Six-month results of 577 nm subthreshold micropulse laser therapy in non-center involving diabetic macular edema.

BACKGROUND: This study aimed to evaluate the efficacy of 577 nm subthreshold micropulse laser (SML) therapy in patients with non-center involving diabetic macular edema (DME). METHODS: Twenty-two eyes of 18 patients diagnosed with non-center involving DME were included in this prospective, observational study. The patient's baseline best corrected visual acuity (BCVA), maximum retinal thickness (MRT), central macular thickness (CMT), and the area of macular exudates were determined and re-evaluated at 1, 3, and 6 months after laser treatment. RESULTS: There was no statistically significant change in BCVA at the 1st, 3rd and 6th months compared to the baseline in the follow-up (p = 0.067, p = 0.270, p = 0.027 according to Bonferroni correction p < 0,01). 1st, 3rd, and 6th month MRT was statistically significantly lower than baseline (p = 0,009, p = 0,006, p = 0,007). No statistically significant change was detected in CMT at the 1st, 3rd and 6th months compared to the baseline in the follow-up (p = 0.384, p = 0.794, p = 0.363). No statistically significant change in the area of macular exudates was detected at the 1st, 3rd, and 6th months compared to the baseline (p = 0.904, p = 0.444, p = 0.277). CONCLUSIONS: This study observed a significant decrease in extrafoveal retinal thickness in patients with DME. There was no progression to central macular involvement, an increase in the area of exudates, and a decrease in BCVA in any patient. SML may be an effective alternative to conventional argon laser in non-center involving DME.

Retinal and peripapillary vascular density in episodic and chronic migraine cases without aura.

BACKGROUND: Migraine is a neurovascular disease that can cause ocular and systemic ischemic damage. Despite from aura, a limited number of studies have considered the effect of the chronic migraine in cases without aura. Our aim was to evaluate the differences in the retinal and optic disk microvasculature among episodic and chronic migraine cases without aura using optical coherence tomography angiography (OCTA) imaging. METHODS: 45 cases with migraine, and 25 control subjects were included in this prospective, cross-sectional study. OCTA was performed at 3 × 3 mm and 6 × 6 mm of the macula and at 4.5 × 4.5 mm of the optic disk. Retinal nerve fiber layer (RNFL) thickness, ganglion cell complex thickness, and vessel densities of the optic nerve and macula were compared among the three groups: a control group, an episodic migraine without aura (EMWOA) group, and a chronic migraine without aura (CMWOA) group. RESULTS: In EMWOA group, circumpapillary vascular density (cpVD) was not decreased significantly in any quadrants (all, p>0.05). Compared to the control group, CMWOA group had significantly lower RNFL thickness in superior-temporal quadrants (p = 0.002 and 0.006, respectively), while cpVD differed only in the temporal quadrant and temporal inferior sector (p = 0.002 and p = 0.009, respectively). CONCLUSIONS: Temporal peripapillary perfusion is valuable in the follow-up of chronic migraine cases. Longitudinal studies are needed to determine the place of OCTA in the follow-up of migraine.

Can optical coherence tomography angiography be a first line ophthalmological evaluation in patients with Behçet's disease?

Objectives: This study aimed to investigate whether early ocular findings can be demonstrated with optical coherence tomography angiography in patients with Behçet's disease. Patients and methods: Thirty-seven eyes of 22 patients with Behçet's disease with ocular involvement, 48 eyes of 26 Behçet patients without any ocular involvement, and 44 eyes of 22 healthy controls were included, for a total of 70 patients (39 males, 31 females; mean age: 42.3±11.7 years; range, 18 to 65 years), in the cross-sectional study conducted between September 2019 and April 2020. The parameters analyzed were the foveal avascular zone (FAZ), central macular thickness, total deep capillary plexus vessel density (DCPVD), parafoveal deep capillary plexus vessel density (PaDCPVD), total superficial capillary plexus vessel density (SCPVD), and parafoveal superficial capillary plexus vessel density (PaSCPVD). Results: Total DCPVD, total SCPVD, PaDCPVD, and PaSCPVD were found to be low in the ocular involvement group compared to the others, and the FAZ area was larger compared to the control group. Capillary plexus densities were positively correlated with the best-corrected visual acuity and negatively correlated with disease duration. No statistically significant difference was found between patients with Behçet without ocular involvement and the control group in terms of the FAZ area, DCPVD, PaDCPVD, SCPVD, and PaSCPVD. Conclusion: Optical coherence tomography angiography demonstrated decreased vascularity in Behçet patients with ocular involvement; however, it revealed no microvascular differences between patients with Behçet's disease who do not have ocular involvement and the control group.

