Clinical value of phenylephrine testing in the upper and lower eyelids of patients with aponeurotic and congenital eyelid ptosis.

AIM: To characterize the phenylephrine test in aponeurotic and congenital eyelid ptosis, to determine the appropriate timing of the phenylephrine test, and to assess the responses of the upper and lower eyelids. METHODS: This was a retrospective analysis of 140 eyes of 87 patients (mean age 52.29±16.45y; 22 males, 65 females) with upper eyelid ptosis. Totally 88.6% had aponeurotic and 11.4% had congenital ptosis. For the evaluation of the responses of the upper and lower eyelids to topical 2.5% phenylephrine, the scleral show height, the marginal reflex distance (MRD) between the inferior margin of the upper eyelid and pupillary light reflex (MRD1), and between the central portion of the lower eyelid and pupillary light reflex (MRD2) were measured at the 2nd, 5th, and 15th minutes. The changes of MRD1 and MRD2 with time (ΔMRD1 and ΔMRD2) were evaluated. RESULTS: The mean MRD1, MRD2, and scleral show heights increased within 5min after testing, remaining largely stable between the 5th-15th minutes. The percentage of eyes with a greater response in MRD1 increased with increased severity of ptosis (P<0.05). Eyes with aponeurotic ptosis were more responsive to phenylephrine testing than congenital ptosis. The mild ptosis group had lower scleral show measurements and higher ΔMRD2 values. The ΔMRD1 and ΔMRD2 values were poorly correlated in all measurement times. CONCLUSION: Performing the phenylephrine test 5min after instilling the reagent is adequate to assess the maximum response of the upper and lower eyelids. The upper and lower eyelid responses in phenylephrine testing are poorly correlated. However, the ΔMRD2 is related with baseline scleral show degree that may be a postoperative predictive factor. Further studies are necessary to determine the relationship between the responses of the lower eyelids to phenylephrine testing.

Efficacy of Intense Pulsed Light Treatment for Moderate to Severe Acute Blepharitis or Blepharoconjunctivitis: A Retrospective Case Series

Objectives: We aimed to evaluate the efficacy of periocular intense pulsed light (IPL) therapy in the treatment of moderate to severe acute blepharitis or blepharoconjunctivitis. Materials and Methods: This was a retrospective study performed in one institution. Eleven patients who received bilateral periocular IPL therapy using an IPL device (E>Eye, ESwin, Paris, France) were retrospectively evaluated. The following findings obtained at baseline and 10 weeks after the treatment were recorded: slit-lamp examinations; symptom scores of the Compression of the Eyelid (COTE) grading system and Ocular Surface Disease Index (OSDI); ocular surface staining with Oxford grading scale (OXFORD) scores; lipid layer thickness (LLT); and non-invasive tear meniscus test (TMH), non-invasive break up time measurement (NIBUT), and meibography performed by using I.C.P. Ocular Surface Analyzer (SBM System, Turin, Italy). Results: Significant improvements in OSDI symptom scores (p<0.0001), LLT (p<0.0001), and meibography (p<0.0001) were obtained at 10 weeks after bilateral periocular IPL therapy. COTE and ocular surface staining scores decreased by 59.72% and 57.14% respectively, while NIBUT and TMH increased by 47.34% and 22.16%, respectively. In parallel to the improvement in OSDI, LLT, and meibography, findings of acute blepharitis or blepharoconjunctivitis improved in slit-lamp examination. There were no adverse effects. Conclusion: Serial IPL therapy improves the clinical signs and symptoms of moderate to severe acute blepharitis or blepharoconjunctivitis, meibomian gland morphology, and secretion quality.

Ciliary body malignant melanoma: A dilemma on staging / Melanoma maligno do corpo ciliar: um dilema no faseamento

Abstract Choroidal melanomas are the most common primary intraocular malignant tumor in adults. They tend to be more malignant; because of their location hidden behind the iris they can not be detected until they become larger. Therapeutic strategy is related by size, extension, number and location of tumor and growth patterns. High frequency ultrasound biomicroscopy (UBM) gives high resolution, cross-sectional images of the anterior segment lesions. Postequatorial lesions and intracranial extension of the melanomas are scanned by magnetic resonance imaging (MRI). We report a case of bilobed tumor with confusing appereance in preoperative imaging studies and macroscopy following enucleation. MRI is the perfect imaging method to reveal extension and size of the tumor in the posterior chamber. Combined use of UBM and MRI provides appropriate staging of ocular melanomas.

