet were performed in the preoperative and postoperative second day and sixth month. FINDINGS: Mean symptom duration was 14.7 ± 10.5 weeks in the full recovery group patients, 50.1 ± 29.1 weeks in partial recovery patients, and 92.4 ± 15.4 weeks in the ones with no recovery. There was a significant difference at p < 0.001 among the groups. On visual field analysis, the visual lost was mostly recognized at upper temporal levels preoperatively. Visual field findings of both eyes were improved in 80% of the patients. Among these, 25% revealed full recovery, 55.6% partial recovery, and 19.4% did not demonstrate significant changes. DTI assessments of affected sides revealed preoperative fractional anisotropy (FA) values below 0.400 and mean diffusivity (MD) values over 1,400 × 10(-6) mm(2) s(-1) were related with no visual improvement in the postoperative 6 months period. The percentage increase of mean FA values of the affected areas postoperatively were found to be 21.9% in totally responded patients, 20.6% in partial responded patients, and 9.8% in patients that did not respond. CONCLUSIONS: There is a correlation between DTI-derived FA values of the optic nerves and visual parameters. DTI assessments of the affected sides with FA and MD values may help to estimate the response of visual improvement to the surgical therapy in the early postoperative period.

Pattern of open eye injuries in northwest Turkey: a retrospective study.

BACKGROUND: We aimed to review the epidemiology and visual outcome of patients with open globe injuries in the northwest part of Turkey. METHODS: All patients admitted to the Department of Ophthalmology, Kocaeli University Faculty of Medicine with open globe injuries between 2004-2008 were reviewed retrospectively. RESULTS: Ninety-five eyes of 95 patients, aged between 3 and 79 years, were reviewed. The type of open eye injury was laceration in 76 eyes (80%) and rupture in 19 eyes (20%). In all age groups, projectile objects were the most common cause of injury. In patients 18 years and older, sharp objects (11.1%) were the least prevalent cause of open globe injuries; however, traumas with sharp objects were common in patients younger than 18 years (38.1%) (p=0.01). In patients younger than 18 years, most injuries occurred at home (68.3%), while in patients 18 years and older, the majority of ocular traumas occurred at work (59.2%) (p=0.000). Isolated Zone I lesions showed more improvement in visual acuity than other zones (p=0.043). CONCLUSION: Open globe injury in northwest Turkey varied with age and gender. Education and safety precautions are essential to prevent open eye injuries.

Why do patients with improved visual acuity drop out of RGP contact lens use? Ten-year follow-up results in patients with scarred corneas.

PURPOSE: To evaluate the long-term results of rigid gas permeable (RGP) contact lenses and to investigate the reasons for patient dissatisfaction with this therapy. METHODS: Records of 17 patients (20 eyes) who started using RGP contact lenses for correction of irregular astigmatism due to scarred corneas between 1995 and 1996 were evaluated retrospectively. Best-corrected visual acuities with or without RGP contact lenses were noted. The mean duration of contact lens use, reasons for discontinuation of therapy, and treatment methods preferred over contact lens use were evaluated. RESULTS: The irregular astigmatisms were induced by herpetic keratitis (3 eyes), corneal trauma (5 eyes), and previous corneal infections (12 eyes). All of the patients had increase in visual acuity with RGP contact lenses (p=0.000). At the end of the follow-up it was found that only one patient was still using RGP contact lenses (5%). The mean duration for contact lens use was 21.42+/-4.53 SE months (2-72 months). The reasons for dropping out contact lenses were intervening surgical procedures (57.8%), loss of patient motivation (26.3%), recurrent punctate epitheliopathy (10.5%), and herpes simplex keratitis reactivation (5.2%). CONCLUSIONS: RGP contact lens use is a successful method of increasing visual acuity in scarred corneas. However, patients with good visual acuity in the fellow eye find it hard to remain motivated for RGP contact lens use in the unhealthy eye. Furthermore, patients prefer permanent treatment methods even though these methods would result in decreased visual acuity.

Limited Vitrectomy in Patients with Idiopathic Macular Hole

Background: Partial posterior hyaloidectomy is suggested to minimize traction on the vitreous base and thus reduce the risk of iatrogenic breaks in patients with macular hole and epiretinal membrane. Aims: To evaluate the safety and efficacy of limited vitrectomy in patients with macular hole. Study Design: Retrospective cohort study. Methods: Fifty-two consecutive patients who underwent macular hole surgery without complete peripheral vitreous removal were included in the study. The improvement in visual acuity, the incidence of retinal breaks and detachment, anatomical results, and intraoperative and postoperative complications of this technique were evaluated. Results: The median visual acuity was 0.2 (0.1-0.4) before surgery and 0.5 (0.3-0.6) after surgery (p<0.001). None of the patients had retinal breaks or detachments. A sulfur hexafluoride was used in 24 patients (46.2%), and perfluoropropane was used in 28 patients (53.8%). Three patients (5.76%) had revision surgery because of recurrence of the macular hole. We did not observe proliferative vitreoretinopathy or surgery-related major complications in any patient during the follow-up period. Conclusion: Limited vitrectomy without removal of the peripheral vitreous seems to be effective and safe with minimal risk of peripheral retinal breaks and detachment.

