Comparison of macular and optic disc vessel density in thyroid orbitopathy: a comparative octa study.

PURPOSE: To determine the microvascular and structural changes in the peripapillary and macular areas observed in patients with active thyroid orbitopathy(TO) before and after steroid treatment and compare with inactive TO and the control group by optical coherence tomography angiography (OCTA). MATERIAL AND METHOD: This cross-sectional study included 34 eyes of 17 active TO patients, 108 eyes of 54 inactive TO patients, and 60 eyes of 30 healthy controls. Central macular thickness (CMT), ganglion cell layer-inner plexiform layer (GCL-IPL) thickness, central choroidal thickness (CCT), retinal nerve fiber layer (RNFL) thickness, choroidal thickness in the peripapillary region, superficial capillary plexus (SCP), deep capillary plexus (DCP) and choriocapillaris vessel densities were determined by OCTA in before and after 12-week steroid treatment of active TO cases, inactive TO and control groups. RESULTS: Between the three groups in macula OCTA, a statistically significant difference was observed in the inferior and nasal quadrants in SCP (all p = 0.01) and only in the temporal quadrant choriocapillaris (p = 0.005). In peripapillary OCTA, a statistically significant difference was found only in the central choriocapillaris (p = 0.03). In the comparison of the active group before and after treatment, there was a statistically significant decrease in CMT and CCT; a statistically significant increase was observed in GCL-IPL (all p < 0.01). There was a statistically significant decrease in SCP and DCP only in the central (all p < 0.01). There was a statistically significant increase was found in the lower quadrant macular SCP vessel density and mean macular DCP in post-treatment measurements (p = 0.01 and p = 0.03, respectively). Peripapillary SCP and DCP vessel density was increased after treatment (p < 0.01). CONCLUSION: Active TO group had lower vessel density than inactive group and after treatment, vessel density was increased. Non-invasive quantitative analysis of retinal and optic disc perfusion using OCTA could be useful in early treatment before complications occur and monitoring patients with TO.

Histopathological View of Benign Essential Blepharospasm: Orbicularis Oculi Hormone Receptor Levels.

Objectives: Benign essential blepharospasm (BEB) is a focal dystonia characterized by involuntary contractions of the orbicularis oculi and periocular muscles. We aimed to investigate the effects of muscle receptor levels on the etiopathogenesis of blepharospasm by evaluating the orbicularis oculi estrogen receptor (ER) and androgen receptor (AR) levels. Methods: Four blepharospasm patients (2 females and 2 males) who underwent upper lid blepharoplasty and/or orbicularis myomectomy and 4 healthy cases (2 females, 2 males) that had upper lid blepharoplasty were included. The pretarsal, preseptal, and orbital parts of the orbicularis muscles of the patients who underwent orbicularis myomectomy and the waste muscle tissue materials taken from the preseptal orbicularis muscles of the patients who had only upper blepharoplasty were analyzed. Immunohistochemical staining was performed with estrogen alpha and androgen. Results: In healthy men, the orbicularis oculi muscle was stained with ER at a moderate intensity and with AR at a high intensity. In men with blepharospasm, the orbicularis oculi were not stained with ER at all, but at a high intensity with AR. In healthy women, the orbicularis oculi were stained with ER and AR at a high intensity (>50%). In women with blepharospasm, the staining intensities of both receptors were moderate. Conclusion: We determined a decrease in ER and AR in females and almost the absence of ER in males with BEB. This decrease in ER may be associated with a functional abnormality in mitochondria and the decrease in hormonal receptors may be associated with sarcopenia in orbicularis oculi muscle fibers.

Efficacy of keratometric values obtained from Sirius topographer® in nidek axial length-scan® for intraocular lens calculation after penetrating keratoplasty.

BACKGROUND: To evaluate the accuracy of keratometric values obtained from Scheimpflug (Sirius) topography using Nidek AL-Scan optical biometry (OB) for intraocular lens (IOL) power calculating after penetrating keratoplasty (PK). METHODS: Thirty eyes of 26 patients were included in this study. The demographic information, complete ophthalmic examination, IOL calculation technique, and its effect on final refractive results were evaluated. RESULTS: The mean age of the patients was 52.76 ± 16.20 years. The mean K readings using Nidek AL-Scan OB, mean simulated K (SimK) (3mm), and mean pupillary power (MPP) (4.5mm) K readings using Sirius were 41.92 ± 5.05 D, 42.99 ± 5.78 D, and 43.30±6.23 D (p= 0.515). CONCLUSIONS: Both devices correctly calculated IOL power after PK; however, Sirius SimK (3mm) gave the lowest mean absolute error (MAE) results and can be safely used for IOL power calculation.

