Real Life Multicenter Comparison of 24-Month Outcomes of Anti-VEGF Therapy in Diabetic Macular Edema in Turkey: Ranibizumab vs. Aflibercept vs. Ranibizumab-Aflibercept Switch.

The aim of this study was to compare the outcomes of diabetic macular edema (DME) treated with aflibercept (AFB) or ranibizumab (RNB) only, and after switching from RNB to AFB. This was a retrospective, real-world, multicenter (7 cities) 24 month study. Overall, 212 eyes in the AFB group, 461 in the RNB group, and 141 in the RNB to AFB group were included. The primary endpoints were differences in visual acuity (VA) and central macular thickness (CMT) from baseline to the final visit. The secondary outcomes were the percentage of eyes that achieved ≥10 letters gain and ≥10 letters loss in vision at month 12 and 24, and the percentage of eyes that achieved a thinning of ≥20% in CMT at month 3 and month 6. The results showed that VA did not significantly differ at baseline (AFB: 0.62 ± 0.38, RNB: 0.61 ± 0.36, RNB to AFB: 0.61 ± 0.38), at checkpoints, or at the final visit (AFB: 0.46 ± 0.38, RNB: 0.5 ± 0.37, RNB to AFB: 0.53 ± 0.36) (p > 0.05). Though the mean CMT at baseline was significantly thicker in the RNB to AFB group (479 ± 129.6 µm) when compared to the AFB (450.5 ± 122.6 µm) and RNB (442 ± 116 µm) groups (p < 0.01), similar measurements were obtained after 12 months. The percentages of eyes that gained or lost ≥10 letters in the AFB, RNB, and RNB to AFB groups at year 1 and 2 were similar, as was the percentages of eyes that demonstrated ≥20% CMT thinning at month 3 and 6. Our study showed similar visual improvements in non-switchers (AFB and RNB groups) and switchers (RNB to AFB group) through 2 years follow-up, however, AFB patients required fewer injections, visits, or need for additional treatments.

Anti-vascular endothelial growth factor therapy in diabetic macular edema: real-life outcomes from a multicenter study in Turkey over 36 months.

PURPOSE: This study aimed to report the visual and anatomical outcomes of intravitreal anti-VEGF treatment for diabetic macular edema (DME) in a real-world clinical setting from Turkey over 36 months. METHODS: This is a retrospective, multicenter (7 sites) study. The medical records of 1072 eyes (both previously treated and naive eyes) of 706 consecutive patients with visual impairment due to center-involving DME treated with intravitreal anti-VEGF injections between April 2007 and February 2017 were reviewed. The eyes were divided into mutually exclusive three groups based on the duration of follow-up (12, 24, or 36 months). Primary outcome measures were changes in visual acuity (VA) and central macular thickness (CMT) from baseline to final visit in each cohort, frequency of visits and intravitreal anti-VEGF injections. As secondary endpoints, VA outcomes were assessed in subgroups stratified by baseline VA [<70 ETDRS letters and ≥70 ETDRS letters] and loading dose status of anti-VEGF injections. RESULTS: VA increased by a mean of 8.2 letters (12-month cohort, p < 0.001), 5.3 letters (24-month cohort, p < 0.001), and 4.4 letters (36-month cohort, p = 0.017) at final visits. The eyes with <70 VA letters achieved more significant VA improvement at final visits in all cohorts compared with eyes with >70 VA letters (p < 0.001). The mean decreases in CMT from baseline to last visits at 12-, 24-, and 36- month cohorts were -100.5 µm, -107.7 µm, and -114.3 µm, respectively (p < 0.001). The mean number of injections given were 4.6, 2.3, and 1.8 during years 1 to 3, respectively. Patients who received loading dose showed greater VA gains than those who did not in all follow-up cohorts. CONCLUSION: Our study revealed that anti-VEGF treatment improved VA and CMT over a follow-up of 36 months. Although these real-life VA outcomes following anti-VEGF therapy for DME were similar to other real-life studies, they were inferior to those noted in randomized controlled trials, mainly due to undertreatment.