Evaluation of nutritional status in children with amblyopia.

PURPOSE: We aimed to compare the body mass index and vitamin and mineral status of children with and without amblyopia. METHODS: Amblyopic children aged between 5 and 18 years (n=46) and age-matched control children (n=32) were evaluated in terms of anthropometric parameters, including height, weight, body mass index and demographic features. Serum vitamin B12 and folate were measured using an Advia Centaur XP (Siemens, Ireland) biochemistry analyzer. We evaluated the inorganic mineral elements from hair samples with inductively coupled plasma-mass spectrometry using a Thermo XSeries 2 analyzer (Thermo Fisher Scientific, Bremen, Germany). RESULTS: No significant difference was found between the two groups in terms of height, weight, and body mass index or serum B12 and folate concentrations (p>0.05). Children with severe amblyopia had lower vitamin B12 and folate and higher body mass index. The levels of phosphorus (p=0.012), selenium (p=0.002), molybdenum (p<0.001), iodine (p=0.002), chromium (p=0.022), boron (p<0.001), and beryllium (p=0.005) were all significantly lower in the amblyopia group compared to the control group. All of these minerals, except phosphorus, were also significantly lower in those with severe amblyopia compared to those with milder amblyopia and controls (p<0.05). CONCLUSION: Amblyopic children are significantly deficient in some inorganic elements. Inorganic elements, vitamin B12, and folate may play an important role in the visual development of amblyopic children.

Epidermal nevus syndrome with azygos anterior cerebral artery.

Epidermal nevus syndrome is a neurocutaneous disorder characterized by the association of epidermal nevi with central nervous system or skeletal abnormalities. Central nervous system abnormalities include hemimegalencephaly, hydrocephalus, various migration disorders, intraspinal lipomas, and enlarged spinal roots. Rarely, vascular anomalies cause neurologic signs. We report on a 30-month-old girl with epidermal nevus syndrome who also exhibited vascular malformations of the azygos anterior cerebral artery, a cortical aneurysm, and right internal carotid artery hypoplasia. This rare vascular abnormality was not previously reported in patients with epidermal nevus syndrome.

Anterior ischemic optic neuropathy after unilateral radical neck dissection: case report and review.

BACKGROUND: Blindness or visual deterioration after neck dissection is a known and a rare complication of the operation. Visual impairment usually occurs immediately after bilateral radical neck dissections either performed synchronously or in a stepwise manner, resulting in permanent blindness. Hypotension and blood loss during long operations, elevated venous pressure postoperatively result in optic neuropathies, which are anterior ischemic optic neuropathy (AION) or mostly posterior ischemic optic neuropathy (PION) affecting different portions of the nerve. METHODS: Review of literature and case report. RESULTS: To date there are only three cases of AION after neck dissection reported in the literature, with a different visual prognosis. CONCLUSION: Vision loss may be reversible when both internal jugular veins are preserved, but permanent when any of them are resected. Here we present the first case of anterior ischemic optic neuropathy developed after unilateral radical neck dissection, resulting in partial visual deterioration.

Analysis of retinal nerve fiber layer thickness in patients with pseudoexfoliation syndrome using optical coherence tomography.

OBJECTIVE: To evaluate the retinal nerve fiber layer (RNFL) thickness in patients with unilateral pseudoexfoliation syndrome (PXS) without glaucoma by using optical coherence tomography (OCT). METHODS: 22 patients with unilateral PXS were evaluated. Group 1 included the eyes with the pseudoexfoliation, group 2 included the fellow eyes; 18 age-matched normal control eyes were assessed in group 3. The mean and segmental RNFL thickness in eyes with pseudoexfoliation and their fellow eyes in patients with unilateral PXS was compared to age-matched control subject eyes. RESULTS: The RNFL in patients with PXS were significantly thinner than controls in all quadrants except the nasal quadrant with regard to segmental analysis (p < 0.05). This RNFL loss was apparent at 7, 10 and 11 o'clock of the PXS eyes with regard to clock hour position (p < 0.05). In the fellow eyes, no significant difference in RNFL measurement was found except the temporal quadrant when compared with the controls. In the analysis with regard to clock hour position, no significant reduction in RNFL thickness was found except in the 11-o'clock segment. In PXS eyes, RNFL thicknesses at the inferior quadrant and the 1-, 2- and 5-o'clock segments were significantly lower than in non-PXS eyes (p < 0.05). CONCLUSIONS: This study suggests that PXS without glaucoma may be associated with a thinner RNFL compared with those of age-matched control subjects and non-PXS fellow eyes. Further studies are needed to clarify the relationship between the decrease in RNFL thickness and the development of glaucomatous damage in eyes with pseudoexfoliation.