Combined Capsular Tension Ring and Segment Implantation in Phacoemulsification Surgery for the Management of Microspherophakia with Secondary Angle-Closure Glaucoma.

We present the long-term results of the implantation of a capsular tension ring (CTR) and Ahmed capsular tension segments (CTS) together for the management of mikrospherophakia in a 35-year-old female patient. The patient had uncontrolled secondary angle-closure glaucoma, despite previous laser peripheral iridotomy, and visual impairment due to lenticular myopia. Clear lens extraction was performed under general anesthesia. The capsular bag was stabilized with a classical CTR and two Ahmed CTSs sutured to the sclera. A single-piece hydrophobic acrylic intraocular lens (32.0 D for the right and 30.0 D for the left eye) was implanted in the capsular bag. The anterior chamber depth was stable, and intraocular pressure (IOP) was 10-12 mmHg in both eyes in the early post-operative period. The bag complex gradually moved forward, IOP gradually increased, and the left eye underwent trabeculectomy surgery in the 4th year of follow-up.

Efficacy of Optic Nerve Sheath Fenestration in Patients with Increased Intracranial Pressure.

Objectives: To evaluate the effectiveness of optic nerve sheath fenestration (ONSF) on visual functions in patients with increased intracranial pressure (IIP). Materials and Methods: The medical records of 24 eyes of 17 patients who had IIP due to idiopathic intracranial hypertension, cerebral venous sinus thrombosis, or intracranial cyst and underwent ONSF surgery to prevent visual loss were evaluated. Pre- and postoperative visual acuity, optic disc images, and visual field findings were reviewed. Results: The mean age of the patients was 30.4±8.5 years, and 88.2% were female. The patients' mean body mass index was 28.67±6.1 kg/m2. The mean follow-up time was 24±12.1 months (range: 3-44). At postoperative 3 months, the mean best-corrected distance visual acuity had improved in 20 eyes (83.3%) and stabilized in 4 eyes (16.7%) compared to preoperative values. In visual field mean deviation, an improvement was observed in 10 eyes (90.9%), while 1 eye (9.1%) eye remained stable. Optic disc edema decreased in all patients. Conclusion: This study indicates that ONSF has beneficial effects on visual function in patients with rapidly progressive visual loss caused by increased intracranial pressure.

Detection of coronavirus in tear samples of hospitalized patients with COVID-19.

PURPOSE: To assess the presence of viral RNA in conjunctival secretions and tears of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected patients in terms of a possible ocular transmission route and also to examine whether a difference between the patients with and without ocular surface positivity existed. METHODS: A prospective cross-sectional study of 70 consecutive patients who were hospitalized in Haseki Training and Research Hospital with SARS-CoV-2 from February 1 to April 1, 2021, was performed. Tears and conjunctival secretions were collected within 24 h of nasopharyngeal sample collection and examined for SARS-CoV-2 using reverse transcription real-time polymerase chain reaction (qPCR). The clinical data, results of blood tests and nasopharyngeal and conjunctival swabs, and CT findings were evaluated for all patients. RESULTS: Seventy patients (37 males, 33 females) were included in this study. Tear-conjunctival samples from eight patients (11.42%) yielded positive PCR results although these eight patients had no eye symptoms or conjunctivitis. In patients with positive conjunctival PCR results, cycle threshold values for conjunctival samples were higher than those for nasopharyngeal samples. All findings (except gender) were similar between patients with either positive or negative conjunctival swab samples. All patients with positive conjunctival swab samples were male; however, the male ratio in patients with negative conjunctival swab samples was only 46.77%. CONCLUSION: In our study, the rate of conjunctival swab PCR positivity was 11.42%. It appears that even in the absence of ocular symptoms, SARS-CoV-2 virus may be present on the ocular surface; therefore, the ocular surface may be a significant viral transmission route.

