Rheumatologic manifestations in a cohort of patients with Vogt-Koyanagi-Harada disease.

OBJECTIVES: Vogt-Koyanagi-Harada Disease (VKHD) is a systemic autoimmune disorder characterized by granulomatous panuveitis. Inflammatory rheumatic diseases (IRDs) are among the differential diagnosis of VKHD. However, current knowledge on the rheumatological aspects of VKHD is still limited. We aimed to investigate the prevalence of rheumatic conditions in VKHD patients. METHODS: VKHD patients were included in the study and they were reviewed in terms of the presence of any rheumatological manifestations. RESULTS: There were 18 patients with a female preponderance (83.3%, female). Inflammatory type of peripheral joint pain (11%) and sicca symptoms (33%) were the most common rheumatological findings. The frequency of spondyloarthritis-related features such as inflammatory back pain and HLA-B27 rate was not increased. None of the patients had radiographic sacroiliitis. Anti-nuclear antibody was positive in high titres nearly in 30% of the patients and three patients had antibodies against extractable nuclear antigens. Nailfold capillaroscopy was abnormal in about one-third of the patients. Pathergy test was negative in all cohorts. While angiotensin-converting enzyme was elevated in nearly 20% of the patients, there were no abnormalities on chest X-rays. CONCLUSION: VKHD shares some features with IRDs. The common features were mostly suggestive of connective tissue disease rather than SpA or rheumatoid arthritis.

Common ocular findings in patients with acne rosacea.

PURPOSE: To evaluate ocular surface manifestations in patients with acne rosecea (AR) and to find out main features indicating a propensity toward an association with disease diagnosis. METHODS: Right eyes of consecutive 76 AR patients and 113 age-gender matched healthy subjects were enrolled. Ophthalmologic examinations including tear break-up time (t-BUT) and Schirmer-2 tests to analyze tear film insufficiency, optical coherence tomography (OCT)-assisted infrared meibography to analyze meibomian gland drop-out, and Ocular Surface Disease Index (OSDI) questionnaire were performed in all participants. RESULTS: No statistically differences were found in visual acuity, intraocular pressure, central corneal thickness, and axial length assessments between the study and control eyes. Study eyes had more foreign body sensation, itching, dryness, hyperemia, conjunctival telangiectasia, and meibomitis (p ≤ 0.005, for all). Significantly higher t-BUT and Schirmer-2 tests; lower-eyelid and total OCT meibography; and OSDI scores were found in AR patients (p < 0.05, for all). Among all, only conjunctival telangiectasia (p = 0.001; OR:0.070, 95% CI:0.015-0.330) was found to be major independent predictor for AR diagnosis. CONCLUSION: Detailed slit-lamp examination to detect any conjunctival telangiectasia seems to be crucial in recalcitrant dry eye cases, not to miss underlying AR. Especially, lower-eyelid OCT meibography score may be sensitively used for disease staging.

Ahmed glaucoma valve implantation with the tube placement in the ciliary sulcus: short-term results.

PURPOSE: To evaluate the clinical outcomes of pseudophakic/aphakic eyes with uncontrolled glaucoma that underwent Ahmed glaucoma valve implantation with the tube placement in the ciliary sulcus. METHODS: Medical records of the patients who underwent Ahmed glaucoma valve implantation through the ciliary sulcus, between December 2017 and June 2019, were reviewed retrospectively. Patients' age, gender, glaucoma diagnosis, visual acuity, intraocular pressure levels, and complications were recorded. RESULTS: Forty-seven eyes of 43 patients with glaucoma were enrolled. The mean age was 54.5 ± 19.9 years (range, 7-88 years) at the time of surgery, and the mean postoperative follow-up period was 7.9 ± 3.4 months (range, 3-16 months). The mean preoperative intraocular pressure level was 35.2 ± 6.8 mmHg (range, 25-55 mmHg), and it was found as 15.6 ± 5.4 mmHg (range, 9-33 mmHg) at the last follow-up visit. Decrease in intraocular pressure level was statistically significant (P < 0.001). At the last follow-up visit, success (postoperative IOP ≥ 6 mmHg and ≤ 21 mmHg with or without antiglaucomatous medications, without further surgery for IOP control, without loss of light perception and without removal of the implant) was achieved in 41 eyes (87.2%). Hyphema was the most common postoperative complication and developed in 11 eyes (23.4%) and resolved spontaneously in all of them within one month. CONCLUSION: In pseudophakic or aphakic eyes with uncontrolled glaucoma, placement of Ahmed glaucoma valve tube in the ciliary sulcus is a safe and effective procedure. Ciliary sulcus can be considered as a potential space during tube shunt surgery in eyes with high risk of tube-corneal touch or corneal decompensation.