Phacoemulsification in patients with uveitis: long-term outcomes.

BACKGROUND: To assess the long-term outcomes of phacoemulsification and intraocular lens (IOL) implantation in eyes with uveitis. METHODS: One hundred and five eyes of 81 patients, who underwent phacoemulsification and IOL implantation between January 2009 and July 2016, were included in this study. The demographic data, preoperative clinical findings, postoperative outcomes, and intraoperative and postoperative complications were recorded. All collected data and risk factors with regard to visual prognosis were analyzed with the help of the Statistical Package for the Social Sciences version 20.0 software program (IBM Corp., Armonk, NY, USA). RESULTS: During follow-up (mean: 35.2 ± 22.2 months), corrected distance visual acuity (CDVA) improved in 87.7% of all eyes and reached a level of 0.3 LogMAR or greater in 61.3% of eyes. Postoperative complications included posterior capsule opacification (50.9%), posterior synechiae (21.7%), cystoid macular edema (16%), epiretinal membrane (13.2%), glaucoma (11.3%), increased intraocular pressure (8.5%), and severe inflammation (6.6%). Uveitis recurred in 55.7% of all eyes. The risk for the development of cystoid macular edema was found to be associated with recurrence in the early postoperative period. Low visual acuity risk was 11.1-fold higher with macular scarring (p = 0.001) and 14-fold higher with optic atrophy (p < 0.001), respectively. CONCLUSIONS: With appropriate management during the pre- and postoperative periods, phacoemulsification and IOL implantation surgery can be safe and effective in eyes with uveitis. However, great caution must be taken to prevent complications both before and after the surgery.

Ultrastructural Analysis of the Anterior Lens Epithelium in Cataracts Associated with Uveitis.

PURPOSE: To investigate the transmission electron microscopic findings of lens epithelial cells (LECs) in patients with different subtypes of uveitis and to compare the findings with those in age-matched controls. METHODS: In this prospective case-control study, the anterior lens capsules were taken from 47 eyes of 47 patients with uveitis of different subtypes (17 with Fuchs uveitis syndrome [FUS], 13 with -Behçet's uveitis, 10 with idiopathic uveitis, and 7 with herpetic keratouveitis) and from 15 eyes of 15 control patients. RESULTS: In the FUS group, the LECs had homogeneous thickening and irregularity, with some small vacuoles and widespread, oval-shaped pigment clusters in some areas. In the Behçet uveitis group, there was evident thinning in the lens epithelium. The subepithelial tissue under the epithelium was thickened, and edematous areas were detected. In the idiopathic uveitis group, the LECs were thinner with small vacuoles, and the cubic structure of the LECs was transformed into a squamous one. Moreover, the LECs included some small vacuoles, similar to those in the FUS group. In the herpetic keratouveitis group, two prominent cell types were observed: (1) completely normal LECs and (2) degenerated-type LECs with pyknotic nuclei, condensation of chromatin, swelling in the cytoplasm, membrane ruptures, and intra-cytoplasmic inclusion bodies. In the control group, the LECs and all of their elements occurred in normal ultrastructural patterns, with the exception of a few small intraepithelial vacuoles, which were fewer in number and smaller than those in the FUS and idiopathic uveitis groups. CONCLUSION: The electron microscopic analysis of LECs of patients with different subtypes of uveitis revealed significant ultrastructural alterations, which may be related to the summation of oxidative stress and intraocular inflammation.

The outcome of initial mitomycin C-augmented trabeculectomy with subconjunctival bevacizumab in the management of secondary glaucoma associated with Fuchs heterochromic iridocyclitis.