Peripapillary and Macular Vascular Density in Patients With Preperimetric and Early Primary Open Angle Glaucoma.

PRCIS: Decreased circumpapillary vascular density (cpVD) and average retinal nerve fiber layer (RNFL) thickness were detected at different locations in eyes with preperimetric glaucoma (PPG). Although RNFL loss was more prominent in preperimetric eyes, in early glaucoma, both cpVD and RNFL thickness showed comparable diagnostic ability. PURPOSE: To evaluate changes in circumpapillary and macular vascular density and investigate correlations between vascular and structural parameters in PPG and early glaucoma. METHOD: This cross-sectional study included a total of 27 patients with PPG in 1 eye and early primary open angle glaucoma in the fellow eye, as well as a control group consisting of 27 eyes of 27 healthy volunteers. All subjects underwent optical coherence tomography angiography (OCTA) imaging. RNFL and macular ganglion cell complex measurements were obtained simultaneously with vascular parameters by AngioVue OCTA using the single-scan protocol. cpVD was examined in 8 sectors. Diagnostic accuracy was evaluated using the area under the receiver operating characteristic curve. RESULTS: In preperimetric eyes, average RNFL thickness and whole-image vessel density had comparable diagnostic performance (area under the receiver operating characteristic curve =0.853 and 0.753, respectively). Compared with the control group, PPG eyes had significantly lower RNFL thickness in all quadrants (P<0.001-0.003) except for the temporal quadrant, whereas cpVD differed only in the nasal inferior and nasal superior sectors (P=0.001 and 0.041, respectively). In early glaucoma eyes, cpVD differed significantly from controls in all sectors except for the inferotemporal, temporal inferior, and temporal superior sectors, whereas perifoveal macular vascular parameters differed in all quadrants (all P<0.05). cpVD was strongly correlated with RNFL thickness in the superior, nasal, and temporal quadrants (r=0.664, 0.698, and 0.649, respectively, P<0.001) and moderately correlated in the inferior quadrant (r=0.450, P<0.001). CONCLUSION: Although RNFL involvement is valuable in the diagnosis and follow-up of PPG, the change in nasal cpVD has an important place in these patients. The role of macular vascular parameters and macular ganglion cell complex in glaucoma follow-up becomes important in early glaucoma. Longitudinal studies are needed to determine the place of OCTA in the diagnosis and follow-up of glaucoma.

Ophthalmic, systemic, and genetic characteristics of patients with Wolfram syndrome.

PURPOSE: To evaluate the ophthalmic, systemic, and genetic characteristics of patients with Wolfram syndrome. METHODS: In total, 13 patients with suspected or clinically diagnosed Wolfram syndrome underwent ophthalmic and systemic examinations and genetic analyses for Wolfram syndrome between August and October 2018. RESULTS: The mean age of the subjects was 24.2 ± 7.1 years, of which 5 (38.5%) subjects were male and 8 (61.5%) were female. The mean best-corrected visual acuity ranged from counting fingers to 20/40, with a mean of 20/250 (1.10 ± 0.69 logarithm of the minimum angle of resolution). Dyschromatopsia was present in all patients (100%). There was a severe decrease in the average peripapillary retinal nerve fiber layer and macular ganglion cell-inner plexiform layer thicknesses (54.7 ± 6.5 and 51.9 ± 4.8 µm, respectively). Optical coherence tomography angiography showed significantly lower whole-image, inside disk, and peripapillary vessel densities in the patients with Wolfram syndrome than in the healthy controls (p < 0.001 for all). All patients who underwent genetic analyses had mutations in the WFS1 gene. Moreover, two novel mutations, p.Met623Trpfs*2 (c.1867delA) and p.Arg611Profs*9 (c.1832_11847del16) at exon 8, were detected. The frequency of systemic findings was as follows: optic atrophy (100%), diabetes mellitus (92.3%), central diabetes insipidus (38.5%), sensorineural hearing loss (38.5%), and presence of urological (30.8%), psychiatric (30.8%), and neurological (23.1%) diseases. CONCLUSION: Wolfram syndrome is a rare genetic disorder that can be associated with severe ophthalmic and systemic abnormalities. All patients who present with unexplained optic atrophy should be evaluated for Wolfram syndrome, even if they do not have diabetes mellitus because optic atrophy can sometimes manifest before diabetes mellitus.

