Rarely seen complication of motor vehicle accidents: Bilateral globe avulsion.

Avulsion of the globe is a rare condition that can occur with severe maxillofacial trauma. A few bilateral cases have been reported. The objective of this study was to present a case of this challenging condition in a 15-year-old male patient who was admitted to the emergency service after a motor vehicle accident.

Keratinocyte growth factor-2 and autologous serum potentiate the regenerative effect of mesenchymal stem cells in cornea damage in rats.

AIM: To investigate the healing process after severe corneal epithelial damage in rats treated with mesenchymal stem cells (MSCs) cultured with or without keratinocyte growth factor (KGF-2) and autologous serum (AS) on amniotic membrane (AM). Many patients are blind and devastated by severe ocular surface diseases due to limbal stem cell deficiency. Bone marrow-derived MSCs are potential sources for cell-based tissue engineering to repair or replace the corneal tissue, having the potential to differentiate to epithelial cells. METHODS: The study included 5 groups each including 10 female "Sprague Dawley" rats in addition to 20 male rats used as bone marrow donors. Group I rats received AM+MSCs, Group II rats AM+MSCs cultured with KGF-2, Group III rats AM+MSCs cultured with KGF-2+AS, Group IV rats only AM and Group V rats, none. AS was derived from blood drawn from male rats and bone marrow was obtained from the femur and tibia bones of the same animals. Therapeutic effect was evaluated with clinical, histopathological and immunohistochemical assessment. MSC engraftment was demonstrated via detection of donor genotype (Y+) in the recipient tissue (X) with polymerase chain reaction. RESULTS: Corneal healing was significantly better in Groups I-III rats treated with MSC transplantation compared to Group IV and Group V rats with supportive treatment only. The best results were obtained in Group III rats with 90% transparency, 70% lack of neovascularization, and 100% epithelium damage limited to less than 1/4 of cornea. CONCLUSION: We suggest that culture of MSCs with KGF-2 and AS on AM is effective in corneal repair in case of irreversible damage to limbal stem cells.

Corneal sensitivity may decrease in adenoviral epidemic keratoconjunctivitis--a confocal microscopic study.

OBJECTIVES: To report a new clinical finding, decreased corneal sensitivity, in epidemic keratoconjunctivitis and to evaluate this sign with corneal confocal microscopy. METHODS: Forty-one eyes of 28 patients who developed corneal infiltrates after an outbreak of epidemic keratoconjunctivitis were included in the study. Clinical and confocal microscopic findings are described. RESULTS: In this outbreak of 72 patients, 28 (38.9%) developed corneal infiltrates. The corneal involvement was unilateral in 15 patients (53.6%) and bilateral in 13 patients (46.4%). Corneal sensitivities were measured in 35 eyes of 24 patients and found to be decreased in 26 eyes (74.3%). Decreased corneal sensation was a feature of mainly stage 2 (7 eyes) and stage 3 (11 eyes) keratitis. Corneal sensitivity returned to normal levels in all eyes in a mean of 8.5 days. The main confocal microscopic features during the period of decreased corneal sensitivity were morphologic changes in the infected epithelial cells, extracellular bright microdeposits, infiltration with round inflammatory cells and dendritic cells, increased brightness in the extracellular matrix and the stroma surrounding the corneal nerves, and increased keratocyte activity. The intensity of the inflammatory reaction in the extracellular space and corneal stroma and the reflectivity of the corneal nerves had subsided by the second confocal measurements. CONCLUSION: There may be a transient decrease in the corneal sensitivity during the course of epidemic keratoconjunctivitis. Confocal microscopy can help to evaluate the changes in the cornea during this period. Future studies are needed to understand the nature of this clinical finding.

Retinopathy of prematurity in extremely low birth weight infants in Turkey.

PURPOSE: This study was designed to determine the incidence rate of retinopathy of prematurity (ROP) in extremely low birth weight (ELBW) infants in the middle Black Sea region of Turkey. METHODS: The charts of 1,719 preterm infants were reviewed between January 2003 and September 2011. Of them, 225 (13.1%) infants with birth weights of less than 1,000 g were enrolled in the study. ROP was classified according to the international classification of retinopathy. RESULTS: Of the 225 ELBW infants, 47.6% had advanced ROP, 23.1% had mild ROP, and 29.3% did not have ROP; 30.2% infants required treatment. ROP was detected in 75.6% of multiple births versus 69.6% of singleton births; there were no significant differences between the two groups (P = .388). CONCLUSION: Extremely premature infants with low gestational ages had high incidence rates of advanced ROP. Most ELBW infants require ROP treatment. In addition, increased survival of ELBW infants owing to advancements in neonatal care warrants the specialization of ophthalmologists in regard to improved diagnosis and treatment of ROP.