Bilateral Congenital Prepapillary Retinal Arterial Loop.

Prepapillary vascular loops are rare congenital vascular abnormalities of the retinal vasculature. This mostly benign condition can sometimes cause complications such as branch retinal artery occlusion and vitreous haemorrhage. Disc collaterals, neovascularisation of the optic disc, idiopathic retinal vasculitis, aneurysms and neuroretinitis (IRVAN) syndrome and Wyburn Mason syndrome should be kept in mind for the vascular differential diagnosis. In addition, when the loops present bilaterally and settle into the region adjacent to the optic disc border, they can be misdiagnosed as papilloedema. The diagnosis is usually made clinically by careful fundus examination. Optical coherence tomography and fundus fluorescein angiography might serve as ancillary tools for the diagnosis. In this report, we present a 52-year-old male with bilateral prepapillary arterial loops referred to our clinic with a preliminary diagnosis of papilloedema.

ACUTE EFFECT OF CAFFEINE ON MACULAR MICROCIRCULATION IN HEALTHY SUBJECTS: An Optical Coherence Tomography Angiography Study.

PURPOSE: To evaluate the acute effects of caffeine on macular microvasculature using quantitative optical coherence tomography angiography analysis. METHODS: Fifty-two healthy subjects aged 24 to 48 years were randomly divided into 2 groups: a control group, which received placebo, and a study group, which was subjected to caffeine. All participants underwent optical coherence tomography angiography at baseline and 1 hour after 200-mg oral caffeine intake in the study group and after oral placebo in the control group. Macular flow area, macular vessel density, and foveal avascular zone (FAZ) area were analyzed in both the groups. RESULTS: The study group consisted of 14 men and 12 women with a mean age of 40.6 ± 8.9 years. The mean age of control group was 39.5 ± 9.4 years, which consisted of 13 men and 13 women. Baseline macular flow area, vessel density, and FAZ area measurements of the study and control groups showed no significant difference (P > 0.05). Oral caffeine intake caused a significant reduction in macular flow area (superficial, deep, and choriocapillaris) and vessel density (P < 0.05). However, there was no statistically significant difference in FAZ area after caffeine intake when compared with baseline measurements (P = 0.063). CONCLUSION: We found a significant decrease in macular flow area (superficial, deep, and choriocapillaris) and vessel density after caffeine intake. Our findings are consistent with previous studies using other techniques. We believe that the results of this preliminary study will be useful in future studies about this topic.

A Novel Biomarker in Diabetic Macular Edema with Serous Retinal Detachment: Serum Chitinase-3-Like Protein 1.

PURPOSE: To determine whether serum chitinase-3-like protein 1 (CHI3L1) and interleukin-6 (IL-6) levels correlate with serous retinal detachment (SRD) in diabetic macular edema (DME) using spectral-domain optical coherence tomography (SD-OCT). METHODS: In this cross-sectional case-control study, 394 patients (treatment-naive DME patients, n = 218; diabetic patients without DME, n = 96; nondiabetic controls, n = 80) were included in the study. Eyes were classified according to SD-OCT features of DME: SRD, cystoid macular edema (CMO), and diffuse retinal thickness (DRT). Serum concentrations of CHI3L1 and IL-6 were analyzed using enzyme-linked immunosorbent assay. RESULTS: Serum CHI3L1 and IL-6 levels were significantly higher in DME with SRD compared to patients with CMO and DRT (p < 0.001 for all groups). Multivariate regression analysis showed that CHI3L1 and IL-6 had a stronger influence on the presence of SRD in DME (r = 1.162, p = 0.026, and r = 1.242, p = 0.016, respectively). Serum concentration of CHI3L1 was significantly correlated with that of IL-6 (r = 0.386, p = 0.0015). CONCLUSIONS: Our data suggest that serum concentrations of CHI3L1 and IL-6 are involved in the process of SRD in DME. CHI3L1 can be investigated further as a new diagnostic biomarker for DME with SRD.