Resumo Melanomas coroidais são os tumores malignos intra-oculares primários mais comuns em adultos. Eles tendem a ser mais malignos; devido à sua localização ser escondida por detrás da íris eles não podem ser detectados até se tornarem maiores. A estratégia terapêutica está relacionada com tamanho, extensão, número e localização dos padrões tumorais e de crescimento. O biomicroscopio ultra-sónico de alta frequência (BMU) fornece imagens transversais de alta resolução das lesões do segmento anterior. Lesões pós-equatoriais e de extensão intracraniana dos melanomas são digitalizadas em ressonância magnética (RM). Relatamos um caso de tumor com dois lóbulos, com aparência confusa em exames de imagem pré-operatórios e macroscopia após enucleação. A RM é o método de imagem perfeito para revelar a extensão e o tamanho do tumor na câmara posterior. O uso combinado de BMU e MRI fornece o faseamento apropriado dos melanomas oculares.

A case of bilateral fourth nerve palsy associated with pseudotumor cerebri syndrome / Caso de paralisia bilateral de quarto nervo associada com síndrome do pseudotumor cerebral

ABSTRACT Pseudotumor cerebri syndrome is puzzling because it results in elevated intracranial pressure with no identifiable underlying cause. Ocular motor nerve palsies, other than a unilateral or bilateral sixth cranial nerve palsy, are rarely seen in patients with this condition. We report here on a 25-year-old female patient with bilateral fourth cranial nerve palsy caused by pseudotumor cerebri syndrome, whose ocular and systemic signs and symptoms of nerve palsy were completely resolved after medical treatment. We infer that fourth nerve palsy could be associated with pseudotumor cerebri syndrome; therefore, clinicians should consider rare ocular motor nerve palsies, even bilaterally, in patients with pseudotumor cerebri syndrome.

RESUMO A sindrome do pseudotumor cerebral é uma síndrome enigmática caracterizada por aumento da pressão intracraniana sem causa definida. Na síndrome do pseudotumor cerebral, as paralisias de nervo oculomotor além da paralisia unilateral ou bilateral do sexto nervo craniano são raramente vistas. Nós reportamos o caso de uma paciente feminina de 25 anos com paralisia bilateral de quarto nervo craniano como resultado da síndrome do pseudotumor cerebral. Após tratamento médico para síndrome do pseudotumor cerebral, os sinais e sintomas oculares e sistêmicos da paralisia nervosa foram resolvidos. Em conclusão, a paralisia de quarto nervo craniano pode estar associada com síndrome de pseudotumor cerebral, portanto médicos devem considerar paralisias raras de nervo oculomotor, mesmo bilateralmente, em pacientes com síndrome do pseudotumor cerebral.

A case of bilateral fourth nerve palsy associated with pseudotumor cerebri syndrome.

Pseudotumor cerebri syndrome is puzzling because it results in elevated intracranial pressure with no identifiable underlying cause. Ocular motor nerve palsies, other than a unilateral or bilateral sixth cranial nerve palsy, are rarely seen in patients with this condition. We report here on a 25-year-old female patient with bilateral fourth cranial nerve palsy caused by pseudotumor cerebri syndrome, whose ocular and systemic signs and symptoms of nerve palsy were completely resolved after medical treatment. We infer that fourth nerve palsy could be associated with pseudotumor cerebri syndrome; therefore, clinicians should consider rare ocular motor nerve palsies, even bilaterally, in patients with pseudotumor cerebri syndrome.

Sectoral Ciliary Body Agenesis Complicated with Cataract Formation Diagnosed by Ultrasound Biomicroscopy

We aimed to present a novel case of sectoral ciliary body agenesis and complicated cataract as an embryogenic defect of eye development diagnosed by ultrasound biomicroscopy. A 20-year-old male patient presented with a complaint of visual impairment in his left eye since childhood. Slit-lamp examination of the left eye revealed pigment precipitation and focal lens opacities extending from the temporal quadrant through the posterior lens capsule, blocking the central optical axis. On ultrasound biomicroscopy examination, there was a hyperechoic reflection belonging to the rudimentary ciliary body structures between 2-5 o'clock in the temporal quadrant. The zonules could not be visualized in the same location. At all other quadrants of the anterior chamber angle, the ciliary body and zonules were normal. This is a very rare case of sectoral ciliary body agenesis complicated by cataract. Ultrasound biomicroscopy may be useful for detecting rare congenital anomalies of the anterior segment, anterior chamber angle, and ciliary body.

