Corneal thickness and endothelial changes in long-term hydroxychloroquine use.

Objective: To determine possible associations between long-term HCQ use and corneal changes in patients who used HCQ for at least 3 years. Materials and methods: The study included 62 healthy controls and 62 consecutive patients who used HCQ for the treatment of rheumatologic disease and were referred to the ophthalmology department between August 2018 and November 2018 for HCQ retinal toxicity screening. Central corneal thickness (CCT), corneal endothelial cell density (ECD), the coefficient of variation (CV) of cell size, and the percentage of hexagonal cells (HEX%) were measured to evaluate changes in the cornea. Results: The mean age of the patient group and control group was 50.10 ± 10.91 and 50.53 ± 10.67 years, respectively. The mean ECD was 2742 ± 347 (cells/mm2) in the patient group and 2875 ± 188 cells/mm2 in the control group. There was a significant difference between groups (p = 0.01). The mean CCT was 567.05 ± 32.35 µm in the patient group and 540.15 ± 38.50 µm in the control group. CCT was significantly higher in the patient group compared with control group (p < 0.001). There was no significant difference between groups in terms of mean CV and HEX values (p > 0.05). Conclusions: Patients using long-term HCQ demonstrated lower ECD and higher CCT than the control group. However, the CV of cell sizes and the HEX % values were not significantly different from the controls.

Agreement and repeatability of central corneal thickness measurements by four different optical devices and an ultrasound pachymeter.

PURPOSE: To compare the repeatability and agreement of central corneal thickness (CCT) measurements by spectral-domain optical coherence tomography (OCT), corneal topography (CT) with a combined Scheimpflug-Placido system, optical biometry (OB), specular microscopy (SM), and ultrasound pachymetry (UP). METHODS: A single observer measured CCT twice in 150 eyes of 150 subjects with each of five devices: Nidek RS-3000 Advance OCT, CSO Sirius combined Scheimpflug-Placido disc system CT, Nidek AL-Scan partial coherence interferometry-based OB, Tomey EM-3000 SM, and Reichert iPac ultrasonic pachymeter. Pachymetry values corrected by the SM device software were also recorded. Levels of agreement between devices were evaluated by Bland-Altman plots with 95% limits of agreement, and repeatability for each device was analysed with intraclass correlation coefficients. RESULTS: The mean CCTs measured by OCT, CT, OB, SM, corrected SM, and UP were 544.60 ± 29.56, 536.19 ± 32.14, 528.29 ± 29.45, 524.88 ± 32.38, 537.88 ± 32.38, and 545.29 ± 30.75 µm, respectively. Mean CCT differed significantly between the devices (p < 0.05) apart from between OCT and UP, and between CT and corrected SM. Mean paired differences between devices ranged between 0.68 and 20.41 µm. Repeatability with all devices was excellent (> 0.99). The range of limits of agreement was the least between OCT and UP. CONCLUSIONS: Different CCT measurement techniques produce quite different results, so CCT evaluation and follow-up should be performed using the same device or devices with close compatibility.

Decreased choroidal thickness in vitiligo patients.

BACKGROUND: Vitiligo is a disease characterized by depigmented macules and patches that occur as a result of the loss of functional melanocytes from the affected skin through a mechanism which has not been elucidated yet. Destruction of pigment cells in vitiligo may not remain limited to the skin; the eyelashes, iris, ciliary body, choroid, retinal pigment epithelium and meninges may also be affected. This study aims to compare the choroidal thickness of patients with and without vitiligo using optical coherence tomography (OCT). METHODS: Spectral-domain optical coherence tomography (SD-OCT) (Retina Scan Advanced RS-3000 NIDEK, Japan) instrument (with λ = 840 nm, 27,000 A-scans/second and 5 µm axial resolution) was used for the imaging. Statistical analysis was performed using SPSS 21.0 software package. RESULTS: In all values except optic nevre area measurements, the choroidal thickness of all vitiligo patients was found out to be thinner compared to the control group. CONCLUSIONS: In vitiligo, the choroidal thickness may be affected by the loss of melanocytes.