PURPOSE: To investigate the outcome of mitomycin C (MMC)-augmented trabeculectomy with subconjunctival bevacizumab in the management of Fuchs heterochromic iridocyclitis (FHI)-related glaucoma in 1-year follow-up period. METHODS: This retrospective study included 50 eyes with FHI-related glaucoma those had underwent initial trabeculectomy with MMC (0.2 mg/ml-3 min). Thirty-one of them had single-dose bevacizumab injection (1.25 mg/0.05 ml) into the bleb area just at the end of the surgery, while 19 eyes did not have. The intraocular pressure (IOP) and the mean number of anti-glaucomatous medications were evaluated. The IOP value ≤ 21 mmHg was defined as complete or qualified surgical success in terms of using medical anti-glaucomatous treatment. Bleb height and vascularity were evaluated with Indiana bleb grading system. Paired sample t test, t test, Chi-square and Kolmogorov-Smirnov tests were used for statistical analysis. RESULTS: The preoperative IOP values of bevacizumab and without bevacizumab groups were 32.8 ± 4.5 mmHg and 32.8 ± 4.5 mmHg, respectively, and they decreased to 17.5 ± 4.6 mmHg and 17 ± 5.2 mmHg at the final visit (p < 0.001 for all values). There were no significant differences in postoperative IOP and the number of medications between the groups at the final visit. In bevacizumab group, complete success was achieved in 100% within the third month but decreased to 22.5% (complete) and 74.1% (qualified) at the first year. In the other group (without bevacizumab group), complete success was achieved in 94.7% within the third month but decreased to 15.8% (complete) and 84.2% (qualified) at the first year. CONCLUSION: Initial trabeculectomy with MMC and subconjunctival bevacizumab injection was found to have lower rates of complete success with relatively acceptable qualified success rates in the management of FHI-related glaucoma. Subconjunctival bevacizumab was not found to have additional effect to improve the surgical success.

Aqueous humor IL-8, IL-10, and VEGF levels in Fuchs' uveitis syndrome and Behçet's uveitis.

PURPOSE: This study investigated the levels of interleukin (IL)-8, IL-10, and vascular endothelial growth factor (VEGF) in the aqueous humor (AqH) of patients with Behçet's uveitis (BU) and Fuchs' uveitis syndrome (FUS) during an inactive period and compared these levels with those in the AqH of noninflammatory healthy control subjects. METHODS: This prospective and case-control study included 33 patients (16 patients with BU and 17 patients with FUS) and 35 control subjects. IL-8, IL-10, and VEGF levels in the AqH were quantified by performing sandwich enzyme-linked immunosorbent assay. Kruskal-Wallis test was used to compare the cytokine levels in the different groups, and statistical significance was set at p < 0.05. RESULTS: IL-8 levels were significantly higher in the AqH of patients with BU and FUS than in the AqH of control subjects (p < 0.001 and p < 0.001, respectively). IL-10 levels were significantly lower in the AqH of patients with BU than in the AqH of patients with FUS and of control subjects (p = 0.001 and p < 0.001, respectively). Although VEGF levels were higher in the AqH of patients with FUS than in the AqH of patients with BU and of control subjects, the difference was significant only between patients with FUS and control subjects (p < 0.001). CONCLUSIONS: We observed a significant decrease in IL-10 levels in the AqH of patients with BU and a significant increase in VEGF levels in the AqH of patients with FUS compared to controls. IL-8 and VEGF levels showed no significant difference among uveitis patients.

Analysis of clinical features and visual outcomes of pars planitis.