Retinal Nerve Fiber Layer Thickness Measurement by Spectral-Domain Optical Coherence Tomography in Patients with Major Depressive Disorder.

INTRODUCTION: In recent years, an increasing number of studies have researched retinal nerve fiber layer (RNFL) changes in neurodegenerative disorders. In this study, our aim was to determine structural RNFL changes in patients with major depressive disorder. METHODS: A total of 30 patients with major depressive disorder and 30 age- and sex-matched controls were recruited. Using optical coherence tomography (OCT), the peripapillary RNFL thickness in major depressive disorder patients and control subjects was measured and compared at each location. RESULTS: Patients with major depressive disorder did not show a statistically significant reduction in overall peripapillary RNFL thickness. CONCLUSION: Our study showed that RNFL thickness is not reduced in major depressive disorder patients and that OCT is not a useful tool for diagnosing and monitoring the progression of major depressive disorder. This study suggests that the pathophysiology of unipolar depression is different than in neurodegenerative disorders, pervasive developmental disorders, schizophrenia, and bipolar disorder.

Spontaneous Haptic Flexion and Misalignment of a New Microincisional Aspheric Intraocular Lens in the Early Postoperative Period in Two Patients.

PURPOSE: To present two cases of spontaneous haptic flexion and misalignment of a new single-piece microincisional aspheric intraocular lens (IOL) following uneventful microincisional phacoemulsification surgery and IOL implantation. METHODS: Case reports. RESULTS: Both patients had decreased visual acuity and significant myopia and astigmatism in their operated eye at the postoperative first month visit. On dilated biomicroscopic examination, flexion of one haptic was observed in both cases. In one of the cases, the misaligned IOL was explanted and a different posterior chamber IOL was implanted. In the other case, the misaligned IOL was repositioned. CONCLUSIONS: Cataract surgeons should be aware of the risk for haptic flexion and misalignment of this new IOL, causing decreased visual acuity and significant refractive error in the early postoperative period. Satisfactory results can be achieved by either IOL exchange or repositioning the IOL.

Phthriasis palpebrarum can resemble tick larva infestation in an eyelid.

The similarities of the larval and nymph stages of the tick and louse (Pthirus pubis) may lead to misdiagnosis in rare cases of infestation of the eyelashes. The most frequent manifestations of tick in the eye are conjunctivitis, uveitis, keratitis, and vasculitis. Tick inoculation of the skin can locally lead to formation of granuloma and abscess. More concerning is the potential systemic sequelae that can result from transmission of zoonoses such as Lyme disease. P. pubis can cause pruritic eyelid margins or unusual blepharoconjunctivitis. We present a case of phthiriasis palpebrarum in a 4-year-old boy.

Screening for Patients with Mild Alzheimer Disease Using Frequency Doubling Technology Perimetry.

We compared the visual field performances of patients with mild Alzheimer disease (AD) with normal subjects and detected visual field impairment attributable to the magnocellular pathway using frequency doubling technology-Matrix (FDT-Matrix). We recruited 43 patients with mild AD (mean age: 68.0 ± 7.2 years) and 33 controls who are visually and cognitively normal (mean age: 64.1 ± 6.4 years). All participants had at least two reliable FDT-Matrix 30-2 tests. Reliability indices, global indices (mean deviation and pattern standard deviation), and glaucoma hemifield test results were measured with FDT-Matrix. The mean test duration was significantly longer in patient group compared with controls (p = 0.002). Among the reliability indices, false negatives were higher in patient group than controls (p = 0.003). There were statistically significant differences in mean deviation and pattern standard deviation values (p < 0.0001 and p < 0.0001, respectively) and glaucoma hemifield test results (p < 0.001) between the patient and the control group. Our results imply that the pathogenesis of cognitive deterioration may not only be confined to the cortical area but also to the magnocellular pathway. We underline that FDT testing can be useful for the identification of early impairment and the follow-up of patients with AD.

Quantitative ultrasound biomicroscopy study of biometry of the lens and anterior chamber.