Effect of dexamethasone intravitreal implant (Ozurdex®) on corneal endothelium in retinal vein occlusion patients : Corneal endothelium after dexamethasone implant injection.

BACKGROUND: To assess corneal endothelial cell changes after intravitreal dexamethasone (DEX) implant (Ozurdex®) injection in patients with macular edema secondary to retinal vein occlusion (RVO). METHODS: Twenty-two eyes of 22 patients were assessed prospectively after intravitreal 0.7 mg DEX implant injection. Twenty-two eyes of 22 healthy volunteers served as control group. Corneal endothelial cell parameters including endothelial cell density (ECD), coefficient of variation of cell size (CV), percentage of hexagonality (Hex) and central corneal thickness (CCT) were analyzed before and 1 and 3 months after injection by specular microscopy. The results of the study were compared statistically. RESULTS: There were 17 (77.3%) patients with branch RVO and 5 (22.7%) patients with central RVO. Mean intraocular pressure (IOP) was 14.73 mmHg before injection, 17.05 mmHg at 1 month and 17.15 mmHg at 3 months after injection. Mean IOP at 1 and 3 months were significantly higher than pre-injection value (p = 0.002 and p = 0.003, respectively). There was a statistically significant reduction in mean ECD at 3 months after injection compared to pre-injection and 1 month (p = 0.013, p = 0.009, respectively) in the injected eyes. Mean ECD showed no significant difference in the uninjected fellow eyes during the follow up (p>0.05). Mean CV and Hex did not reveal a statistically significant difference in injected and uninjected fellow eyes (p > 0.05). No significant change was observed in mean CCT values during the follow up (p = 0.8). CONCLUSION: Intravitreal dexamethasone implant may cause a transient reduction in corneal endothelial cell density in short term without changing cell morphology.

Hyaluronic acid viscoelastic medium as an aid for microsurgical venous anastomoses.

The thin-walled structure of veins leads them to stay collapsed during anastomoses, thereby the incidence of technical failures is more common than arterial anastomoses. In order to overcome this problem, we are introducing the use of viscoelastic material based on our experience on rats. Six rats were used in order to study the technical feasibility of the viscoelastic material during microsurgical vein anastomosis. End-to-end anastomoses were performed on rat jugular veins using 0.5-1 mL of the viscoelastic medium applied to the ends of the veins and surgical field under ×30 operating microscope magnification. Then 1.8% (n:3) and 3.0% (n:3) hyaluronic acid was used as a viscous medium in order to keep the vein lumens open during anastomosis. In conclusion, we have found that 3.0% hyaluronic acid viscoelastic medium facilitates microvenous anastomosis in rat. Studies involving human practice are needed for further evaluation of this technical refinement.

Retinal nerve fiber layer thickness in vitiligo patients.

BACKGROUND: This study was designed to investigate the effect of vitiligo on the retinal nerve fiber layer (RNFL) thickness. MATERIALS AND METHODS: This prospective study was conducted in the Department of Ophthalmology at Kirikkale University during 2010 and 2011. Sixty eight eyes of 34 vitiligo patients were included in the study. Eighty four eyes were served as control. RNFL thickness was measured by scanning laser polarimetry (Nerve Fiber Analyzer, GDx VCC: 5.3.3; Laser Diagnostic Technologies, San Diego, CA, USA). RESULTS: The mean duration of vitiligo was found to be 9.8 ± 2.3 years. The mean average RNFL thickness outside the disc margin was significantly lower in the right eyes of vitiligo group in comparison to the controls (P = 0.02). The mean average thickness of RNFL beneath the measuring ellipse in the superior sector of both eyes were significantly lower than the controls (P = 0.004, P = 0.008, respectively). The topographical distributions of RNFL thickness in superior, inferior, nasal and temporal quadrants were similar for two groups. CONCLUSION: RNFL thickness seems to be unaffected in vitiligo patients.