PURPOSE: To evaluate the demographic characteristics, clinical features, treatment and outcomes of patients with pars planitis in a tertiary referral center in Turkey. METHODS: Medical records of patients with pars planitis were retrospectively reviewed. The data including demographic and ocular features and treatment outcomes were recorded. The distribution of clinical findings and complications were evaluated according to age and gender groups. The changes in final BCVA compared to the initial BCVA were noted. Statistical analysis was performed using SPSS software (Version 18.0, SPSS Inc., Chicago, USA). RESULTS: Twenty-seven patients (54 eyes) were included in this study. 16 patients were male (59.3%), and 11 were female (40.7%). Mean age at diagnosis was 12.84 ± 8.26 (range 4-36) years. Mean follow-up period was 61.3 ± 52.15 (range 9-172) months. Mean BCVA was 0.58 ± 0.36 (range 0.03-1.00) (0.40 ± 0.45 logMAR) at presentation, and 0.81 ± 0.28 (range 0.10-1.00) (0.14 ± 0.27 logMAR) at final visit (P = 0.001). Vitreous inflammation (100%), vitreous haze (92.6%), snowballs (74.1%), snowbanks (66.7%), anterior chamber cells (66.7%) and peripheral retinal vascular sheathing (48.1%) were the most common presentations. Ocular complications included vitreous condensation (51.9%), cystoid macular edema (22.2%), cataract (18.5%), inferior peripheral retinal detachment (11.1%), glaucoma (5.6%) and vitreous hemorrhage (3.7%). Treatments included topical, periocular, intravitreal and systemic corticosteroids, immunosuppressives, peripheral laser photocoagulation and pars plana vitrectomy when needed. CONCLUSIONS: Pars planitis is an idiopathic chronic intermediate uveitis mostly affecting children and adolescents. In spite of its chronic nature with high potential of causing ocular complications, adequate treatment and close follow-up lead to favorable visual outcomes.

Are optic nerve heads of patients with helicobacter pylori infection more susceptible to glaucomatous damage?

BACKGROUND: To compare retinal nerve fiber layer thicknesses (RNFLT) of patients with or without Helicobacter pylori infection and to reveal the possible RNFLT changes after H. pylori eradication. MATERIALS AND METHODS: Sixty-five eyes of 65 patients that tested positive for H. pylori (Group 1) and 48 eyes of 48 patients that tested negative for H. pylori (Group 2) were included. RNFLT analyses were performed with spectral-domain (SD) optical coherence tomography (OCT) in a total of five regions: the superior, inferior, nasal, and temporal quadrants and the average. Then, a comparison was made between groups. After H. pylori eradication in 38 patients, RNFLTs were compared with both pre-eradication values and Group 2. RESULTS: The groups were similar in terms of age and gender. Temporal quadrant RNFLT was thinner in Group 1 than in Group 2 (P=.02). After H. pylori eradication, RNFLTs did not differ from pre-eradication values in Group 1 (P>.05 for all), whereas temporal quadrant RNFLT after H. pylori eradication was thinner compared to Group 2 (P=.03). CONCLUSIONS: H. pylori may cause the localized defects on RNFL that are the early signs of glaucoma.

Ocular manifestations of late-onset behçet disease.

PURPOSE: to describe the demographic characteristics and ocular manifestations of patients with late-onset Behçet disease (BD). PATIENTS AND METHODS: The patients for this retrospective study were selected using the data obtained from the medical records of 16 patients with late-onset BD between January 2000 and May 2008. RESULTS: twelve (75%) of the cases were male and 4 (25%) were female. The mean age of patients was 53.8 ± 2.9 years (range, 51-60 years). The mean follow-up period was 4.3 ± 1.1 years (range, 3-8 years). Throughout the follow-up period, panuveitis, posterior uveitis, and anterior uveitis were detected in 11 (68.7%), 4 (25%) and 1 (6.2%) of 16 patients, respectively. CONCLUSION: in our series, the most frequent type of uveitis was panuveitis and male sex seems to be a significant risk factor for developing panuveitis. Late-onset BD showed a marked preponderance of males with a sex ratio of 3:1.

Bilateral acute depigmentation of the iris: report of 26 new cases and four-year follow-up of two patients.