Effects of Preoperative Topometric Indices on Visual Gain After Intracorneal Ring Segment Implantation For Keratoconus.

OBJECTIVES: To assess the corneal topometric parameters that can be predictive for better visual gain after intracorneal ring segment (ICRS) implantation in eyes with keratoconus. METHODS: A total of 42 eyes of 32 patients who underwent ICRS implantation at Dokuz Eylul University, Deparment of Ophthalmology, Cornea Divison were included. Changes in uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), refractive errors, and corneal topometric indices measured using Scheimpflug topography (Pentacam, Oculus) were evaluated retrospectively. RESULTS: After creation of intrastromal tunnels of 5.01±0.03 mm inner diameter, 5.71±0.03 mm outer diameter and at 384.21±34.12 µm depth, 1 or 2 ICRS of 150 to 350 µm thickness and 90 to 210° arc length were implanted. Preoperative UDVA of 0.09±0.10 and CDVA of 0.29±0.14 Snellen lines improved postoperatively to 0.42±0.26 and 0.62±0.24, respectively (P<0.001 for both). Preoperative spherical equivalent of -6.35±4.58D and refractive astigmatism of -5.89±2.40D decreased to -3.59±3.86 and -2.25±1.66D, retrospectively (P<0.001 for both). Strong negative correlations were detected between preoperative mean simulated keratometry (SimKavg)/index of surface variance (ISV) and changes in UDVA/CDVA (P<0.01, for all). Postoperative change in ISV was positively correlated with thicknesses of implanted rings. Change in topographical keratoconus classification was positively and change in index of vertical asymmetry was negatively correlated with number of implanted rings (P<0.05 for all). CONCLUSIONS: Preoperative ISV value seems to be beneficial in predicting visual gain after ICRS implantation, in addition to SimKavg. Future work on new nomograms for ICRS selection that include ISV, besides refractive, topographic, and cone location data, is warranted.

Topically applied 1% voriconazole induces dysplastic changes on the ocular surface: animal study.

PURPOSE: To identify the risk of inducing ocular surface dysplasia following topical administration of 1% voriconazole eye drop. METHODS: Fourteen noninflamed healthy eyes of 14 white adult New Zealand rabbits were included in the study. The rabbits were randomly divided into two groups comprised of 7 rabbits each. Group 1 received topical 1% voriconazole and Group 2 received topical saline as the control group. In all animals, right eye was selected for the study. In Group 1 (Voriconazole Group), single drop of voriconazole was instilled every 10 min consecutively for 17 times a day for 60 days. In Group 2 (Control Group), single drop of saline was instilled every 10 min consecutively for 17 times a day for 60 days. At two months, animals were sacrificed and study eyes were enucleated with the eyelids. The specimens were stained with hematoxylin-eosin and histopathologic changes in cornea, bulbar and palpebral conjunctiva were evaluated under light microscope. RESULTS: There were no macroscopically visible lesions on the ocular surface of any rabbits. Histopathological evaluation showed mild to moderate dysplasia localized mainly in the limbus and extending to the adjacent cornea and bulbar conjunctiva in all rabbits in Voriconazole Group. Severe dysplasia or carcinoma in situ was not observed. In the Control Group, dysplasia was not observed, at all. CONCLUSION: This animal study provides a possible relationship between topically administered 1% voriconazole and ocular surface dysplasia. We recommend ophthalmologists to be aware of the risk of ocular surface dysplasia in patients received voriconazole eye drop.

Wide-Field Fluorescein Angiography in Patients with Idiopathic Acute Anterior Uveitis.

