Diurnal Spikes of Intraocular Pressure in Uveitic Glaucoma: A 24-hour Intraocular Pressure Monitoring Study.

PURPOSE: The aim of this study was to document diurnal changes in intraocular pressure (IOP) in uveitic glaucoma (UG) and compare it with primary open angle glaucoma (POAG) patients. METHODS: Eight patients with UG and seven patients with POAG were included in this study. The patients were matched for age, gender, and glaucoma medications. None of the patients experienced angle closure, uveitis attack, and ocular surgery, and were not under steroid or immunomodulatory therapy within the last three months. The 24-hour IOP fluctuations were recorded with the help of a contact lens sensor (Sensimed Triggerfish ®, Switzerland). The diurnal IOP fluctuations were modeled with best-fit lines and statistical comparisons between the longitudinal responses of the two groups were determined with nonlinear regression. RESULTS: The comparison of mean 24-hour contact lens sensor (CLS) amplitudes revealed a significant difference between the fluctuation levels of UG and POAG groups (213 ± 160 millivolt equivalents (mVeq) vs. 162 ± 168 mVeq, respectively p = .003). The top level of the best-fit curves was significantly higher in the UG group (266 ± 143 mVeq) compared to the POAG group (159 ± 162 mVeq, p < .001). Both curves had their top levels between 5:00 PM and 8:00 AM. The longitudinal regression analysis revealed that the amplitudes of the 24-hour fluctuation waves were significantly different (p = .041). CONCLUSIONS: This study demonstrated for the first time that the diurnal variation in IOP was significantly higher in UG patients. This difference was also more distinct between 5:00 PM and 8:00 AM clock-hours. The uveitis and glaucoma specialists should consider this potential for higher IOP fluctuations, while tailoring the glaucoma treatment in uveitic patients.

The role of pars plana vitrectomy in the management of fungal endogenous endophthalmitis.

PURPOSE: To identify the causative microorganism of fungal endogenous endophthalmitis in our tertiary referral uveitis center and review the therapeutic role of pars plana vitrectomy in patients with fungal endogenous endophthalmitis. METHODS: Seven eyes of six cases were identified as fungal endogenous endophthalmitis through positive cultures of ocular fluids and clinical presentations. The final anatomical and functional results were evaluated. RESULTS: Four women (66.7%) and two men (33.3%) underwent vitrectomy. Control of infection was achieved early on in all cases. Candida (71.4%) and Aspergillus (28.6%) species were identified as causative fungi in patients with fungal endogenous endophthalmitis. Two patients were reoperated due to reinfection and retinal detachment, respectively. Visual acuity improved in six eyes (85.7%) and worsened in one eye (14.3%). At the final examination, the retina was flat in all cases. No eye developed phthisis bulbi. CONCLUSION: Candida species are the most common causative organisms of fungal endogenous endophthalmitis in this study. Pars plana vitrectomy in fungal endogenous endophthalmitis may enhance the treatment of infection by removing fungal elements in the vitreous and aid in diagnosis. Vitrectomy may also be an important tool in the management of vision-threatening post-infectious sequelae such as retinal detachment and reinfections.

Ocular Posterior Segment Involvement in Patients with Antiphospholipid Syndrome and Systemic Lupus Erythematosus.

Purpose: To describe posterior segment findings of antiphospholipid syndrome (APS) and compare them with systemic lupus erythematosus (SLE).Methods: A total of 11 patients with primary APS, 29 secondary APS patients, and 29 SLE patients without APS were included. All patients were referred from rheumatology clinic for detailed ophthalmologic examination. When patients had suspicious lesions, fundus fluorescein angiography was performed (n = 56).Results: The most common retinal examination finding was peripheral venous tortuosity (17.5%) in APS, which was not observed in SLE group. Common FFA findings were pigment epithelial window defects (10%) and vascular filling delays (7.5%) in APS, which were observed in 27.5% and 3.5% of patients with SLE consecutively.Conclusion: Venous tortuosity was significantly more in patients with APS. There was no significant difference for other ocular findings between the groups. Ocular complication rate was lower compared to earlier reports, probably due to better management of disease activity with current treatment protocols.

Ocular findings and blood flow in patients with Takayasu arteritis: a cross-sectional study.