PURPOSE: To report new cases of bilateral acute depigmentation of the iris (BADI), a recently described clinical entity, and to report the 4-year follow-up of 2 patients that was published previously. DESIGN: A retrospective case series. PARTICIPANTS: Twenty-six Turkish patients who were diagnosed with BADI between 2006 and 2008 and 2 patients who were reported previously. METHODS: We reviewed the patients' charts and clinical photographs. Observation procedures included clinical examination, anterior segment color photography, laser flare photometry, and pupillometry. We performed an anterior chamber tap in 2 patients for polymerase chain reaction (PCR) to demonstrate the DNA of herpes simplex virus (HSV), varicella zoster virus (VZV), and cytomegalovirus (CMV) in the aqueous samples. MAIN OUTCOME MEASURES: Demographic features, presenting symptoms, laboratory findings, changes in iris stromal pigment and architecture, and time to resolution of pigment dispersion in the anterior chamber. RESULTS: Nineteen patients were female, and 7 patients were male. Mean age was 32.3+/-8.6 years. All had bilateral involvement. Twenty patients (76.9%) presented with photophobia and red eyes, and 4 patients (15.4%) presented with a recent change in eye color. Ten patients (38.5%) had flu-like symptoms preceding the onset of ocular symptoms. Diagnostic laboratory workup, viral serology, and PCR analysis of the aqueous humor were unrewarding. Diffuse depigmentation of the iris stroma from the collarette to the iris root was seen in 16 patients, and geographic areas of depigmentation were seen in 10 patients. There was heavy pigment deposition in the trabecular meshwork in all patients. Anterior chamber flare was elevated in eyes with circulating pigment. The pupil was not affected. Twenty patients received topical corticosteroids. Pigment dispersion resolved in 1 to 16 weeks (median, 9 weeks). The intraocular pressure was elevated in 8 steroid-treated eyes but was controlled with antiglaucomatous medications. In 2 patients reported previously, the depigmented iris stroma became repigmented after 4 years. CONCLUSIONS: Patients with BADI present with bilateral, symmetrical, nontransilluminating depigmentation of the iris stroma and pigment discharge into the anterior chamber. Young female persons are more commonly affected. The cause remains unknown. After 4 years, the ocular findings in 2 patients normalized.

Photodynamic therapy with and without adjunctive intravitreal triamcinolone acetonide: a retrospective comparative study.

BACKGROUND AND OBJECTIVE: To compare photodynamic therapy (PDT) with and without adjunctive intravitreal triamcinolone acetonide (IVTA) in the treatment of choroidal neovascularization secondary to age-related macular degeneration. PATIENTS AND METHODS: Sixty-six eyes received PDT with IVTA and 73 eyes received PDT only. Outcome measures included changes in visual acuity and greatest linear dimension (GLD), the presence of angiographic leakage, the re-treatment rate, and adverse events. RESULTS: Patients treated with PDT with IVTA had reduced mean GLD compared to patients treated with PDT only at all study time points (3 [P = .0049], 6 [P = .003], and 12 [P = .05] months). Forty-four percent of patients in the PDT with IVTA group and 22% of patients in the PDT only group achieved angiographic closure at 3 months (P = .027). There were no significant differences in the final visual acuity outcome or the re-treatment rate between the two groups. CONCLUSION: PDT with IVTA therapy has a favorable outcome on GLD. There is a modest improvement in visual acuity with PDT with IVTA therapy, which diminishes over time.

Inflammatory mediators and posterior segment involvement in ocular Behcet disease.