PURPOSE: To elucidate whether wide-field fluorescein angiography (WFFA) can yield additional information in patients with newly diagnosed idiopathic acute anterior uveitis (AAU). METHODS: The WFFA was performed in patients with idiopathic AAU, and the findings were analyzed according to the scoring system by Angiography Scoring for Uveitis Nomenclature. RESULTS: Forty-four eyes of 30 patients (22 eyes of 13 patients in the pediatric group and 22 eyes of 17 patients in the adult group) were studied. The mean age was 12.41 ± 3.92 (range, 5-18) years in the pediatric group and 42.36 ± 32.07 (range, 24-68) years in the adult group. Thirteen eyes (59%) of pediatric patients and 12 eyes (54%) of adult patients showed some evidence of posterior segment activity on the WFFA (p = .764).     Systemic treatment was administered in 53.8% of the pediatric and 5.9% of adult patients, depending on the disease severity. CONCLUSION: Pediatric patients with idiopathic AAU may have subtle posterior segment manifestations more than adult patients, and posterior segment findings may affect the treatment preferences of physicians.

Endogenous Endophthalmitis Caused by Aspergillus lentulus in an Immunocompromised Patient with Lung Cancer

A 78-year-old man with a history of lung cancer, chemotherapy, radiotherapy, and coronavirus disease 2019 infection experienced visual deterioration of two-weeks' duration in his right eye. There was multifocal, yellowish-white retinitis foci, vascular engorgement, and scattered intraretinal hemorrhages extending from posterior pole to retinal periphery in the right eye, whereas the left eye was normal. Intravitreal vancomycin, ceftazidime, clindamycin, and dexamethasone were given for endogenous endophthalmitis initially. Vitreous culture confirmed the presence of Aspergillus lentulus, and he was treated with intravitreal amphotericin-B and voriconazole injections together with systemic amphotericin-B, voriconazole, posaconazole, and micafungin therapy. During follow-up, vitreoretinal surgery was performed because of rhegmatogenous retinal detachment, and he received one additional cycle of chemotherapy due to recurrence of the cancer. Although the retina was attached, enucleation was eventually required due to painful red eye. Atypical squamous cells beneath the neurosensory retina suggesting metastasis were noted on histopathological examination. Timely ocular examination is crucial for any immunocompromised patient having ocular symptoms. High level of suspicion for a fungal etiology is a must in these patients.

Evaluation of Macular Pigment Optical Density in Eyes with Hyperopic Anisometropic Amblyopia Using Fundus Reflectometry.

Objectives: This study aimed to evaluate the macular pigment optical density (MPOD) scores in eyes with hyperopic anisometropic amblyopia and compare those with their fellow and control eyes using one-wavelength fundus reflectometry. Methods: This cross-sectional study enrolled 33 patients diagnosed with hyperopic anisometropic amblyopia aged 12-40 years. The control group consisted of 36 hyperopic and 42 emmetropic children, age-matched to the patients. Central macular thickness (CMT), MPOD, axial length (AL), best-corrected visual acuity, and refraction errors were measured between the study group and the control group. Results: Eyes with the diagnosis of hyperopic anisometropic amblyopia had significantly higher mean and maximum (max) MPOD scores compared with their fellow eyes as well as hyperopic and emmetropic eyes (p<0.001 for all). The mean AL in eyes with hyperopic anisometropic amblyopia was statistically shorter than that in hyperopic and emmetropic controls (p=0.027, p<0.001, respectively). The mean CMT was found to be thicker in eyes with hyperopic anisometropic amblyopia when compared to their fellow eyes, as well as hyperopic and emmetropic controls, eventhough there was no significant difference was found among the four groups (p=0.052). The mean MPOD levels were significantly correlated with the difference in CMT (r=-0.21, p=0.032), and logMAR visual acuity scores (r=-0.44, p<0.001) in the hyperopic anisometropic amblyopia group. Conclusion: The present study indicates that the MPOD is reduced in eyes with hyperopic anisometropic amblyopia. This reduction may be due to less visual stimulus-induced deterioration of foveal development and microarchitecture in anisometropic amblyopic eyes.

Intraretinal Macroaneurysms and Multimodal Imaging: A Retrospective Analysis.