BACKGROUND/AIMS: Takayasu arteritis (TAK) is a chronic granulomatous vasculitis that can lead to ischaemic ocular complications. We aimed to document ocular complications, ocular blood flow and the association of them with systemic clinical findings in TAK. MATERIAL AND METHODS: We included 65 patients with TAK (60 female, 5 male, mean age: 41.8±12.9 years) and 30 healthy subjects (30 female, mean age: 39.0±7.5 years) in this study. All of the patients had a detailed rheumatological and ophthalmological evaluation. Ocular blood flow in ophthalmic artery (OA) and central retinal artery (CRA) was evaluated with colour Doppler ultrasonography. RESULTS: Hypertensive retinopathy was observed in 33.9%, and Takayasu retinopathy was observed in 6.2% of patients. Posterior subcapsular cataracts or a history of cataract surgery was seen in 15.4% of the cases. None of the patients experienced visual loss due to ischaemic or neovascular complications. Patients with TAK had increased resistivity index (RI) in ophthalmic artery (0.75 vs 0.66, p=0.002) and CRA (0.75 vs 0.67, p=0.001). Patients with hypertensive retinopathy had significantly longer disease duration (p=0.016). Ophthalmic artery RI was significantly higher in patients with ipsilateral radial artery pulselessness compared with patients without (0.77 vs 0.68, p=0.031). CONCLUSION: This study reported the lowest prevalence of Takayasu retinopathy and is the only series without permanent visual loss. We documented for the first time that radial artery pulselessness can predict reduction of ipsilateral ocular perfusion. We believe that better management of TAK with current medications reduced ocular complication rates.

Long-Term Efficacy of Pegylated Interferon Alpha-2b in Behçet's Uveitis: A Small Case Series.

PURPOSE: To assess the long-term efficacy and safety of pegylated interferon alpha-2b (peg-IFN-α-2b) for severe uveitis associated with Behçet's disease. METHODS: Peg-IFN-α-2b was administrated at an initial dosage of 0,5-1,5 µg/kg/week. If any complications were observed, the dosage was tapered. Ocular examinations, systemic findings, and treatment compliance of the patients were evaluated. RESULTS: Control of ocular inflammation was achieved in all patients (n = 4). The average increase in visual acuity after drug administration of 0,425 ± 0,125 logMAR was not statistically significant (Wilcoxon Test, p = 0,066) due to small number of cases. Any side-effects with laboratory abnormalities returned to baseline levels with reduction of the doses. Due to less frequent injections, increased satisfaction of the patients was noted. CONCLUSIONS: This series highlights the peg-IFN-α-2b administration in Behçet's uveitis. Peg-IFN-α-2b has a potential long-term therapeutic effect for the treatment of severe uveitis. Efficacy with a reduced number of injections improved the quality of Behçet patients' lives.

Ocular culture-proven endogenous endophthalmitis: a 5-year retrospective study of the microorganism spectrum at a tertiary referral center in Turkey.

PURPOSE: The aim of this study was to review the clinical profile of endogenous endophthalmitis (EE), including predisposing systemic conditions, responsible microorganisms, clinical presentations, and outcomes. METHODS: We reviewed data from 21 eyes of 15 patients diagnosed with EE and compared their clinical characteristics over a 5-year period. All patients were ocular fluid cultures proven. Generalized estimating equations (GEE) were used to analyze the effects of vitrectomy, diabetes, malignity, and clinical presentation condition on VA. RESULTS: Diabetes was the most common illness of EE patients (40.0%). In this geographical region, Pseudomonas aeruginosa (4.8%), Methicillin-sensitive Staphylococcus aureus (4.8%), Methicillin-resistant Staphylococcus aureus (4.8%), and Mycobacterium tuberculosis (4.8%) were identified as causative bacterial microorganisms (n = 5) in patients with EE, and Candida Species (71.4%) and Aspergillus (4.8%) were identified as causative fungal microorganisms (n = 16) in patients with EE in the vitreous specimens. Fungemia (76.2%) (especially yeasts) was the most common extraocular infection source among patients with EE. Fourteen eyes (66.7%) were managed with intravitreal injections of antimicrobial medicines, and seven eyes (33.3%) also underwent vitrectomy. GEE models revealed that logMAR final VA values were found as lower than initial VA assessments. CONCLUSION: Depending on the different regions of the world, the characteristics of disease have been declared invariable. This study provides information about the clinical and microbiological profile of ocular culture-proven EE patients in a region of straddling the Asia and European continents. Aggressive medical and surgical treatment may result in favorable outcomes.