Simultaneous reconstruction of medial canthal area and both eyelids with a single transverse split forehead island flap.

In this report, we are presenting a case in which we have split the paramedian forehead flap, thus providing 2 axially perfused skin flaps for simultaneous reconstruction of the upper and lower lid structures after resection of basal cell carcinoma from the left medial canthal area. We found that split forehead flap seems to be a favorable option for simultaneous reconstruction of the upper and lower eyelid defects by enabling nicely vascularized and abundant amount of regional skin.

Traumatic Dislocation of the Globe into the Ethmoid Sinus

Traumatic globe dislocation into the paranasal sinuses is a rare condition. Globe displacement with preserved integrity can result in functional and cosmetic recovery with rapid and appropriate intervention. In this article, we discuss the presentation and treatment of globe dislocation into the ethmoid sinus in a 36-year-old patient who presented to the emergency department with the complaint of vision loss due to a fall.

Intraocular pressure and superior ophthalmic vein blood flow velocity in Graves' orbitopathy: relation with the clinical features.

BACKGROUND: The aim of this study is to evaluate the association of intraocular pressure (IOP) and superior ophthalmic vein blood flow velocity (SOV-BFV) with the clinical features of Graves' orbitopathy. METHODS: During the 2002-2007 period, 66 eyes of 34 Graves' orbitopathy cases were classified as mild, moderate and severe orbital disease, and evaluated according to their clinical features as: i)type 1 vs type 2 cases, and ii) cases with or without dysthyroid optic neuropathy. In all patients, a full ophthalmic examination including IOP and Hertel measurements was performed. SOV-BFV was analyzed with color Doppler sonography. RESULTS: The Hertel value, IOP in primary and upgaze position were higher, and SOV-BFV was lower in moderate and severe Graves' orbitopathy cases that showed statistical significance from mild cases, and controls (p = 0.001). Moderate and severe Graves' orbitopathy cases showed comparable Hertel measures and IOP in primary and upgaze position (p = 0.39); however, SOV-BFV was significantly lower in severe cases when compared to moderate cases (p = 0.001).This study demonstrated statistically significant negative correlation between IOP in both primary (r = 0.43,p = 0.008) and upgaze position (r = 0.51,p = 0.002), and SOV-BFV. Additionally, statistically significant positive correlation was detected between Hertel values and SOV-BFV(r = 0.402,p = 0.007).There was a statistical difference between type 1 and 2 cases in Hertel values(p = 0.006), IOP in upgaze position (p = 0.026) and SOV-BFV (p = 0.003). SOV-BFV of the eyes showing dysthyroid optic neuropathy was statistically lower than eyes without dysthyroid optic neuropathy (p = 0.006). CONCLUSIONS: IOP and SOV-BFV have significant association with the clinical features of Graves' orbitopathy. The decrease in SOV-BFV increases the severity of Graves' orbitopathy, and may have a role in the clinical course of dysthyroid optic neuropathy.

Schwannoma of the lower eyelid in a 13-year-old girl.

A 13-year-old girl presented with a history of a slowly enlarging, mobile, right lower eyelid mass of 2 years' duration. Excisional biopsy revealed the characteristic histopathologic features of a schwannoma. After complete excision, there was no recurrence at 1-year follow-up. Schwannoma is a rare eyelid tumor, appearing sporadically and in a solitary form, which should be considered in the differential diagnosis of eyelid tumors in children.

Enophthalmos due to atelectasis of the maxillary sinus: silent sinus syndrome.