Contrast sensitivity of thyroid associated ophthalmopathy patients without obvious optic neuropathy.

PURPOSE: To compare the contrast sensitivity levels of thyroid associated ophthalmopathy (TAO) patients without obvious optic neuropathy with those of healthy people. METHODS: Forty eyes of 20 TAO patients without dysthyroid optic neuropathy and 40 eyes of 20 healthy subjects were evaluated in this prospective case-controlled study. The contrast sensitivity functions (CSFs) of all subjects were measured by the functional acuity contrast test (FACT) in five frequencies which were 1,5 cpd (A), 3 cpd (B), 6 cpd (C), 12 cpd (D), and 18 cpd (E). Results were compared for both groups, and a correlation of CSF with Hertel and clinical activity scores was assessed. RESULTS: There was no statistically significant difference between TAO patients and control groups for age and sex. TAO patients had lower levels than the control group in all the frequencies of CSFs (P < 0.05) and the difference in contrast sensitivity functions between the groups seems to be more significant in higher frequencies (B, C, D, and E) (P < 0.001). CONCLUSIONS: TAO patients without DON can have contrast sensitivity loss and this would probably imply subtle optic nerve dysfunction in early disease phase.

Screening for retinopathy of prematurity (ROP) in the middle Black Sea region of Turkey.

This study was designed to determine the frequency of retinopathy of prematurity (ROP) and the effectiveness of the screening protocol in preterm infants for our country. With these objectives, the charts of 1000 preterm infants were reviewed in Ondokuz Mayis University, Department of Ophthalmology. ROP frequency, the effect of gestational age (GA) and birth weight (BW) and the effectiveness of the screening protocol were evaluated. In this study, ROP was observed in 30.8% of infants and not observed in 69.2% of infants. Threshold ROP was detected in 7.0%. The frequency of threshold ROP was 43.5%, 20.0%, 12.6%, and 8.8% in the infants with GA of < or = 26, 26-28, 29-30, and 31-32 weeks, respectively. Threshold ROP was not observed in babies born after 34 weeks. Treatment was required for 11% of the infants. ROP treatment requirement (11%) was limited to babies with GA of < 34 weeks of gestation. Incidence of ROP was inversely proportional with GA and BW. Treatment was not required when GA was > 34 weeks. A new ROP screening protocol is proposed for Turkey, which is: screening of preterm babies with GA of < 34 weeks and BW of < 1800 g.

Comparison of central corneal thickness measurements by Galilei Dual-Scheimpflug analyzer® and ultrasound pachymeter in myopic eyes.

BACKGROUND AND OBJECTIVE: To compare the central corneal thickness (CCT) measurements by Galilei Dual-Scheimpflug analyzer (GSA) (Ziemer Group, Port, Switzerland) and ultrasound pachymeter (UP) in myopic eyes. PATIENTS AND METHODS: In this prospective study, CCT of 161 myopic eyes of 81 refractive surgery candidates (35 female, 46 male; mean age: 23.18 ± 4.08 years) were measured by GSA and UP consecutively. The data were analyzed statistically by paired t test, Bland-Altman plot, and Pearson correlation test to assess the agreement of the measurements. RESULTS: The mean CCTs obtained by GSA and UP were 559.85 ± 30.87 and 560.41 ± 34.45 µm, respectively. No significant difference was found between the measurements (P = .684) and regression analysis showed a high correlation between the measurements obtained with both devices (r = 0.86; P < .001). A strong agreement between the two methods was also found by Bland-Altman plot. CONCLUSION: In myopic eyes, the CCT measurements of GSA and UP are similar and highly correlated. Because of high agreement between these devices, the GSA is a non-contact method that may be an alternative to UP for measurement of CCT.

Widespread vitreoretinal traction simulating retinal vasculitis in a patient with uveitis.