Muller muscle conjunctival resection or external levator advancement; a quantitative comparison of symmetry in unilateral ptosis.

PURPOSE: To compare muller muscle conjunctival resection (MMCR) and external levator advancement (ELA) in terms of objective and subjective symmetry in unilateral ptosis. METHODS: The patients who underwent unilateral MMCR (group1, n = 25) and ELA (group2, n = 25) were reviewed retrospectively. With the written algorithm, margin reflex distance-1 (MRD1), localization of the contour peak, and the percentage of overlapping curvatures (POC) of both upper eyelid curves were calculated. Semi-automated measurements were compared with the manual measurements. The correlation between objective and subjective symmetry was evaluated. RESULTS: Preoperative levator functions were similar in both groups (13.93 ± 3.25 mm and 13.3 ± 2.86 mm, respectively). We found strong correlations between manual and semi-automated measurements (ICC: 0.942, 95% CI = 0.924-0.956, p < 0.001). Preoperative MRD1 (2.15 ± 0.90 vs 1.51 ± 1.01, p = 0.022) and POC was lower in group 2 (66% vs 47.2%, p = 0.01). In the postoperative period, the increase in MRD1 and POC were similar in both groups (p = 0.2 and p = 0.7 respectively), and the contour peak displaced temporally (p < 0.01) providing a symmetric peak in both groups. Subjective symmetry increased as the difference in MRD1 between two eyes decreased (r = -0.456, p = 0.001), and POC increased (r = 0.396, p = 0.004). CONCLUSIONS: Besides subjective symmetry, MMCR and ELA are equally effective in ensuring symmetry objectively, as measured with MRD1 and contour peak symmetry and POC in unilateral ptosis. POC may be used as a criterion of symmetry in the evaluation of ptosis.

An algorithm for Botulinum toxin A injection for upper eyelid retraction associated with thyroid eye disease: long-term results.

PURPOSE: To evaluate the efficacy and complications of transconjunctival Botulinum toxin A injections performed according to an algorithm, for the management of upper eyelid retraction associated with thyroid eye disease. METHODS: Seventy one eyes of 60 patients at the inactive stage, who had undergone Botulinum toxin A injection were reviewed retrospectively. Botulinum toxin A was injected transconjunctivally, just above the superior tarsal border of the upper eyelid in doses between 2-15 units according to an algorithm, depending on the amount of retraction. Margin-reflex distances were measured according to the photographs taken under standard conditions before and after the injections at the tenth day, then the second month and the fourth month. Additional Botulinum toxin A injections were performed in patients who had an undercorrection on the tenth day. Complications such as diplopia and ptosis were recorded. RESULTS: The study included 38 females, 22 males with a mean age of 43.3 ± 13.1. Normal margin-reflex distances (3-4 mm) were reached in the 58 of 71 eyes (81.7%). Additional injections were needed in eight eyes (11.2%) for residual retraction on the tenth day. Ptosis was the major complication in four eyes for 1-3 weeks after injection. Upper eyelid retraction recurred after 5.1 ± 0.9 months in all patients. CONCLUSION: In the treatment of upper eyelid retraction due to thyroid eye disease, transconjunctival injection of Botulinum toxin A is an effective, safe, transient, and repeatable method with few complications in patients. The algorithm used in this study resulted in high success rate in long-term follow-up.

The efficacy of low vision aids with contact lenses in pediatric population.

PURPOSE: To compare the efficacy of contact lens use with low vision aids (LVA) with the efficacy of spectacle use with low vision aids. METHODS: Thirty-six pediatric patients with low vision were enrolled in this study between January 2015 and March 2017. The patients were examined for best-corrected visual acuity (BCVA) with spectacles, spectacles with LVA, contact lenses and contact lenses with LVA. Toleration of the patients with contact lenses and LVA were recorded at the final follow-up exam. RESULTS: The mean BCVA with spectacles was detected as 1.11 ± 0.25 log MAR and the mean BCVA improved to 0.35 ± 0.13 log MAR with the use of spectacles and LVA, which was statistically significant. The mean BCVA with contact lens, which was 0.99 ± 0.22 log MAR, improved to 0.40 ± 0.21 log MAR with contact lens and LVA, which was also significant. There was a statistically significant improvement in BCVA of the patients with contact lenses only when compared to spectacles only. The mean BCVA significantly improved in patients using LVA with contact lenses when compared to LVA with spectacles. Tolerations of the patients with contact lenses and LVA were found to be well at 29 of 36 (80.55%) at final follow-up (26.11 ± 6.85 months). CONCLUSION: Contact lens use in pediatric patients with low vision especially with LVA offers better visual acuity, a decrease in nystagmus amplitude, wider field of view and comfort.