Silent sinus syndrome is a clinical entity with the constellation of progressive enophthalmos and hypoglobus due to gradual collapse of the orbital floor with opacification of the maxillary sinus, in the presence of subclinical maxillary sinusitis. It occurs secondary to maxillary sinus hypoventilation due to obstruction of the ostiomeatal unit. In this paper, a 35-year-old woman with a complaint of asymmetry in her left eye and denting of upper eyelid was reported. In the left eye, upper sulcus was deepened and there was 3-mm hypoglobus. There was no diplopia or restriction of eye movements in any gaze positions. Hertel exophthalmometry revealed a 4-mm enophthalmos on the left eye. Computed tomographic scan of the orbita and paranasal sinuses showed left maxillary sinusitis, air-fluid level, and collapse of left maxillary sinus walls. In addition, inferior bulging in the left orbital floor was also reported. The treatment was a 2-stage operation. In the first stage, she underwent endoscopic septoplasty plus left maxillary antrostomy, and in the second stage, she underwent a subciliary orbital floor repair of the iliac bone resulting in the improvement of the enophthalmos and her cosmetic appearance. Regarding this case, the literature is also reviewed in detail.

The comparison of the relationships about the presence of branch retinal vein occlusion and endothelial functions between diabetic and non-diabetic patients.

OBJECTIVES: The aim of this study was to investigate the endothelial functions in both patients with diabetics and non-diabetics with branch retinal vein occlusion by using pulse wave analysis and flow-mediated dilatation methods. PATIENTS AND METHODS: This cross-sectional study included a total of 136 participants (47 diabetic patients with branch retinal vein occlusion, 43 non-diabetic patients with branch retinal vein occlusion, and 46 otherwise healthy subjects). Evaluation of endothelial functions was performed by flow-mediated dilatation and pulse wave analysis methods. Stiffness index, reflection index (RI), and pulse propagation time were calculated. RESULTS: The mean stiffness index and RI were significantly higher in the diabetic branch retinal vein occlusion group compared with the non-diabetic branch retinal vein occlusion and the healthy controls (for stiffness index: 11.5 ± 2.8 vs. 10.1 ± 2.5 and 8.3 ± 2.0, P < 0.001; and for RI: 75.1 ± 11.7 vs. 65.4 ± 8.4 and 60.2 ± 18.8, P < 0.001, respectively), whereas the pulse propagation time was significantly lower in the diabetic group (156.4 ± 32.3 vs. 174.4 ± 46.5 and 205.0 ± 58.5, P < 0.001, respectively). There was a significant negative correlation between visual acuity and stiffness index (r = -0.512, P < 0.001). Besides, there was also a significant positive correlation between visual acuity and pulse propagation time (r = 0.398, P < 0.001). CONCLUSION: This study demonstrated that the stiffness index and RI values were higher in patients with branch retinal vein occlusion compared to the healthy subjects.

Evaluation effectiveness of 0.1% nepafenac on injection-related pain in patients undergoing intravitreal Ozurdex injection.

PURPOSE: To evaluate the analgesic effect of topical 0.1% nepafenac solution during intravitreal Ozurdex injection. METHODS: This prospective, randomized, double-blind placebo-controlled study included 59 patients who were diagnosed with retinal vein occlusion or pseudophakic cystoid macular edema and were selected to receive intravitreal Ozurdex injection. The patients were divided into two groups. Group 1, consisting of 31 eyes of 31 patients, received topical 0.1% nepafenac with topical anesthesia (0.5% proparacaine HCl, Alcaine; Alcon, TX, USA), and group 2, consisting of 28 eyes of 28 patients, received placebo with topical anesthesia. RESULTS: There were 14 (45.2%) men and 17 (54.8%) women in group 1 and 16 (57.1%) men and 12 (42.9%) women in group 2. The mean age of the subjects was 64.42 ± 5.51 years in group 1 and 62.32 ± 7.54 years in group 2. The median visual analog scale pain score was 2 (1-3) in group 1 and 4 (1-6) in group 2. The visual analog scale pain score was significantly lower in group 1 than in group 2 (p < 0.001). CONCLUSION: Topical 0.1% nepafenac has an additive analgesic effect when combined with topical anesthesia for intravitreal Ozurdex injection.