PURPOSE: To quantify the changes induced by cataract extraction (CE) in angle recess area (ARA), angle opening distance at 250 and 500 µm (AOD250, AOD500), and aqueous depth (AQD) in comparison with axial lens thickness (LT) and to reveal effects of LT and lens position (LP) on angle parameters and AQD using ultrasound biomicroscopy (UBM). METHODS: Thirty-five eyes of 35 patients (22 male; mean age 69.5 ± 7.8 years) with senile or presenile cataract who consecutively underwent cataract surgery were enrolled in this institutional study. We performed UBM examinations before and 1 month after surgery under a standard protocol. Axial images of the anterior segment and radial sections of the angle at 4 quadrants were obtained. Aqueous depth and LT were measured in immersion A-scan mode and we used UBM Pro 2000® software for the ARA, AOD250, and AOD500. RESULTS: Aqueous depth and angle parameters at 4 quadrants were increased significantly after CE (p<0.05). The mean LT was 4.53 ± 0.37 mm and LP was 4.96 ± 0.25 mm preoperatively. There were statistically significant correlations between LT, LP, and AQD and angle parameters preoperatively. We also determined statistically significant correlations between LT, LP, and postoperative changes in AQD and angle parameters In comparison with LT, the mean increases in AQD, ARA, AOD250, and AOD500 were 0.21, 0.014, 0.012, and 0.017 times, respectively. CONCLUSIONS: The results suggest that LT is as a significant factor as LPon the final dimensions of the anterior chamber and angle.

Combined laser treatment in a patient with pigment dispersion secondary to a large iris pigment epithelial cyst.

We reported a case of bilateral extensive iris pigment epithelial cysts masquerading as pigment dispersion. A-30-year-old male patient presented with a dull pain in both eyes and a decreased visual acuity OD. He underwent a complete ophthalmic examination. OD was injected and the cells were graded as +3 and pigmented a +2, in the OS. Intraocular pressures (IOP) were measured as 42 (OD) and 22 (OS) mmHg. Gonioscopy revealed a confluent accumulation of dense pigment in both eyes. Visual fields, peripapillary retinal nerve fiber layer thickness (Spectral OCT/SLO OTI-OPKO Health. Inc, Miami, FL) and optic nerve head tomography (HRT-II Heidelberg Engineering, Heidelberg, Germany) results were within normal limits. On ultrasound biomicroscopy (UBM), bilateral extensive cysts were identified in the midzonal portion of the iris and in the ciliary body. An, antiglaucomatous treatment was started. Then, we decided to perform both Nd:YAG laser iridocystotomyc and selective laser trabeculoplasty. Fourteen months after the combined therapy, the cysts had not recurred, and still apposed and the IOPs were under control without medication.

Selective laser trabeculoplasty induced changes in the thickness of ciliary body and iris evaluated by ultrasound biomicroscopy.

BACKGROUND: Selective laser trabeculoplasty (SLT) is widely used for the treatment of glaucoma. The main target tissue of this treatment modality is trabecular meshwork. We aimed to detect the SLT-induced changes in the thickness of ciliary body (CBT) and iris (IT), quantitatively. METHODS: Thirty-one patients treated by SLT were examined by ultrasound biomicroscopy (UBM) at different locations of ciliary body and iris at four quadrants, before and after (3rd, 7th, and 30th days) SLT. The IT was measured at various locations; 500 µm anterior to the scleral spur (IT(1)), 2 mm from the iris root (IT(2)) and near the pupillary edge where the iris thickness was maximum (IT(3)) at four quadrants. The CBT at positions 1 and 2 mm posterior to the scleral spur were measured (CBT(1-2)). Additionally, intraocular pressure (IOP) levels were measured in all visits and post-laser 1 h. RESULTS: There were statistically significant higher CBT values at 3rd and 7th-day measurements in the study compared to pre-treatment levels (p < 0.0001, p < 0.0001, respectively). CBT(2) values at day 30 were similar compared to pre-treatment values (overall p = 0.140), but CBT(1) values at day 30 were not exactly similar compared to pre-treatment values in superior and nasal quadrants (overall p = 0.027). IT values obtained in the 3rd and 7th days were significantly higher in all quadrants and regions when compared to the pre-treatment values (p < 0.0001, p < 0.0001, respectively). There were no statistically significant differences in any of the IT values at the 30th day in comparison to the pre-treatment values (p = 0.45). CONCLUSIONS: The results suggest that SLT induces prominent increases in CBT and IT returning to baseline thickness in a month, which may be caused by inflammation, vascular engorgement, or mechanical muscular contraction.