Ocular findings in posterior microphthalmos.

AIM: To report a critical case series of six patients with posterior microphthalmos (PM). METHOD: Complete ophthalmologic examinations of all patients were performed using best-corrected visual acuity (BCVA), cycloplegic refraction, applanation tonometry, slit lamp biomicroscopy of the anterior segment, fundoscopy, A and B mode ultrasonography (USG), keratometry, and optic coherence tomography (OCT). RESULTS: The most significant clinical characteristics of male patients aged 10-25 years was the presence of shorter posterior segments (mean: 15.27-18.91 mm) accompanying high hyperopia (mean +9.00 - +18.50 diopter) despite the normal anterior segment findings. The BCVA ranged between 20/320 and 40/100. Retinal folds were detected bilaterally on the papillomacular band in all patients. Although neurosensory retina was included in the fold in OCT images, retinal pigment epithelium, choroid, and sclera were not included in the fold. Pigmentary retinopathy was detected in one patient. CONCLUSION: Despite normal anterior segment, posterior microphthalmos is characterized with high hyperopia, and shorter axial length and bilateral papillomacular retinal fold. Refractive amblyopia, uveal effusion syndrome, retinal detachment and macular hole are complications that can be corrected. Posterior microphthalmos must be kept in mind in patients with a normal anterior segment, and high hyperopia.

Traumatic superior orbital fissure syndrome.

Objective: Traumatic superior orbital fissure syndrome is a rare complication that occurs in association with craniofacial trauma. In the present case, there were no associated orbital fractures or other lesions to explain. Methods: We present a-16-year-old patient with total ophthalmoplegia, ptosis, and anesthesia of the upper eyelid and forehead 6 hours after a reported trauma to the left eye. We measured the width of the superior orbital fissure on the horizontal plane including the optic canal using computed tomography scans. Results: Radiological examinations did not reveal any orbital fractures. However, the superior orbital fissure on the affected side was only 1.86 mm, increasing susceptibility to indirect trauma. Conclusions: A narrow superior orbital fissure may play a role for superior orbital fissure syndrome altering the transmitted force from the trauma and edema.

Discriminating performance of macular ganglion cell-inner plexiform layer thicknesses at different stages of glaucoma.