Purtscher-Like Retinopathy Associated with Synthetic Cannabinoid (Bonzai) Use

Purtscher's retinopathy is a microvascular occlusive disease initially described as retinal edema, cotton wool-like exudation, and hemorrhages occurring after severe head trauma. A similar clinical presentation called Purtscher-like retinopathy is associated with systemic diseases instead of trauma. In the present case, ophthalmic eksamination of a patient with complaints of blurred vision related to substance (Bonzai) use revealed bilateral cotton-wool spots. Purtscher-like retinopathy was diagnosed based on fluorescein angiography and optical coherence tomography findings. This is the first case of Purtscher-like retinopathy associated with Bonzai use described in the literature.

Elevated Tear Human Neutrophil Peptides 1-3, Human Beta Defensin-2 Levels and Conjunctival Cathelicidin LL-37 Gene Expression in Ocular Rosacea.

Purpose: To investigate the role of innate immunity in ocular rosacea. Methods: Thirty-two patients with ocular rosacea patients (group-1) and 28 healthy volunteers (group-2) who served as controls were enrolled in the study. Tear function parameters were assessed, conjunctival impression cytology was performed and tear samples were collected. Human-neutrophil-peptides (HNP) 1-3 and human-beta-defensin-2 (hBD-2) levels were measured in tears by using ELISA tests. Cathelicidin leucin-leucin-37 (LL-37), hBD-2, human-beta-defensin-9 (hBD-9) gene expression levels were measured in the conjunctival impression cytology samples using real-time polymerase chain reaction. Results: Tear HNP1-3 (p = 0.024), hBD-2 (p < 0.001), conjunctival LL-37 gene expression rate (p = 0.014) and ocular surface disease index scores (p = 0.001) were higher and the tear break-up time was lower (p = 0.003) in group-1. No other differences were found between the groups. Conclusion: The results of this study suggest the role of abnormal innate immunity in the pathophysiology of ocular rosacea by revealing elevated antimicrobial peptide levels.

Comparison of the Neodymium-doped Yttrium Aluminum Garnet Capsulotomy Rate with Viscoimplantation and the Hydroimplantation Intraocular Lens Technique.

PURPOSE: To investigate the rate of neodymium-doped yttrium aluminum garnet (Nd:YAG) laser capsulotomy in the hydroimplantation intraocular lens (IOL) technique. METHODS: This retrospective study was comprised of 6,192 eyes in 3,790 patients who underwent surgery from January 2013 to September 2017 and then were followed up for at least 1 year. The eyes of these patients were divided into two groups: either viscoimplantation or hydroimplantation. The follow-up examinations were carried out on the 1st day, 4th day, 1st month, and 3 months to 1 year postoperatively. The Nd:YAG capsulotomy rates were evaluated by the different IOL implantation techniques and IOL materials. RESULTS: The mean follow-up duration of the patients was in the viscoimplantation group 14.85 ± 2.43 and 15.05 ± 1.93 months in the hydroimplantation group. The Nd:YAG capsulotomy rate was significantly lower in the hydroimplantation group compared with the viscoimplantation group for the entire hydrophilic IOL model (p < 0.001). In addition, the Nd:YAG rate was lower in the hydroimplantation group that used a hydrophilic IOL than it was in the viscoimplantation group, which used a hydrophobic IOL. CONCLUSIONS: The hydroimplantation technique reduced the Nd:YAG capsulotomy rate.

Evaluation of Retinol Palmitate Treatment of Photokeratitis in Rat Eyes Exposed to Ultraviolet B Radiation.