Evaluation of choroidal thickness and retinal vessel density in patients with inactive Graves' orbitopathy.

BACKGROUND: To investigate choroidal thickness using spectral domain-optical coherence tomography and retinal vessel density with optical coherence tomography angiography in patients with inactive Graves' orbitopathy. METHODS: A total of 36 eyes of 36 patients with inactive Graves' orbitopathy (6 men and 30 women in Group 1) and 36 eyes from 36 controls (8 men and 28 women in Group 2) were recruited for this prospective case-control study. Choroidal thickness measurements were obtained using enhanced depth imaging with spectral domain-optical coherence tomography. Optical coherence tomography angiography images were generated with 6 × 6-mm angiographic optical coherence tomography scans. Retinal vessel densities of the superficial retinal layer and deep retinal layer of the macula and foveal avascular zone measurements were obtained for each eye. RESULTS: The mean age was 42.5 ± 9.9 years in Group 1 and 42.8 ± 6.5 years in Group 2 (p = 0.76). The mean choroidal thickness was 370.7 ± 83.5 µm and 338.2 ± 72.4 µm in Group 1 and 2, respectively (p = 0.09). There was no significant difference between the groups in retinal vessel density either in superficial or deep retinal layers (p > 0.05 for all), and no difference was found between the groups in foveal avascular zone area and perimeter (p = 0.69, p = 0.73, respectively). CONCLUSIONS: Similar retinal vessel density values were found in both superficial and deep retinal layers in Graves' orbitopathy compared with healthy subjects. Although statistically insignificant, choroidal thickness was slightly higher in patients with Graves' orbitopathy than in healthy subjects. Foveal avascular zone area and perimeter measurements were unaffected by the disease.

Serum calcium, magnesium, phosphorus, and vitamin D in benign essential blepharospasm.

PURPOSE: This study aims to compare serum calcium, magnesium, phosphorus, and 25-hydroxy (OH)-vitamin D levels in patients with benign essential blepharospasm (BEB) and healthy subjects and to determine their association with disease severity and frequency. METHODS: This is a prospective study conducted in a tertiary care hospital. Fifty patients (female, 39; male, 11) with BEB and 22 healthy subjects (female, 15; male, 7) included in the study. Serum calcium, magnesium, phosphorus, and vitamin D levels of BEB and healthy groups were measured. Blepharospasm severity and frequency were assessed using scales ranging from 0 to 4 by following the Jankovic Rating Scale (JRS). RESULTS: Though there was no significant difference regarding magnesium, phosphorus, and 25(OH)-vitamin D levels between the two groups, serum calcium levels of the BEB group were significantly lower than the control group (9.5 ± 0.4 and 9.9 ± 0.4 mg/dl, respectively; P = 0.002), although in the normal range (9-10.5 mg/dl). In the BEB group, the mean Jankovic severity and frequency scores were 3.29 ± 0.54 and 3.59 ± 0.61, respectively. There was a moderate negative correlation between serum 25(OH)-vitamin D levels and Jankovic severity score (r = - 0.332; P = 0.022). CONCLUSION: Serum calcium levels of the BEB group were significantly lower than the healthy group. Serum vitamin D levels showed a moderate negative correlation with disease severity. The role of calcium and vitamin D in the evolution of the BEB need further investigation at the cellular and anatomical levels.

Müller Muscle Conjunctiva Resection for Revision of Residual Ptosis After External Levator Advancement Surgery.