AIM: To determine the discriminating performance of the macular ganglion cell-inner plexiform layer (GC-IPL) parameters between all the consecutive stages of glaucoma (from healthy to moderate-to-severe glaucoma), and to compare it with the discriminating performances of the peripapillary retinal nerve fiber layer (RNFL) parameters and optic nerve head (ONH) parameters. METHODS: Totally 147 eyes (40 healthy, 40 glaucoma suspects, 40 early glaucoma, and 27 moderate-to-severe glaucoma) of 133 subjects were included. Optical coherence tomography (OCT) was obtained using Cirrus HD-OCT 5000. The diagnostic performances of GC-IPL, RNFL, and ONH parameters were evaluated by determining the area under the curve (AUC) of the receiver operating characteristics. RESULTS: All GC-IPL parameters discriminated glaucoma suspect patients from subjects with healthy eyes and moderate-to-severe glaucoma from early glaucoma patients (P<0.017, for all). Also, minimum, inferotemporal and inferonasal GC-IPL parameters discriminated early glaucoma patients from glaucoma suspects, whereas no RNFL or ONH parameter could discriminate between the two. The best parameters to discriminate glaucoma suspects from subjects with healthy eyes were superonasal GC-IPL, superior RNFL and average c/d ratio (AUC=0.746, 0.810 and 0.746, respectively). Discriminating performances of all the parameters for early glaucoma vs glaucoma suspect comparison were lower than that of the other consecutive group comparisons, with the best GC-IPL parameters being minimum and inferotemporal (AUC=0.669 and 0.662, respectively). Moreover, minimum GC-IPL, average RNFL, and rim area (AUC=0.900, 0.858, 0.768, respectively) were the best parameters for discriminating moderate-to-severe glaucoma patients from early glaucoma patients. CONCLUSION: GC-IPL parameters can discriminate glaucoma suspect patients from subjects with healthy eyes, and also all the consecutive stages of glaucoma from each other (from glaucoma suspect to moderate-to-severe glaucoma). Further, the discriminating performance of GC-IPL thicknesses is comparable to that.

Ocular and Genetic Characteristics Observed in Two Cases of Fish-Eye Disease.

PURPOSE: To present ocular findings and anterior segment-optical coherence tomography (AS-OCT) imaging findings of 2 cases of fish-eye disease (FED) involving 2 novel genetic variants of the lecithin-cholesterol acyltransferase (LCAT) gene. METHODS: A case report. RESULTS: A 46-year-old woman and 63-year-old man presented with blurred vision, burning sensation, and whitening of both eyes for 2 and 3 years, respectively. Ophthalmologic examination revealed slightly decreased visual acuity, yellowish-white diffuse corneal opacities causing corneal clouding, and dry eye disease bilaterally in both patients. AS-OCT imaging demonstrated diffuse hyperreflective corneal opacities predominantly located in the anterior stroma. On systemic examination, both patients had very low plasma high-density lipoprotein cholesterol levels. However, they did not have any systemic associations with familial LCAT deficiency or Tangier disease, which are differential diagnoses for corneal clouding and low plasma high-density lipoprotein cholesterol. Both patients were diagnosed with FED based on clinical findings. Furthermore, genetic analysis, in which novel variants of c.86A>G (p.Asn29Ser) in the first exon and c.1052A>G (p.Tyr351Cys) in the sixth exon on the LCAT gene were detected, confirmed the diagnosis. CONCLUSIONS: Although it is a rare genetic disorder, FED should be considered in the differential diagnosis of corneal clouding. Corneal lipid deposits, visible on AS-OCT are suggestive of FED, and genetic analysis can be used to confirm the clinical diagnosis. Finally, there may be a relationship between dry eye disease and LCAT enzyme deficiency disorders, which should be investigated in further studies.

Horner Syndrome as a Rare Complication of Radiofrequency Tonsil Ablation.

Horner syndrome is a rare but likely underdiagnosed complication of tonsillary surgery. The authors report the case of a 2.5-year-old boy who developed miosis and mild ptosis after radiofrequency tonsil ablation surgery. Pharmacologic testing with apraclonidine 0.5% eye drops confirmed left Horner syndrome. This case highlights the close anatomical relationship between the tonsils and cervical sympathetic trunk and draws attention to the occurrence of Horner syndrome after tonsillectomy. [J Pediatr Ophthalmol Strabismus. 2018;55:e14-e15.].

Primary Conjunctival Tuberculosis.

A 12-year-old girl was referred to our clinic because of unilateral conjunctivitis not responding to treatment. In the left eye, lower bulbar and tarsal conjunctiva had a polypoidal appearance due to micronodules and there was a subconjunctival nodular mass in the inferior fornix. Systemic examination was unremarkable except for a left preauricular lymphadenopathy. Excision biopsy of the subconjunctival mass revealed a granulomatous inflammation with caseation necrosis, but acid-fast bacilli (AFB) was negative. Fine needle-aspiration biopsy of the preauricular lymph node was performed. In microbiological examination, both AFB and mycobacterial culture were positive. The isolated mycobacteria strains were identified as Mycobacterium tuberculosis complex and full remission was achieved with 6 months of anti-tuberculosis treatment. Although primary tuberculous conjunctivitis is a very rare condition, it should be considered in the differential diagnosis of treatment-resistant unilateral conjunctivitis. For definitive diagnosis, microbiological and histopathological examinations should be performed both in conjunctiva and regional lymph node.