OBJECTIVES: Acute exposure to ultraviolet B radiation can cause photokeratitis. Retinol palmitate (RP) is known to have antioxidant properties and improve corneal healing. The aim of this study was to evaluate the effect of topical RP against phototoxic keratitis in rats. METHODS: A total of 14 male Wistar Albino rats were exposed to 1 J/cm2 dose of 311 nm ultraviolet B radiation. The subjects were then divided into 4 study groups using the right and left eye: The RP-5 group (n=7) received topical 250 IU/g RP ointment and the Sham-5 group (n=7) received only the vehicle base component of the ointment 5 minutes after the exposure. The RP-120 group (n=7) received topical RP and the Sham-120 group (n=7) received the vehicle alone 120 minutes after the exposure. The eyes were enucleated 24 hours after the exposure and stained with hematoxylin and eosin for histopathological examination and a terminal deoxynucleotidyl transferase dUTP nick end labeling assay to test for apoptosis. RESULTS: There was no statistically significant difference between the mean corneal epithelial thickness of the RP-5 group and the Sham-5 group (p=0.369). Furthermore, there was no significant difference between the RP-120 and the Sham-120 groups (p=0.765). The timing of the administration of RP resulted in no significant difference in the mean corneal epithelial thickness (p=0.608). Apoptotic cell count scores were not significantly different between corneas that received RP and those who received only the vehicle (p=0.530, p=0.107). CONCLUSION: Topical administration of a single dose of RP was not superior to the use of the vehicle base alone in a photokeratitis model produced using 1 J/cm2 of narrowband ultraviolet radiation in rats.

0.1% Nepafenac reduces pain and increases patient comfort during cataract surgery.

PURPOSE: To evaluates analgesic effectiveness of 0.1% nepafenac during cataract surgery. METHODS: This prospective randomized randomized double-masked, placebo-controlled study comprised 80 eyes of 40 consecutive patients who underwent bilateral cataract surgery and implantation of foldable intraocular lens with topical anesthesia with and without topical nepafenac drops. Each eye of patients was assigned to group 1 and group 2. Topical anesthesia combined with 0.1% nepafenac used three times a day the day before the surgery and once half an hour just before the surgery was group 1, consisting of 40 eyes, and topical anesthesia with using placebo was group 2 consisting of 40 eyes. Patients were asked to score their pain using a visual analog scale (VAS) and verbal pain scale (VPS) immediately following the surgery. When the patient moved or squeeze the eye during surgery, the surgical comfort was evaluated as bad and otherwise, it was evaluated as good. RESULTS: When the intensity of pain during the surgery was evaluated, the percentage of patients reporting mild or no pain in group 1 was %825 and in group 2 was %45. Mean VAS pain score and mean VPS pain score in group 1 was significantly lower than that in group 2(p = 0.024, p < 0.001). Surgical comfort in group 1 was %825 and in group 2%65(P = 0.075). CONCLUSION: 0.1% nepafenac reduces pain of patients who undergone routine clear corneal phacoemulsification with topical anesthesia and may increase patient comfort during the surgery when used preoperatively.

Safety of hydroimplantation in cataract surgery in patients with pseudoexfoliation syndrome.

AIM: To evaluate the safety of hydroimplantation in cataract surgery in patients with pseudoexfoliation syndrome. METHODS: This prospective randomized study comprised 100 eyes of 100 consecutive patients who underwent cataract surgery and implantation of foldable intraocular lens (IOL). Each eye was assigned to group 1 or group 2. Hydroimplantation without using viscoelastic agent as group 1 (n=50), and hydroxypropylmethylcellulose (Eyevisc, Biotech, India) was used in group 2 (n=50). RESULTS: There were no statistically significant differences in central corneal thickness (CCT) and corneal endothelial cell count (ECC) between both groups at each visit and percentage change in CCT and ECC (P>0.05). The mean intraocular pressure (IOP) at postoperative 5h increased statistically significantly in group 2 (P<0.001). There was no statistically significant difference in IOP between two groups, before and after surgery excluding the 24h postoperative IOP, but patients in group 2 had higher IOP than that in the group 1 at 24h after surgery (P=0.035). No case in either group experienced posterior capsular rupture, or zonular dialysis. Fixation of the globe during IOL implantation was better in group 1 than that in group 2. CONCLUSION: Hydroimplantation has advantages in terms of IOP changes and duration of the surgery and seems to be safe in patients with pseudoexfoliation syndrome.