Purpose: To analyze the multimodal imaging characteristics of intraretinal macroaneurysms. Patients and Methods: Intraretinal aneurysms larger than 150 µm in diameter on fluorescein angiography were termed as intraretinal macroaneurysm and grouped as primary and secondary according to the absence or presence of any coexisting posterior segment diseases. Results: A total of 20 intraretinal macroaneurysms were observed in 18 eyes of 18 patients. Mean age of the cohort was 65.44 ± 9.14 years (Range; 49-82 years). Mean diameters of intraretinal macroaneurysms were 238.20 ± 61.12 µm (Range; 163.00-292.50 µm) and 242.72 ± 49.58 µm (Range; 168.00-328.00 µm) on fluorescein angiography and optical coherence tomography, respectively. Primary group had 10 eyes with 11 intraretinal macroaneurysms, whereas eight eyes had nine intraretinal macroaneurysms in the secondary group. Three of the eight eyes (37.5%) had diabetic retinopathy, four (50%), retinal vein occlusion, and one (12.5%), posterior uveitis in the secondary group. No statistically significant differences were found between the two groups in terms of age, sex, presence of intraretinal or subretinal fluid, the mean age, the mean central macular thickness, the mean distance of intraretinal macroaneurysms from the fovea, the mean diameter of intraretinal macroaneurysms measured on fluorescein angiography, and the mean diameter of intraretinal macroaneurysms measured on optical coherence tomography. Presence of intraretinal fluid was significantly more frequent than the presence of subretinal fluid in all eyes (p = 0.004). Conclusion: Intraretinal macroaneurysms are diagnosed more and more with the utilization of multimodal imaging techniques. We propose a simple classification system in order to help achieving a standardized terminology and ensure consistent understanding. The classification can be simplified as primary or secondary intraretinal macroaneurysm according to the absence or presence of the associated posterior segment disorders.

Intravitreal Ranibizumab and Dexamethasone Implant Injections as Primary Treatment of Diabetic Macular Edema: The Month 24 Results from Simultaneously Double Protocol.

PURPOSE: To compare efficacy of simultaneously administered intravitreal dexamethasone implant (DEX implant) and ranibizumab (simultaneous double protocol) injections with ranibizumab monotherapy for diabetic macular edema (DME) at month 24. METHODS: This is a prospective, consecutive, clinical interventional study. Naïve eyes with DME were randomized into two groups: 34 eyes received simultaneous double-protocol therapy and 34 eyes received ranibizumab monotherapy. The primary efficacy endpoint was change in visual acuity in month 24. The secondary efficacy endpoints were to evaluate gain of ≥15 letters, morphological changes and central foveal thickness. Decreased vision from DME (study eye BCVA, 20/40 or worse Snellen equivalent using ETDRS testing), the presence of DME with ≥300 µm foveal intraretinal cystoid spaces (within 1000 µm of the centre of the fovea), subfoveal neuroretinal detachment (SND), intraretinal hyperreflective foci (HRF, within 500 µm of the centre of the fovea) or foveal lipid exudates and external limiting membrane (ELM) and ellipsoid zone (EZ) disruption (within 500 µm of the centre of the fovea) on SD-OCT were eligible to enrol. RESULTS: The mean baseline BCVA was 48 ± 23 letters in double protocol group and 52 ± 14 letters ranibizumab monotherapy group (p = 0.416). The mean number of ETDRS letters changed from baseline at 12 months versus change from baseline at month 24 in double protocol group and ranibizumab monotherapy group were +21.6 versus +20.2 and +9.6 versus +9.1, respectively. At the month 24 time point, 65.4% of patients in double protocol group and 26.2% of patients in ranibizumab monotherapy group had gained ≥15 ETDRS letters in BCVA from baseline (p < 0.001). The external limiting membrane (ELM) and ellipsoid zone (EZ) integrity were better in the double protocol group in comparison to ranibizumab monotherapy group at month 24. In addition, there was no statistically significant increase in the proportion of patients with epiretinal membrane in double protocol group at month 24, by the contrast with ranibizumab monotherapy group (p = 0.06 and p = 0.04 in the double protocol and ranibizumab monotherapy groups, respectively). From baseline to month 24, the mean central foveal thickness (CFT) was 672 ± 293 µm reduced to 278 ± 84 µm in double protocol group and was 631 ± 279 µm reduced to 356 ± 108 µm in ranibizumab monotherapy group (p < 0.001 and p < 0.001). From baseline to month 24, 38% (13/34) of eyes in double protocol group and 18% (6/34) of eyes in ranibizumab monotherapy group had at least 5 mmHg of IOP elevation (p = 0.012). Two grades or more increased cataract density were detected 27% (6/22) of eyes in the double protocol group and in 12.5% (3/24) of eyes in the ranibizumab monotherapy group from baseline to month 24 (p = 0.032). CONCLUSION: According to the improvements in visual acuity and morphological changes achieved at month 24, the simultaneous double protocol therapy can be an effective treatment option for DME with inflammatory biomarkers on OCT or/and decreased visual acuity.