Factors Affecting Relapse and Remission in Behçet's Uveitis Treated with Interferon Alpha2a.

PURPOSE: To investigate factors affecting relapse and remission in patients with Behçet uveitis (BU) in the context of using the interferon alpha2a (IFNα2a) therapy. METHODS: Clinical records were reviewed of 32 patients (totaling 54 eyes) presenting with severe BU who had been treated with IFNα2a therapy. Factors influencing relapsing-remitting course of BU during IFNα2a therapy and after the cessation of the agent were evaluated. Possible affecting factors of recurrence were age, gender, duration of the Behçet disease, time elapsed before starting the drug, number of relapses before the starting of IFNα2a, laterality, and presence of panuveitis. RESULTS: Thirty patients (93.7%) responded to IFNα2a therapy. Annual attack rate before and after IFNα2a treatment was determined to be 4.03 ± 3.19 (attack per year) and 0.58 ± 1.07, respectively (P < 0.001). In univariable statistical evaluation, women tended to have a lower relapse risk than men. Multivariable analyses showed that age was the major factor determining relapse rate, while the effect of gender was not statistically significant (P = 0.196). The other probable influencing factors were not found to be statistically significant (P > 0.05). Increase in visual acuity observed during last examination compared to initial examination was determined to be statistically significant (P = 0.018). CONCLUSIONS: Even if the female gender was evaluated as a good prognostic factor in univariable analyses, it was not assessed as an effective prognostic factor in multivariable analyses. Being aged may be regarded a good prognostic factor on the relapsing-remitting course of patients with BU who were treated with IFNα2a therapy.

Conventional immunosuppressive therapy in severe Behcet's Uveitis: the switch rate to the biological agents.

BACKGROUND: To report the switch rate of conventional immunosuppressive (CIS) therapies to the biological agents (BA) in patients with refractory Behcet's uveitis (BU). METHODS: In this retrospective study, clinical records were reviewed of 76 patients' 116 eyes presenting with BU who had been treated with immunosuppressive drug therapy. Mann Whitney U test was used for the intergroup comparisons of parameters without normal distribution as well as calculation of descriptive statistical methods (mean, standard deviation, median, frequency and rate). Wilcoxon Signed Ranks test was used for the intragroup comparisons of parameters without normal distribution. Pearson's Chi-Square test and Fisher-Freeman-Halton test were used for the comparisons of qualitative data. RESULTS: Except for one, all patients were first treated with CIS regimens for BU. Thirty-one patients (41.3%) who were unresponsive to CIS regimens were switched to IFNα2a therapy. After that, eight of these cases were switched to the anti-TNF-α treatments. The presence of initial ocular complications were found to be statistically higher in BA treated patients than the CIS treated cases (p < 0.001). Both in CIS treated and in BA treated cases, an increase in visual acuity (VA) was observed during the last examination compared to the initial examination and was significant (p < 0.001 and p = 0.018, respectively). CONCLUSIONS: CIS treatment was found to be effective and safe, as suggested in the management guidelines for severe BU. Biological therapy was also found effective for the improvement of the VA. We observed that 58.7% of cases could be treated with strong immunosuppressive therapies, however, nearly half of the patients could have lost their VA if BAs were not existent. During the treatment course of severe cases with BU, classical therapy stage must still be protected as the first-line therapy due to the their reasonable activity and safety.

Bartonella henselae Neuroretinitis in Patients without Cat Scratch.