PURPOSE: To assess the serum level of mediators and their relation with posterior ocular involvement in patients with Behcet disease (BD). METHODS: This study was a prospective, institutional clinical trial including 43 patients with ocular BD. Patients were divided into two subgroups: those with active posterior segment involvement (Group A) and those with inactive ocular BD (Group B). Group A included patients with posterior uveitis (vitritis or chorioretinal involvement), while Group B included patients with no active intraocular inflammation within the last 3 months. Serum levels of interleukin (IL)-6, IL-8, tumor necrosis factor alpha (TNF-alpha), vascular endothelial growth factor (VEGF), and malondialdehyde (MDA) were measured by sandwich enzyme-linked immunosorbent assay and spectrophotometric assay and compared among the groups by independent sample t test and Mann-Whitney U-test. RESULTS: Serum levels of the mediators in Group A (IL-6 [23.1 pg/mL], IL-8 [161.1 pg/mL], TNF-alpha [30.5 pg/mL], VEGF [455.9 pg/mL], MDA [10.7 microm]) were found to be significantly higher than those in Group B (IL-6 [12.2 pg/mL], IL-8 [48.4 pg/mL], TNF-alpha [18.6 pg/mL], VEGF [138.0 pg/mL], MDA [5.1 microm]). CONCLUSIONS: This study demonstrated that increased serum levels of inflammatory mediators including IL-6, IL-8, TNF-alpha, VEGF, and MDA were possibly involved in the development of posterior uveitis in BD.

Choroidal mass as an initial presentation of lung cancer.

Choroidal mass may be a presenting sign of systemic malignancy. The diagnosis of metastatic ocular tumor is important because it can indicate poor prognosis. We report a case of a 45-year-old man presenting to our clinic with the complaint of decreased vision in the left eye, which is the initial finding of non-small cell lung-carcinoma.

Bilateral acute depigmentation of iris: 3-year follow-up of a case.

Bilateral acute depigmentation of the iris (BADI) usually affecting young women, is a newly defined clinical diagnosis with bilateral symmetrical pigment loss of iris stroma without iris transillumination defect. Herein, we want to share the results of a 3-year-long follow-up of a 23-year old female patient with BADI. She was admitted to our clinic with a complaint of discoloration of both her brown irises. An ocular evaluation of the patient revealed symmetrical pigment deposition in trabecular meshwork. No iris transillumination defect, pupillary sphincter paralysis, keratic precipitates, and inflammatory reaction in anterior chamber were seen. The depigmented iris stroma became repigmented symmetrically after 3-year follow-up period. Although it is rare, BADI should be considered in the differential diagnosis of the diseases with bilateral iris depigmentation.

The evaluation of the effect of Helicobacter pylori infection on choroidal thickness.

BACKGROUND/AIMS: To evaluate the effects of Helicobacter pylori infection on choroidal thickness (CT) using enhanced depth imaging spectral domain-optical coherence tomography (SD-OCT). MATERIALS AND METHODS: A total of 63 right eyes of 63 patients who tested positive for H. pylori (Group 1) and 46 right eyes of 46 patients who tested negative for H. pylori (Group 2) were evaluated. The CTs at the subfoveal area and at 1 mm ranging up to 3 mm from the fovea at the nasal and temporal quadrants were measured and compared. After the eradication of H. pylori, the CT values were also compared with the pre-eradication values in 38 patients. RESULTS: The mean age of patients was 43.6}9.5 years in Group 1 and 46.6}11.5 years in Group 2 (p=0.13). Differences in CT values between Groups 1 and 2 before and after H. pylori eradication were not statistically significant (p>0.05 for all values). CONCLUSION: The CT values of H. pylori positive and H. pylori negative patients were similar. Eradication of H. pylori infection appears to have produced no change in short-term CT.

Topographic optic disc analysis by Heidelberg retinal tomography in ocular Behcet's disease.

AIM: To compare the topographic characteristics of the optic discs in patients with severe and mild ocular Behçet's disease by using Heidelberg retinal tomographaphy (HRT). METHODS: This prospective study included 47 eyes of 47 patients with ocular BD who were being followed-up at the Uveitis Clinic of the Ankara Ulucanlar Eye Research Hospital, Ankara, Turkey. The patients were divided into two groups. Group 1 consisted of 21 eyes with mild uveitis, and group 2 consisted of 26 eyes with severe uveitis. All patients underwent topographic optic disc analysis by HRT II, and the quantitative optic disc parameters of both groups were compared by non-parametric Mann-Whitney U test. RESULTS: The mean cup volume, rim volume, cup area, disc area and cup depth in group 1 were found to be statistically significantly greater than those in group 2 (p<0.0001, p = 0.03, p = 0.021, p = 0.01 and p = 0.017, respectively), while the difference between the mean cup-to-disc ratios in group 1 and group 2 were found to be statistically insignificant (p = 0.148). CONCLUSION: A relationship was found between the severity of ocular BD and optic disc topography determined by HRT. In eyes with smaller optic discs, uveitis was observed to have a more severe course with more frequent relapses than those with larger discs.