Evaluation of choroidal vascularity index in systemic sclerosis patients.

OBJECTIVE: To investigate the comparison of choroidal vascularity index (CVI) between patients with systemic sclerosis and healthy individuals. METHODS: This study was designed prospective non-randomized cross-sectional study. Eighty-six eyes (43 patients) with limited cutaneous systemic sclerosis (lcSSc), 60 eyes (30 patients) with diffuse cutaneous systemic sclerosis (dcSSc) and 60 eyes (30 subjects) of age-and sex-matched healthy individuals were recruited. Subfoveal choroidal thickness, CVI and modified Rodnan skin score (mRSS) were evaluated. Enhanced depth imaging- optical coherence tomography scans were binarized using Niblack's autolocal threshold and CVI was determined as the luminal choroidal area/total choroidal area ratio. RESULTS: The mean CCT values were 268.00±68.59 µm, 286.90±70.88 µm, 321.73±94.13 µm in lcSSc group, dcSSc group and control group, respectively. The mean CVI was 61.84±2.84% in lcSSc group, 54.62±5.84% in dcSSc group and 62.41±4.13% in control group (p=0.001). The mean CVI of the SSc patients was 58.91±5.58 and there was significant difference between control group (p<0.001). The mean mRSS was 3.84±2.50 in lcSSc group and 14.07±6.81 in dcSSc group (p<0.001). There was a statistically significant negative correlation between mRSS and CVI (r=-0.448, p<0.001) CONCLUSION: Choroidal vascularity index provides valuable information to monitor the disease progression and lower CVI values seem to be related to the disease severity in patients with systemic sclerosis.

Dexamethasone intravitreal implant for macular edema and some other rare indications in uveitis.

In the present study, 110 eyes of 81 patients with uveitis who underwent intravitreal dexamethasone implant (IDI) injection and had a follow-up of at least 6 months between January, 2012 and September, 2022, were retrospectively analyzed. A total of 298 IDI injections were administered (mean, 2.71±2.37; range, 1-12). The mean age of the patients was 49.44±16.67 years (range, 15-86 years). The mean follow-up time after the first IDI was 34.31±26.53 months (range, 6-115 months). In total, 77 (95.1%) patients had non-infectious uveitis, while 4 patients (4.9%) received IDI for uveitic macular edema in association with infectious uveitis (1 patient with acute retinal necrosis and 3 patients with systemic tuberculosis). IDI was injected under the umbrella of intravitreal ganciclovir injection in the patient with healed acute retinal necrosis for the associated pseudophakic cystoid macular edema. A total of 6 patients (7.4%) received IDI prior to phacoemulsification surgery to control the possible post-operative macular edema. In addition, 3 patients (3.7%) with Vogt-Koyanagi-Harada disease received bilateral IDI as the systemic therapy could not be administered due to side-effects of the systemic treatment. In total, 1 patient (1.2%) with idiopathic retinal vasculitis, aneurysms and neuroretinitis was treated with IDI injections in both eyes in addition to systemic therapy to reduce the ongoing inflammation. Of note, two eyes (1.8%) received simultaneous single IDI and anti-vascular endothelial growth factor administration for the treatment of unilateral extrafoveal macular neovascularization (one with active serpiginous choroiditis and one with sympathetic ophthalmia). IDI was administered for the treatment of uveitic macular edema in 68 patients (83.9%). Best-corrected visual acuity improved from 0.69±0.64 to 0.60±0.76 logMAR at the final visit (P=0.008). Baseline mean central macular thickness (CMT) was 499.74±229.60 µm (range, 187-1,187 µm) and the mean final CMT was 296.60±152.02 µm (range, 126-848 µm). Intraocular pressure elevation requiring topical antiglaucomatous eye drops occurred in 28 eyes (25.5%). During the follow-up period, bilateral glaucoma surgery was required in 1 patient (1.2%) and 25 of 65 phakic eyes (38.4%) underwent phacoemulsification. Retinal detachment occurred in one eye (0.9%), endophthalmitis in one eye (0.9%), and transient intravitreal hemorrhage occurred in three eyes (2.7%) after the IDI injections. On the whole, the present study demonstrates that although IDI is mostly employed in non-infectious uveitic eyes with macular edema, it can also be administered in cases with systemic therapy intolerance, pseudophakic macular edema prophylaxis, and with great caution, in selected cases involving infectious uveitis and macular edema.