Cat scratch disease (CSD) is a syndrome characterized by lymphadenopathy, fever, and skin lesions following a cat scratch or bite. Bartonella henselae is the primary bacterial agent responsible for CSD. In this report, we describe cases with atypical presentation of serologically proven B. henselae neuroretinitis. In this study, 3 patients with neuroretinitis were evaluated. Animal contact histories; results of ocular examinations and systemic investigations; clinical findings; and treatment compliance of the patients were assessed. All patients denied history of contact with cats or other animals, and they did not have CSD findings. Serologic testing via indirect immunofluorescence assay (IFA) was used to diagnose Bartonella neuroretinitis. The IFA test results were positive for all patients. Two patients were treated with antibiotics. Optic disc edema and macular exudates resolved gradually, and at their last follow-up visits, all signs had disappeared. There was no disease recurrence after the completion of treatment. Serious complications were seen in the untreated patient. In conclusion, B. henselae infection should be considered even when there are no systemic signs and symptoms of CSD in patients with neuroretinitis.

Late clinical characteristics of infants with retinopathy of prematurity and treated with cryotherapy.

AIM: To describe the clinical characteristics and late results of patients with retinopathy of prematurity (ROP) treated with "6h cryotherapy". METHODS: Out of 1252 infants screened for ROP, 52 patients were treated with temporal 6h cryotherapy from 1997 to 2005 were recalled to our clinic. Among these 23 patients were available and 46 eyes of 23 infants were included to evaluate for visual acuity, refractive error, ocular alignment, nystagmus, retinal examination (abnormal branching of retinal vessels, retinal thinning, latis degenerations, tortuosity of vessels, straightening of temporal vessels, narrowing of the angle of vessel in the juxtapapillary entrance, pigment changes, macular heterotopia), optic atrophy and optic disc cupping, axial length at birth and axial length at 1y. RESULTS: The median age at examination was 7 (5-18)y. In 32.6% of patients, the visual acuity was ≤20/200 and the mean best corrected visual acuity was 20/35 as measured with a Snellen chart. Mean spherical refractive error was -1.76±2.69 D. The degree of myopia at the last examination was found to be correlated with the elongation of the eye in the first year of life. Exotropia was present in 17.4% (n=8) of infants and esotropia in 13% (n=6). The most common retinal abnormality was abnormal branching of retinal vessels (82.6%) followed by retinal thinning (52.2%). CONCLUSION: The late clinical outcomes of infants with ROP treated in our clinic with cryotherapy seems to comparable with results of laser treatment.

National Eye Institute Visual Function Scale in Type 2 Diabetes Patients.

Aim. To examine subscale and total scores of NEI-VFQ questionnaire of type 2 diabetes patients at different diabetic retinopathy (DRP) stages. Methods. A total number of 201 patients have been included. Prior to ophthalmological examination all patients participated in the NEI-VFQ questionnaire. The patients were divided into 5 groups according to the International Clinical Diabetic Retinopathy Disease Severity Scale (ICDRS). Results. The diabetes duration in general health scores (p = 0.029); the stage (p = 0.011); and clinically significant macular edema (CSME) (p = 0.019) in general vision were found to be the most efficient factors. In near vision activities the most efficient factors were near vision acuity (NVA) (p = 0.0001) and DRP stage (p = 0.020). EDTRS visual acuity was found to be the most efficient factor in vision specific role difficulties (p = 0.034) and dependency (p = 0.011) whereas Snellen visual acuity was found to be among the most effective factors in distance activities (DA) (p = 0.014) and total scores (p = 0.026). Discussion. Difference was based not on the diabetes duration, clinically significant cataract (CSCat), CSME presence, and DRP stage but on the visual acuity levels of the better seeing eye of the patients.

Cytomegalovirus Retinitis in Three Pediatric Cases with Acute Lymphoblastic Leukemia: Case Series and Review of the Literature.

Cytomegalovirus (CMV) retinitis is typically diagnosed in patient with AIDS and those who underwent allogeneic hematopoietic cell transplant. However, it may develop in patients with acute lymphoblastic leukemia (ALL) who have not undergone hematopoietic cell transplantation. To increase awareness of CMV retinitis in this group, we describe 3 patients ages 3, 9, and 12, with ALL who developed CMV retinitis. The diagnosis of CMV retinitis was made on the basis of ophthalmological findings suggesting typical retinal lesions. In 2 cases, CMV DNAemia was present, while in 1 patient CMV DNA was detected only in vitreous fluid using the PCR technique. All cases were treated with intravenous ganciclovir for 2 or 3 weeks as induction therapy, followed by oral valganciclovir prophylaxis. Initially, active retinitis lesions resolved in all cases; however, in 1 patient CMV retinitis relapsed 3 times during follow-up. In this case, by using foscarnet therapy, satisfactory responses were achieved and the progression of CMV retinitis lesions stopped and eventually regressed.