PURPOSE: To evaluate surgical outcomes of Müller muscle conjunctival resection surgery for reoperation of residual ptosis after external levator advancement in patients with aponeurotic ptosis. METHODS: A total of 23 eyes of 23 patients who had undergone Müller muscle conjunctival resection for residual ptosis between January 2016 and July 2018 were reviewed retrospectively. Margin reflex distance (MRD), interlid crease, and show distance measurements were performed with a ruler in millimeters during the office examination, and the photographs of patients were taken before the procedure and on the 10th day, at the first, third, and sixth months after the procedure. The successful outcome was described as MRD1 between 3 and 5 mm, interlid MRD1 difference ≤1 mm, interlid crease difference ≤2 mm, interlid show difference ≤2 mm, and the presence of symmetrical lid contour. RESULTS: The mean increases in MRD1 were statistically significant at the first, third, and sixth months postoperatively when compared with preoperative values both before external levator advancement and before Müller muscle conjunctival resection (p = 0.000). There was statistically significant decrease in interlid MRD1 difference, interlid crease difference, and interlid show difference relative to preoperative values. Interlid crease and show difference within the range of successful outcome criteria were achieved in all patients. However, interlid MRD1 difference exceeded 1 mm in only 1 patient who had overcorrection. CONCLUSIONS: In patients who have residual ptosis without contour abnormality following external levator advancement, and positive response to phenylephrine testing, Müller muscle conjunctival resection is an effective approach.

Anterior-Approach Versus Posterior-Approach Levator Advancement Surgery in Aponeurotic Ptosis.

PURPOSE: To compare the effectiveness and complications of levator reinsertion in aponeurotic ptosis surgery using anterior and posterior approaches. METHODS: Seventy-eight (36 females, 42 males) patients with acquired aponeurotic ptosis were evaluated. Pre- and postoperative margin reflex distance, symmetry of height, contour and skin crease, corneal problems, and lagophthalmus were evaluated and compared between the 2 groups. Independent and paired samples t-test, Pearson Chi-square, and Fisher exact test were used to evaluate the results. RESULTS: The anterior approach was performed on 43 eyelids and the posterior approach was performed on 35 eyelids. The mean age of the anterior-approach group was 62.1 ±â€Š11 years, and posterior-approach group was 50.1 ±â€Š15.1 years, respectively (P < 0.001). The male-female ratio was 28/15 in the anterior-approach group, and 14/21 in the posterior approach group (P = 0.027). The success rate of the anterior approach was 69.8% and the posterior approach was 57.1% (P = 0.248). The mean margin reflex distance change was statistically significant in both anterior- and posterior-approach techniques (P < 0.001, P < 0.001, respectively). Three (6.9%) patients in the anterior-approach group and 11 (31.4%) in the posterior-approach group required reoperation (P = 0.005). Lagophthalmus rates were similar (3 eyes in the anterior versus 7 eyes in the posterior group, P = 0.103). CONCLUSIONS: Both anterior- and posterior-approaches are effective and safe techniques for aponeurotic ptosis treatment. The posterior approach seems to be preferred by female and younger patients because there is no undesirable scar formation although it has the disadvantage of higher rates of reoperation.

Do ocular pulse amplitude and choroidal thickness change in patients with thyroid eye disease?

Purpose: The aim of this study was to evaluate whether orbital changes induced by thyroid eye disease affect the ocular pulse amplitude and choroidal perfusion. Materials and Methods: A total of 38 eyes of 38 patients with thyroid eye disease (Group 1) and 38 eyes of 38 control individuals (Group 2) with normal intraocular pressure were enrolled in this study. Thyroid eye disease activity was defined using clinical activity score. Intraocular pressure measurement with Goldmann applanation tonometer, axial length, central corneal thickness, Hertel exophthalmometry and systolic and diastolic blood pressure measurements were taken from each patient. Ocular pulse amplitude and intraocular pressure were measured using dynamic contour tonometry. Choroidal thickness was measured by enhanced depth imaging-optical coherence tomography at subfoveal, nasal and temporal 1000 µm area. Results: Intraocular pressures measured with Goldmann applanation tonometer and dynamic contour tonometry and mean ocular pulse amplitude were not statistically different between groups. However mean choroidal thicknesses were significantly lower when compared to control group. Ocular pulse amplitude and intraocular pressure measurement with dynamic contour tonometry did not change significantly with the increase in clinical activity score. There was not statistically significant correlation between ocular pulse amplitude and choroidal thicknesses in patients with thyroid eye disease. Conclusion: Ocular pulse amplitude and choroidal perfusion were not found to change with orbital involvement in thyroid eye disease and with disease activity, especially in patients with normal intraocular pressure. Although choroidal thickness was thinner than control group, choroidal perfusion did not change as a compensatory mechanism for maintaining ocular homeostasis.