PURPOSE: To describe a case of uveitis with widespread vitreoretinal traction simulating retinal vasculitis angiographically. METHODS: Interventional case report. RESULTS: A 62-year-old woman was examined for low vision in her left eye that persisted for ∼1 year. She had been treated for polymyalgia rheumatica for 1 year. Visual acuity was 20/20 in the right eye and 20/100 in the left eye. There were a few aged vitreous cells in both eyes. On fundus examination, there was mild epiretinal membrane in the left eye. Fluorescein angiography revealed diffuse fluorescein leakage in the late phase of angiography in the macular peripapillary and superior retinal hemisphere in the left eye, which appeared similar to retinal vasculitis. With optical coherence tomography, there was vitreomacular traction on the macular, peripapillary, and major branches of vessels in the left eye. Fundus examination was normal in the right eye. Pars plana vitrectomy was performed in the left eye uneventfully. Visual acuity was 40/100 at the postoperative 1-year follow-up. CONCLUSION: Vitreoretinal traction can be widespread and can cause diffuse fluorescein leakage resembling vasculitis or other types of uveitis.

Is symptomatic atherosclerotic cerebrovascular disease a risk factor for normal-tension glaucoma?

OBJECTIVE: To compare the incidence of glaucomatous optic disk appearance between patients with symptomatic atherosclerotic stroke and healthy individuals with normal intraocular pressures (IOP). SUBJECTS AND METHODS: 46 patients with ischemic stroke with evident lacunar infarction or large vessel atherosclerosis, and 93 age- and sex-matched healthy individuals, all with normal IOP, were included. Patients and controls were examined for the presence of high cup-to-disk ratios (> 0.5). RESULTS: Seven patients (15.22%) in the ischemic cerebrovascular disease (CVD) group and 3 controls (3.23%) had glaucomatous optic disk appearance. All subjects with glaucomatous optic disk appearance in the control group and 3 patients in the study group had visual field defects in concordance with normal-tension glaucoma (NTG). The incidence of glaucomatous optic disk appearance was significantly higher in the group with symptomatic atherosclerotic CVD. CONCLUSION: Atherosclerotic CVD is a risk factor for having glaucomatous optic disk appearance. Symptomatic atherosclerosis involving the brain vasculature may also affect the eye and lead to NTG. Patients with ischemic strokes due to large artery atherosclerosis or small artery occlusion must be examined and followed for NTG.

Fibrin glue-assisted sutureless limbal stem cell transplantation surgery for the treatment of severe ocular chemical injury.

PURPOSE: To report the use of fibrin tissue glue in securing the keratolimbal allograft (KLAL) and living-related conjunctival limbal allograft to the ocular surface in patients with severe ocular chemical injury. DESIGN: A retrospective review of interventional case series. METHODS: Conjunctival limbal allografts were harvested from the first-degree living-related relatives under topical anesthesia and fixated to the superior and inferior limbal quadrants in the recipient eye. The KLALs were fixated mainly to the nasal and temporal limbus with the help of fibrin tissue glue after being cut into 2 crescents and manually dissected to near one-third thicknesses in a lamellar fashion. RESULTS: Five eyes of 4 patients were included in the study. The sources of the chemical injuries were: CaOH2 (3 eyes), NaOH (1 eye), and mitomycin C (1 eye). The limbal stem cell deficiency was 360 degrees in 4 eyes and 300 degrees in 1 eye. Corneas were covered with conjunctiva or fibrovascular tissue adjacent to the areas with limbal stem cell deficiency. The fibrin tissue glue was effective in securing both the keratolimbal and the conjunctivolimbal grafts at the surgery. Postoperatively, the corneal epithelium healed within 1 week in all of the eyes. Neither graft dislocation nor graft rejection occurred after a mean of 18.2 months of follow-up. CONCLUSIONS: The use of fibrin glue to fixate the KLAL and the living-related conjunctival limbal allograft in patients with severe chemical trauma is practical and effective. This technique may also be beneficial in terms of decreasing the risk of rejection in this patient group.

Unsuccessful probing and nasolacrimal canal agenesis in congenital epiphora.