Screening for retinopathy of prematurity in a tertiary ophthalmology department in Turkey: incidence, outcomes, and risk factors.

BACKGROUND AND OBJECTIVE: The aim of this study is to determine the incidence of retinopathy of prematurity (ROP), the number of preterm infants requiring treatment for ROP, and the factors influencing the development of ROP requiring treatment in a Turkish population. PATIENTS AND METHODS: Data on 1,252 infants who were screened for ROP in an ophthalmology department were retrospectively reviewed. Infants with a gestational age (GA) of no more than 28 weeks (n = 157) were designated group 1, those between 29 and 32 weeks (n = 572) were assigned to group 2, and those between 33 and 37 weeks (n = 523) were assigned to group 3. RESULTS: In group 1, ROP was detected in 70.0% of infants, 17.8% of whom required therapy. In group 2, ROP was detected in 41.4%, and 4.0% of those required therapy. In group 3, 18.1% were diagnosed with ROP, with 0.8% requiring treatment. CONCLUSION: Retinopathy of prematurity occurs, even among more mature infants, at a frequency that merits astute screening within parameters that reflect socioeconomic differences that appear to have an effect on the incidence.

Cytomegalovirus Retinitis in an ALL Child during Maintenance Therapy Treated Successfully with Intravenous Ganciclovir.

Purpose. In here we described cytomegalovirus retinitis (CMVR) in 12-year-old male patient with acute lymphoblastic leukemia (ALL) who was on maintenance phase therapy. Methods. He was referred to our clinic for seeing of spots with the right eye for 3 days. At presentation, his best corrected visual acuity was 20/20 in the right eye and 20/20 in the left eye. Slit-lamp biomicroscopic examination of the anterior chamber of the left eye was within normal limits, whereas we observed 3+ anterior chamber cellular reaction in the right eye. On retinal examination, we found active retinitis lesions (cream-colored lesions associated with hemorrhages) and perivascular cuffing in the retinal periphery in the right eye. Left eye was normal. Results. On the basis of clinical picture, we made the diagnosis of CMVR in the right eye. Vitreous aspiration was performed and 23096 copies/mL of CMV DNA was detected by polymerase chain reaction (PCR) technique. The patient was successfully treated with intravenous ganciclovir for two weeks and discharged with oral valganciclovir prophylaxis. Conclusion. CMVR should be in mind in children with ALL on maintenance phase therapy even in those without hematopoietic stem cell transplantation. These patients can be treated successfully by intravenous ganciclovir alone.

Decreased subfoveal choroidal thickness and failure of emmetropisation in patients with oculocutaneous albinism.

PURPOSE: The purpose of this work was to describe the choroidal structure in patients with oculocutaneous albinism (OCA). METHODS: 20 eyes of 10 patients with OCA and 14 eyes of 7 healthy controls were recruited for the study. Enhanced depth imaging optical coherence tomography (OCT) images of the subjects were taken. The choroidal thickness (CT) was measured from the outer boarder of the retinal pigment epithelium to the inner boarder of sclera at 500 µm intervals of a horizontal section from the optic disc. Statistical analysis was performed to evaluate variations in CT at subfoveal and peripapillary areas. RESULTS: In the fundoscopic examination and OCT imaging, the foveal light reflex was absent and the foveal pit could not be observed in all of the patients with OCA. The mean subfoveal CT of the patients with OCA was significantly thinner (242±56 µm) compared with healthy controls (349±70 µm) (p<0.001); while there was no statistically significant difference in the peripapillary CTs of the patients with OCA and controls (157±42 µm vs 151±31 µm respectively, p=0.77), indicating a localised abnormality of choroidal anatomy. CONCLUSIONS: This study for the first time demonstrated that CT is decreased in patients with OCA at the subfoveal region. These data combined with the underdevelopment of the foveal pit indicate that there is a generalised developmental or genetic abnormality in the posterior pole of patients with OCA. This choroidal structural abnormality might be related to the previously reported failure of emmetropisation in these children. Further research is needed to understand choroidal metabolism and its relationship with these anatomical changes in albinism.