Corneal Topographical Changes After Müller's Muscle-conjunctival Resection Surgery.

PURPOSE: To evaluate corneal refractive and topographical changes after Müller's muscle conjunctival resection surgery on patients with mild ptosis. METHODS: A total of 28 eyes of 28 patients with mild ptosis underwent Müller's muscle conjunctival resection. Visual acuity, margin reflex distance, and cycloplegic refraction were analyzed preoperatively and at first, third, and sixth months postoperatively. Change in corneal topography was analyzed with Sirius System using parameters including corneal astigmatism (CYL), average simulated keratometry value (simK), apical keratometry front (AKf), symmetry index front (SIf), and central corneal thickness (CCT) at the same intervals. RESULTS: Best-corrected visual acuity and cycloplegic refraction did not change significantly at all controls postoperatively. The mean change in corneal astigmatism, simK, SIf, and CCT did not show significant differences. Apical keratometry front showed a significant decrease at 3 and 6 months. CONCLUSION: The pressure of upper eyelid in patients with ptosis appeared to have resulted in steepening of the superior cornea along this axis. The surgical correction of ptosis induces flattening of superior cornea as shown by significant decrease in apical keratometry front value postoperatively and restores corneal topography to a more regular state.

Medial Rectus Bridge Faden Operations in Accommodative and Partially Accommodative Esotropia With Convergence Excess.

PURPOSE: To evaluate the results of the bilateral bridge Faden operation on the medial rectus muscles with and without recession in the treatment of accommodative and partially accommodative esotropia with convergence excess. METHODS: A retrospective analysis was performed on the medical records of 103 patients who underwent the bridge Faden operation on both medial rectus muscles, with or without recession, for the treatment of accommodative and partially accommodative esotropia with convergence excess. Preoperative and postoperative near and distance deviations and near-distance disparities were evaluated. RESULTS: The study population consisted of 38 (37%) girls and 65 (63%) boys. The mean age was 9.32 ± 5.83 years (range: 1 to 18 years) and the mean follow-up period was 14.49 ± 2.78 months. Fifty-one patients underwent the bridge Faden operation on both medial rectus muscles with recession (recession group) and 52 patients underwent the bridge Faden operation on both medial rectus muscles without recession (no recession group). The mean preoperative amount of esotropia at near was 43.51 ± 7.00 and 24.24 ± 3.56 prism diopters (PD) for the recession and no recession groups, respectively. The mean preoperative amount of esotropia at distance was 26.63 ± 6.86 and 9.22 ± 2.09 PD for both groups, respectively. The mean preoperative near-distance disparity was 17.14 ± 3.00 and 14.05 ± 4.14 PD for both groups, respectively. In both groups, there was a statistically significant difference in the near and distance deviations and the near-distance disparity between preoperative and postoperative values (P < .05). Postoperatively, there was no significant difference between 1 month, 6 months, and 1 year and between 6 months and 1 year (P > .05). CONCLUSIONS: The bridge Faden operation on both medial rectus muscles either with or without recession was a successful surgical procedure in patients with accommodative and partially accommodative esotropia. During the follow-up period, the success rates did not decrease. [J Pediatr Ophthalmol Strabismus. 2017;54(6):369-374.].

An Atypical Case of Microphthalmos With Cyst: Cyst Masquerading as Phthisical Eye.

A 6-year-old boy diagnosed with congenital microphthalmic OS was referred for prosthetic eye fitting. He was otherwise healthy without known congenital anomalies. His visual acuity was 20/20 in the OD and no light perception in the OS. His disfigured OS with a conjunctivalized opaque cornea appeared smaller than his OD. He had left esotropia with severely restricted ductions in all directions of gaze. The preoperative orbital MRI of the patient revealed a small orbital cyst posteroinferior to the OS. Because the patient could not tolerate the prosthetic eye worn over his disfigured eye, evisceration was planned. During the surgery, blunt dissection of the conjunctiva and Tenon's capsule uncovered a large orbital cyst that was misdiagnosed as phthisis bulbi preoperatively based on the clinical examination and imaging findings. The structure that was thought to be an orbital cyst on orbital MRI was the microphthalmic eye. Enucleation with cyst excision was performed. Patient had uneventful postoperative course and has been wearing an artificial eye for 1 year since surgery.