Intraocular pressure and ocular pulse amplitude variations during the Valsalva maneuver.

BACKGROUND: To evaluate the effect of the Valsalva maneuver (VM) on short-term variations of intraocular pressure (IOP) and ocular pulse amplitude (OPA) values in healthy, young, male subjects. METHODS: IOP and OPA values were measured before and during VM by Pascal dynamic contour tonometer (DCT) in 55 eyes of 55 healthy male volunteers aged 20 through 27 years. RESULTS: Mean IOP before VM was 17.2 +/- 2.9 mmHg and during the VM was 19.8 +/- 4 mmHg. The increase in mean IOP during the VM was found to be statistically significant (p = 0.001). The IOP increased in 46 (83.6%) of 55 eyes. However, in nine eyes (16.4%), IOP decreased during the VM. Mean OPA value before VM was 3.6 +/- 1.4 mmHg and during the VM was 3.6 +/- 1.3 mmHg. The change in mean OPA value was found to be statistically insignificant (p = 0.9). CONCLUSIONS: The IOP significantly increases during VM, whereas OPA remains stable. Strong autoregulatory mechanisms may provide consistent ocular perfusion in healthy subjects during VM.

Intracameral Perfluoropropane (C(3)F(8)) Gas in the Repair of Extensive Descemet's Membrane Detachment During Phacoemulsification Surgery.

Descemet's membrane detachment (DMD) is one of the rare complications seen during or after cataract surgery. It can cause permanent corneal decompensation if untreated or not reattached spontaneously. A patient with an extensive DMD (involving approximately upper two-thirds of the cornea) during uncomplicated phacoemulsification surgery is reported. After the aspiration of cortical remnants, Descemet's membrane was detached progressively from the clear corneal incision. Descemet's membrane was reattached at the end of the procedure using an air bubble injection. However, DMD was observed again the day after surgery. It was successfully treated with intracameral injection of 0.2 mL volume of 14% perfluoropropane (C(3)F(8)) gas with resultant immediate resolution of his corneal edema. It is believed that early surgical intervention (if possible intraoperatively) with intracameral injection of 14% isoexpansile mixture of C(3)F(8) is a safe and efficient treatment modality for DMD. Appropriate and prompt management may prevent the complications and visual loss.

Capsulorhexis in white cataract using a green-light endoillumination probe.

The authors describe a technique for performing a safe and controlled continuous curvilinear capsulorhexis (CCC) in white cataracts using the contrast-enhancing effect of green light from an endoillumination probe. After attaching a green filter to the endoillumination unit of the vitrectomy set, a CCC was performed under the green light of the endoillumination probe, which was placed on the periphery of the cornea in a manner that followed the tearing edge of the capsulorhexis. This technique may be an alternative to capsular dyes in performing a safe and controlled CCC in white cataracts.

Laser suture lysis or releasable sutures after trabeculectomy.

PURPOSE: To compare the efficacy and complication rates of laser suture lysis (LSL) or releasable sutures techniques after trabeculectomy. MATERIALS AND METHODS: Forty-eight eyes of 43 consecutive patients with uncomplicated glaucoma who were recruited for primary trabeculectomy with mitomycin-C were divided into 2 groups. Group 1 and group 2 comprised 27 and 21 eyes that were randomly assigned to a standard surgery and releasable suture groups, respectively. A target intraocular pressure (IOP) had been determined on the basis of the severity of the glaucoma and was called a complete success, qualified success, or failure. RESULTS: In group 1, the mean change in IOP after LSL was 7.31+/-1.98 mm Hg, 6.1+/-1.1 mm Hg, and 3.9+/-1.5 mm Hg when sutures were lysed on the first, second, and third months. In group 2, the mean change in IOP after releasable suture removed was 8.20+/-2.74 mm Hg, 5.12+/-1.65 mm Hg, and 4.4+/-1.0 mm Hg when sutures were released at the first, second, and third months. At the end of 6 months, the success (complete and qualified success) rates were 92% and 90% for LSL and releasable suture groups, respectively. There was no statistically significant differences in success (P>0.05) and complication (P>0.05) rates between groups. CONCLUSIONS: We observed an effective IOP reduction in eyes that had suture release both in the early and late postoperative periods after LSL and suture release. We believe that both the laserable and releasable suture techniques can be preferred to permanent sutures for closing scleral flaps in primary trabeculectomy with mitomycin-C in uncomplicated glaucoma.