Intravitreal ranibizumab and dexamethasone implant injections as primary treatment of diabetic macular edema: simultaneously double protocol.

PURPOSE: To assess the 12-month efficacy and safety of simultaneously administered intravitreal dexamethasone implant (DEX implant) and ranibizumab (simultaneous double protocol) injections in comparison with ranibizumab monotherapy as the first-line treatment of diabetic macular oedema (DMO). METHODS: Prospective, consecutive, clinical interventional study. Patients were randomized into two groups: 24 naive DMO patients (34 eyes) who received simultaneous double-protocol therapy and 22 DMO patients (34 eyes) who received ranibizumab monotherapy were included. Monthly ranibizumab (0.5 mg) was administered for the first 6 months and later on, an as-needed treatment basis. DEX implant injection was performed at any time during the loading dose of the three consecutive monthly injections of ranibizumab, and with as-needed reinjections of ranibizumab from 6th month onwards. Change in visual acuity was the primary efficacy endpoint. Secondary efficacy endpoints were a gain of ≥15 letters and a change in the central foveal thickness. RESULTS: Mean BCVA increased from baseline to month 12 in the simultaneously double-protocol therapy group compared with the ranibizumab monotherapy group (21.6 versus 9.6 letters [P < 0.001]). The corresponding proportions of eyes gaining ≥15 letters were 60% versus 29.4% (P < 0.0001). Moreover, the mean reductions in the central foveal thickness were 413 versus 282 µm (P = 0.001). At 12 month, the simultaneous double-protocol therapy decreased a significant number of foveal cysts and subfoveal neuroretinal detachment compared with those by ranibizumab monotherapy. CONCLUSIONS: The simultaneous addition of DEX implant at any time during the three monthly loading doses of ranibizumab in patients with DMO significantly improved the visual outcomes and revealed superior anatomic outcomes than those with the ranibizumab monotherapy.

Evaluation of the Macular and Choroidal Perfusion in Healthy Turkish Population Using Optical Coherence Tomography Angiography.

PURPOSE: To investigate the effect of age- and sex-related differences on macular and choroidal perfusion in healthy Turkish individuals by optical coherence tomography angiography (OCTA). METHODS: Two hundred-eight eyes of 116 healthy Turkish individuals (60 females and 56 males, mean age 40.35 ± 12.64 years) were included in this study. OCTA was performed on a 3 × 3-mm region on the macula. The superficial macula wholeimage vessel density (wiVD), foveal VD and parafoveal VD vessel density, foveal avascular zone (FAZ) as well as choriocapillaris flow index (CFI) were quantified. RESULTS: The mean vessel density was 53.1% ± 2.8% in superficial macula wiVD, 31.7% ± 6.9% in superficial foveal VD and 55.2% ± 3.4% in superficial parafoveal VD for 3 × 3-mm OCTA images. Analysis of 3 × 3-mm scan has revealed a mean value of FAZ area was 0.313 ± 0.112 mm2. The mean CFI for 3 × 3-mm scan was 1.937 ± 0.059. A significant decrease was observed in the mean values of wiVD, parafoveal VD and CFI with age (p < 0.001, p = 0.001, and p < 0.001, respectively), with average yearly reductions of 0.3%, 0.4% and 0.4%, respectively. However, there was no correlation between age and foveal VD (p > 0.05). The FAZ area has shown an age-dependent annual increment, showing an average of 1.26%. The parafoveal VD and FAZ area were significantly higher in females than males (p = 0.027 and p = 0.015, respectively) while other parameters seemed similar (p > 0.05 for all). CONCLUSIONS: Our results suggest that age- and sex-related variations were effective on macular and choroidal perfusion. These normative values obtained using OCTA may be clinically useful to the evaluation of retinal and choroidal disorders.