PURPOSE: To present 3 cases with nasolacrimal canal agenesis who underwent repetitive unsuccessful probing for treatment of congenital epiphora. MATERIALS AND METHODS: Three patients who had undergone topical antibiotic therapy, lacrimal sac massage and repetitive probing in Ondokuz Mayis University, Medical School, Ophthalmology Department between June 2006 and March 2007 were included in the study. Thin-section computerized tomography (CT) scan was performed in all cases since nasolacrimal duct could not be detected during repetitive probing. RESULTS: Among the patients 2 were males and 1 was a female. They were within the age range 5-7. Since it was not possible to cannulate the nasolacrimal canal during probing, CT scans were performed and nasolacrimal duct agenesis was detected in 3 patients. One of the patients had additional upper punctum agenesis, who also had no right frontal sinus and left sphenoid sinus. All tomographic images revealed a rudimentary upper nasolacrimal canal ending blindly and a lower canal leading into the maxillary sinus, which was very typical for the duct agenesis. In all patients, lacrimal fossas were shallow and irregular. CONCLUSION: Nasolacrimal duct agenesis should be considered in patients with congenital nasolacrimal duct obstruction and unsuccessful repetitive probing, especially if it is difficult to cannulate nasolacrimal canal during probing. Although assessing whether dacryocystorhinostomy is in favor of the patient, the lacrimal sac and fossa should be examined with imaging in details.

Morphological parameters of the periorbital arterial arcades and potential clinical significance based on anatomical identification.

The aim of the study was to investigate the locations, diameters, and connections of the periorbital arterial vessels. The peripheral and marginal arcades of the superior and inferior eyelids were revealed by bilateral meticulous anatomic dissections in 12 adult male and 5 female preserved cadavers. Silicone rubber injection was used to fill the regional arteries. The mean external diameter of the lacrimal (0.4 mm), supraorbital (1.0 mm), supratrochlear (0.9 mm), superior medial palpebral (0.9 mm), inferior medial palpebral (1.0 mm), dorsal nasal (0.8 mm), and infraorbital (2.0 mm) arteries were measured. Contribution of superficial temporal artery to palpebral arcades via frontal, zygomatico-orbital, and transverse facial branches was demonstrated. The purpose of this study was to demonstrate the periorbital arterial supply with contributing anastomosis from facial vasculature and impact on clinical practice.

Regression of severe corneal stromal neovascularization with topical cyclosporine 0.05% after penetrating keratoplasty for fungal corneal ulcer.

PURPOSE: To report regression of corneal stromal neovascularizations with the use of topical cyclosporine 0.05% in a corneal transplant patient performed for fungal corneal ulcer. DESIGN: Case report. METHODS: A 14-year-old boy treated for fungal corneal ulceration developed 360 degrees corneal stromal neovascularization peroperatively. Topical cyclosporine 0.05% was used to decrease the risk of rejection. RESULTS: The neovascularizations regressed totally within 2 months and no signs of graft rejection were present at 6 months follow up. CONCLUSION: Topical cyclosporine 0.05% may result in regression of stromal corneal neovascularizations and help to reduce the risk of graft rejection in selected cases.

Jellyfish sting injury to the cornea.

A 25-year-old woman presented to the emergency room 2 hours after a jellyfish sting to the left eye. Centrally located linear epithelial defects were observed on slit-lamp evaluation. The epithelial defects improved but did not heal totally after meticulous patching with antibiotic ointment and cycloplegic drops. Small, subepithelial negative staining areas within the epithelial defects were observed on day 3. Confocal microscopy was performed and revealed thread-like hyperreflective structures, mainly located at the basal epithelial layer. Following debridement of the traumatized areas, the corneal epithelium healed completely in 24 hours, resulting in increased visual acuity and decreased foreign body sensation. Jellyfish stings to the eye may involve the intrusion of the nematocysts, thread-like venomous structures, into the cornea. Debridement of these foreign bodies can be helpful in the treatment of resistant cases.

Use of 0.5% apraclonidine solution in evaluation of blepharoptosis.

PURPOSE: To evaluate the effect of instillation of a specific alpha2-adrenergic agonist, topical 0.5% apraclonidine solution, on upper eyelid position in patients with blepharoptosis. METHODS: This study included 45 eyelids of 35 adult patients with blepharoptosis. Of these, 37 eyelids had acquired ptosis and 8 had congenital ptosis. Palpebral fissure height and margin-reflex distance in the upper eyelid were measured before and after instillation of 0.5% apraclonidine, 2.5% phenylephrine, and both drugs. RESULTS: After instillation of 2.5% phenylephrine, 0.5% apraclonidine, and both drugs, the mean increases in palpebral fissure height were 2.12 mm+/-1.4 mm, 2.11 mm+/-1.4 mm, and 2.26 mm+/-1.3 mm, respectively, and the mean increases in margin-reflex distance were 1.93 mm+/-1.2 mm, 1.89 mm+/-1.3 mm, and 2.03 mm+/-1.2 mm, respectively (p=0.86 and p=0.85). The apraclonidine solution did not alter the test results in 14 eyelids in which the phenylephrine test results were negative. CONCLUSIONS: Topical 0.5% apraclonidine solution can be as effective as topical 2.5% phenylephrine in elevating a ptotic upper eyelid, and may be used for preoperative evaluation of blepharoptosis. Combined use of both drugs may not provide any additional benefit.