Ocular surface chemical injury treated by regenerating agent (RGTA, Cacicol20).

Objective: To present the successful outcome of regenerating agent (RGTA) treatment in a patient with severe ocular surface chemical injury. Methods: Case report Results: A 14-year-old female patient was admitted to our clinic following chemical burn in the left eye. Her best corrected visual acuity (BCVA) was 20/40; and she had total corneal and 75% conjunctival epithelial loss, corneal haze, and limbal ischemia for nine clock hours in the left eye. The patient had already received standard therapy consisting of patching, preservative-free artificial tears, topical netilmicin, topical dexamethasone, oral doxycycline, and vitamin C for two weeks. We initially cleaned the conjunctival necrotic tissues, applied the silicon hydrogel bandage contact lens, exchanged the topical netilmicin with preservative-free moxifloxacin and supplemented this therapy with RGTA (Cacicol20, Paris, France) once in two days. The BCVA of the patient improved to 20/20 and the ocular surface re-epithelization was completed on day 20. Conclusion: RGTAs are effective biological agents for the treatment of corneal epithelial defects following severe ocular surface chemical injuries.

Bilateral transient visual loss and meningeal irritation signs following retrobulbar anesthesia.

A 62-year-old man underwent an uneventful cataract surgery in the left eye following retrobulbar anesthesia. Fifteen minutes after the surgery, the patient had visual loss in his right (unoperated) eye, headache, dizziness, nausea, and vomiting. The bandage on the left (operated) eye was removed and the initial ophthalmic examination revealed bilateral dilated pupils with absence of light perception. His fundus examination and vital signs were unremarkable. Immediately, a computerized tomography (CT) was performed to scan both orbit and brain. The orbit CT revealed air bubbles within the left optic nerve sheath, which confirmed inadvertent injection and administration of anesthetic medications into the optic nerve sheath. Within three hours, meningeal irritation signs recovered spontaneously and visual acuity improved to 20/20 in the right eye and 20/40 in the left eye.

Purtscher-Like Retinopathy Associated with Atypical Hemolytic Uremic Syndrome.

A 25-year-old woman presented with acute bilateral blurred vision and history of headache, dizziness, and syncope for three days. Her visual acuity was 20/60 in both eyes. Fundoscopy revealed multiple bilateral peripapillary yellow-white patches like cotton wool spots, intraretinal hemorrhages and macular edema. The patient was diagnosed with Purtscher-like retinopathy based on the retinal findings and lack of trauma history. She was urgently admitted to the nephrology clinic due to thrombotic microangiopathy findings (hemoglobinemia, thrombocytopenia, and acute renal failure). After excluding thrombotic microangiopathy, the patient was diagnosed with atypical hemolytic uremic syndrome (aHUS) with the clinical and laboratory findings. Eculizumab treatment was added to hemodialysis and plasmapheresis therapy. Three months after starting treatment, retinal lesions regressed and visual acuity increased to 20/20 in both eyes. To the best of our knowledge, this is the first reported case of Purtscher-like retinopathy associated with aHUS.

Chronic Meningitis Complicating Intracranial Hypertension in Neurobrucellosis: A Case Report.

In neurobrucellosis, even though meningitis is encountered frequently, chronic intracranial hypertension is a rare manifestation. Early diagnosis and treatment is very important for the prevention of permanent visual loss secondary to poststasis optic atrophy in these cases. We report a case that presented with permanent visual loss secondary to intracranial hypertension in neurobrucellosis. Our goal is to draw attention to the consideration of neurobrucellosis in cases with papilla stasis, even in the absence of neurological findings in endemic areas.