Optic nerve sheath decompression saves sight in severe papilloedema: results from 81 eyes in 56 patients with pseudotumor cerebri.

PURPOSE: To report the outcome of optic nerve sheath decompression (ONSD) for papilloedema in a teaching hospital in western Turkey. METHODS: The charts of 56 patients who had ONSD surgery between April 2007 and September 2019 were collated; and a total of 81 operated and 31 fellow eyes were included. Pre- and postoperative ophthalmologic examination including best-corrected visual acuity (BCVA), colour vision (CV), visual field (VF) analysis, fundoscopic examination and demographic and medical characteristics of the patients were noted and outcomes after surgery were investigated. RESULTS: Of all study eyes, 49 (43.7%) eyes had BCVA 0.2 or less and 62 (55.3%) eyes had mean deviation (MD) below - 20.0 dB. 62 (55.3%) eyes had Frisen grade 4 or 5 papilloedema. Almost half of the eyes had severe vision loss. After ONSD, BCVA, CV and MD in both operated and fellow non-operated eyes improved significantly (p < 0.001, p = 0.009 and p < 0.001 for operated, p < 0.001, p = 0.007 and p < 0.001 for fellow eyes, respectively). Earlier surgery and higher cerebrospinal fluid opening pressure were related to better outcomes. None of the patients had major operative complications. CONCLUSION: Optic nerve sheath decompression can safely improve vision not only of the operated but also of the non-operated eye, even in cases with severe vision loss from severe bilateral papilloedema. Regardless of initial VA and VF, patients may benefit from ONSD; the earlier it is done the more likely the better outcome.

Unilateral acute retinal necrosis in a multiple sclerosis patient treated with high-dose systemic steroids.

A 50-year-old man with multiple sclerosis developed unilateral acute retinal necrosis following a long-term systemic corticosteroid administration for treatment of an attack of paraparesis. The patient was treated with systemic acyclovir, aspirin, oral steroids and topical cyclopentolate and prednisolone acetate for almost 3 months. Pars plana vitrectomy and 360° endolaser photocoagulation posterior to necrotic retinal areas were performed a week after the initial diagnosis. Varicella zoster DNA was confirmed by PCR analysis in the vitreous sample. Two months later, pars plana vitrectomy with silicone oil injection was performed successfully to treat complicated retinal detachment. Careful peripheral fundus examination is essential when acute unexplained visual loss is noted in patients receiving systemic corticosteroids to exclude acute retinal necrosis syndrome.

Favorable clinical outcome with intravitreal aflibercept treatment in a case with bilateral choroidal neovascular membrane and quiescent Vogt-Koyanagi-Harada syndrome.

Objective: To describe the favorable clinical outcome in a case with bilateral choroidal neovascular membrane and quiescent Vogt-Koyanagi-Harada (VKH) syndrome by administering bilateral intravitreal aflibercept injections. Case report: A 30-year-old woman was diagnosed with VKH syndrome at another institution and had been in remission with oral mycophenolate mofetil for two years. However, nearly simultaneous right juxtafoveal and left subfoveal type 2 choroidal neovascular membrane was detected two years after the initial diagnosis. The right eye (OD) received three and the left eye (OS) received four aflibercept injections within a time span of eight months. Visual acuity was 20/30 in OD and 20/25 in OS at the last follow-up visit. Conclusion: Although suppression of inflammation is a must in eyes with inflammatory type choroidal neovascular membranes, anti-VEGF (vascular endothelial growth factor) therapy with agents, such as aflibercept in the present case, is a key therapeutic adjunct and may possibly help improve the visual prognosis.