Tear secretion and ferning patterns among premature and full-term newborns.

In this study, we aimed to assess the quality and quantity of tears among premature and term newborns. Tear ferning and Schirmer's tests were conducted over the first 10 days of life. Correlations between tear ferning patterns, Schirmer's scores, post-conceptional age, and birth weight were evaluated. Forty-six newborns (23 preterm, 23 term) were enrolled, with a mean post-conceptional age of 36.6 weeks and a mean weight of 2598.2 g. Mean total, basal and reflex Schirmer's test results were 13.5 mm, 6.7 mm and 6.8 mm, on the right and 14.0 mm, 7.1 mm and 6.9 mm on the left eye, respectively. Median ferning score was 2 (range 1-3) bilaterally. Schirmer scores were correlated with ferning capacity and post-conceptional age. Our study shows that newborns secrete moderate quantity, good quality tears. Ferning capacity, Schirmer scores and post-conceptional age are correlated.

Bilateral simultaneous primary orbital lymphoma presenting with unilateral enophthalmos.

A 73-year-old woman was examined for palpable orbital masses behind the right upper eyelid and left lower eyelid leading to entropion. Hertel exophthalmometry readings were 6.0 mm in the right eye and 11.0 mm in the left eye with a base of 102 mm. MRI revealed bilateral hypointense orbital soft-tissue masses. Pathologic evaluation of incisional biopsy specimens revealed malignant tissue composed of diffuse, mitotically active, atypical large lymphoid cells positive for CD-20 with immunohistochemical staining, confirming the diagnosis of malignant diffuse large B-cell lymphoma. Systemic survey was negative for extraorbital involvement. After R-CHOP chemotherapy (Rituximab 375 mg/m2 intravenously, Cyclophosphamide 750 mg/m2 intravenously, Doxorubicin 50 mg/m2 intravenously, Vincristine 1.4 mg/m2 intravenously, Prednisolone 100 mg orally), Hertel measurements were 9.0 mm in the right eye and 11.0 mm in the left eye. The mass lesions were totally regressed in follow-up MRI. Although rare, non-Hodgkin lymphoma may present bilaterally as primary orbital lesions and can unexpectedly cause enophthalmos instead of proptosis.

Orbital drainage of different sizes of colloids in rabbits: a dynamic scintigraphic study.

PURPOSE: To investigate the drainage patterns of radiolabeled colloids of different sizes injected into the orbital cavity in an animal model. METHODS: Twenty-one orbits of 11 rabbits were included in the study. In group 1, human serum macroaggregates with particle sizes of 10 to 100 microm, labeled with 10 mL of 1480 MBq (40 mCi) technetium pertechnetate Tc 99m (99mTc), were used. In group 2, human serum albumin colloidal particles with particle sizes of 50 to 80 nm, labeled with 5 mL of 740 MBq (20 mCi) 99mTc, were used. In group 3, colloidal tin with particle sizes of 300 to 600 nm, labeled with 9 mL of 1665 MBq (45 mCi) 99mTc, were used. The dynamic acquisition of liver for 10 minutes (120 frames for 5 seconds) in a 128 x 128 matrix was acquired immediately after intraorbital injection and at the end of the second hour. RESULTS: The liver in groups 2 and 3 and the lung in group 1 were visualized in 10 seconds or less in six, five, and four rabbits, respectively. The injected activity persisted in the orbits in varying percentages in all rabbits at the end of acquisition. CONCLUSIONS: Intraorbital injections have a great potential for systemic absorption and should not be considered as local pharmaceutical administration.

Bilateral horizontal Vogt's striae in keratoconus.

PURPOSE: To report a keratoconus case with bilateral horizontal Vogt's striae. METHOD: The clinical findings of the patient and the development of the direction of striae are discussed. RESULTS: Vogt's striae, defined as vertical stress lines, are rarely horizontal. One patient with unilateral horizontal stress lines on his left eye has been reported in the literature. Our patient has horizontal Vogt's striae in both eyes. CONCLUSION: Horizontal Vogt's striae may be seen in keratoconus as a rare slit-lamp biomicroscopic finding.