Orbital myositis associated with celiac disease.

A 26-year-old female patient presented with redness, lid edema on the right eye and diplopia on left gaze. There was a minimal limitation of adduction of the right eye, accompanied with pain and diplopia. Orbital magnetic resonance imaging confirmed the diagnosis of orbital myositis. Anti-endomysial immunoglobulin (Ig) A, anti-endomysial IgG, anti-gliadin IgA and anti-tissue transglutaminase IgG antibodies were positive, while other tests for autoimmune diseases were unremarkable. The patient stated that her diarrhea had been relieved by a gluten-free diet. Methylprednisolone therapy (1 mg/kg) was started and on her next visit her complaints were relieved. Later, methotrexate (15 mg/week) was added to the therapy as the patient became steroid-dependent, and she has been attack-free for the last 3 months under methotrexate and low-dose methylprednisolone (4 mg/day) treatment. Associations between orbital myositis and various autoimmune diseases have previously been reported. We report here the first case of associated orbital myositis and celiac disease.

Serum erythropoietin, insulin-like growth factor 1, and vascular endothelial growth factor in etiopathogenesis of retinopathy of prematurity.

BACKGROUND AND OBJECTIVE: The role of growth factors in the pathogenesis of retinopathy of prematurity (ROP) is known. To better understand this issue, the authors investigated vascular endothelial growth factor (VEGF), insulin-like growth factor 1 (IGF-1), and erythropoietin (EPO) levels in the cord blood of premature newborns. PATIENTS AND METHODS: IGF-1, VEGF, and EPO levels were measured in cord blood samples obtained from 93 infants less than 32 weeks of gestational age at birth, and their predictive value in the development of ROP was investigated. RESULTS: The mean birth age and mean birth weight were 32.2 ± 1.5 weeks and 1,678 ± 326 g, respectively, in infants without ROP and 29.6 ± 2.3 weeks and 1,384 ± 343 g, respectively, in infants with ROP. Multivariate logistic regression analysis showed that only the gestational age and the serum VEGF at birth were independently associated with the risk of developing ROP (P = .002, Exp[B] = 0.514, CI = 95%: 0.341-0.775; P = .028, Exp[B] = 0.999, CI = 95%: 0.997-1.00). CONCLUSION: Serum VEGF levels at birth were lower in infants who later developed ROP. This may have a predictive value for ROP and contribute to the pathogenesis, because affected infants may be more susceptible to extrauterine hyperoxic insult.

Bilateral acute iris transillumination.

OBJECTIVE: To describe a series of patients with bilateral acute iris transillumination, pigment dispersion, and sphincter paralysis. METHODS: We reviewed the medical records and clinical photographs of 26 patients seen at 5 centers in Turkey and Belgium between March 16, 2006, and July 6, 2010. Observation procedures included clinical examination, anterior segment color photography, gonioscopy, laser flare photometry, and pupillometry. RESULTS: All 26 patients (20 women and 6 men; mean [SD] age, 43.2 [10.5] years) had bilateral involvement. Twenty-three patients (88%) had acute-onset disease with severe photophobia and red eyes. Nineteen patients (73%) had a preceding flulike illness and used systemic antibiotics, including moxifloxacin. Diagnostic laboratory workup was unremarkable. There was pigment discharge into the anterior chamber, and flare was elevated in the absence of inflammatory cells. Most patients had severe diffuse transillumination of the iris and mydriatic distorted pupils. Pupillometry revealed a compromised reaction to light. The most serious complication was an intractable early rise in intraocular pressure. Gonioscopy revealed heavy pigment deposition in the trabecular meshwork. Although symptoms were relieved promptly by application of topical corticosteroid, the median duration of pigment dispersion was 5.25 months. CONCLUSIONS: Bilateral acute iris transillumination with pigment dispersion and persistent mydriasis is a new clinical entity that is not an ocular adverse effect of oral moxifloxacin treatment, as previously suggested. The etiopathogenesis of this entity remains to be elucidated.