Trabeculectomy with mitomycin C in secondary glaucoma associated with Behçet disease.

PURPOSE: To determine the outcome of initial trabeculectomy with mitomycin C (MMC) in the management of secondary glaucoma associated with Behçet disease (BD) in a 1-year follow-up period. METHODS: Twenty-three eyes of 13 cases with secondary glaucoma associated with BD, were evaluated prospectively. They underwent primary trabeculectomy with MMC. The operative success was defined as an intraocular pressure (IOP) < or =20 mm Hg (+/- medical therapy) in the absence of phthisis and without the necessity of further surgery for glaucoma and success rates at the postoperative first day, first month, sixth month, and first year were determined. RESULTS: Success was achieved in all of the eyes (100%) at the postoperative first day and month, in 21 eyes (91.3%) at the postoperative sixth month and in 19 eyes (82.6%) at the postoperative first year. The mean preoperative IOP was 30.9+/-5.3 mm Hg under the mean 3.3+/-0.7 antiglaucoma medications but it reduced to 16.8+/-3.1 mm Hg under the mean 1.7+/-0.8 medications at the postoperative sixth month and 18.5+/-3.2 mm Hg under the mean 2.6+/-1.1 medications at the postoperative first year. CONCLUSIONS: Trabeculectomy with MMC provides reduction of IOP and the number of antiglaucoma medications in cases with secondary glaucoma associated with BD in a 1-year follow-up period.

Vogt-Koyanagi-Harada syndrome in children: report of a case and review of the literature.

This article reviews the therapeutic approaches in children with Vogt-Koyanagi-Harada (VKH) syndrome, and reports on a 9-year-old girl with progressive visual loss due to VKH syndrome in spite of treatment. In previous reports, corticosteroids were found to be the most effective agents in the treatment of VKH syndrome, while combination therapies with cyclosporine, methotrexate, or azathioprine were used with favorable results in refractory cases. In the current case, none of the treatments sufficiently stabilized the vision, but triple combination of corticosteroids, cyclosporine, and methotrexate suppressed the relapses of intraocular inflammation. Treatment of children with VKH syndrome is challenging. Various treatment modalities have been reported with various responses, but there is still no definite treatment regimen, and the treatment is usually individualized in pediatric VKH cases.

A case of bilateral iris mammillations with unusual pupillary appearance and pseudo-hypertension.

Iris mammillations are congenital abnormalities characterised by villiform elevations regularly spaced on the surface of the iris. The aetiology of iris mammillations is unknown. They can be either isolated or associated with melanocytosis involving the uveal tract and the periocular tissue, resulting in a risk for uveal melanoma. These lesions can be complicated by high intraocular pressure and, in the case of associated melanocytosis of the iris, sclera or periocular tissues, by uveal melanoma. Patients with iris mammillations should be followed regularly due to these potential complications. We report a case of bilateral iris mammillations with unusual pupillary appearance and pseudo-hypertension and emphasise the importance of iris mammillations and that central corneal thickness should be considered when intraocular pressure is measured.

Nonsurgical management of an intraorbital pencil without cranial or globe penetration.

A 3-year-old boy suffered a penetrating orbital pencil injury in the right upper eyelid. Examination showed no signs of globe perforation, fractures, or neurologic deficits. The pencil was removed with controlled and slow motion. Visual acuity was 20/20 and anterior and posterior segment findings were normal 2 months after the injury.