Clinical Features of Untreated Type 2 Macular Telangiectasia and Efficacy of Anti-Vascular Endothelial Growth Factor Therapy in Macular Neovascularization

Objectives: To compare best corrected visual acuity (BCVA), central macular thickness (CMT), and central choroidal thickness (CCT) in patients with type 2 macular telangiectasia (MacTel 2) and a control group and to evaluate the efficacy of intravitreal anti-vascular endothelial growth factor (anti-VEGF) treatment in MacTel 2 patients with macular neovascularization (MNV). Materials and Methods: We conducted a retrospective chart review of consecutive MacTel 2 patients who underwent a full ophthalmologic examination including BCVA and dilated fundus examination with slit-lamp biomicroscopy, fluorescein angiography, and optical coherence tomography imaging at baseline and follow-up visits. BCVA, CMT, and CCT were compared between all identified patients (n=26) and a control group (n=30). A subgroup analysis was performed among eyes with MNV (n=7) before and after treatment. Results: CMT and CCT were significantly lower in the MacTel 2 group compared to the control group. Forty-one treatment-naive eyes without MNV proliferation showed no significant change in BCVA, CMT, or CCT during follow-up. Eight eyes of 7 MacTel 2 patients developed MNV during follow-up. All of the patients were treated with intravitreal anti-VEGF. Conclusion: It is important to closely follow MacTel 2 patients for MNV development. To avoid adverse effects, we prefer to monitor patients who have not yet developed MNV. Patients with proliferative MacTel 2 with decreasing visual function may benefit from intravitreal anti-VEGF treatment.

Lacrimal dilator-facilitated incisionless vs. standard sub-Tenon's block: a randomized, prospective and non-inferiority comparative study.

BACKGROUND/OBJECTIVES: Standard sub-Tenon's block (STB) involves incision (dissection) of conjunctiva and Tenon's capsule with the help of blunt scissors and forceps, insertion of a blunt sub-Tenon's cannula under the Tenon's capsule and injection of local anaesthetic agent. STB is frequently associated with minor complications such as chemosis and postoperative subconjunctival haemorrhage but rare sight and life-threatening complications. To reduce these minor complications, several variations of incisionless STB have been described however, there are no comparative data. One such incisionless STB involves the use of lacrimal dilator which is easily available in the operating theatre. We compared incisionless lacrimal dilator-facilitated with the standard STB for effectiveness, chemosis, and postoperative subconjunctival haemorrhage. SUBJECTS/METHODS: After obtaining ethical approval, patients scheduled to undergo elective phacoemulsification cataract surgery were enroled to receive incisionless lacrimal dilator-facilitated STB (Group LD) or a standard STB using Wescott scissors and blunt forceps (Group WS). All patients received 3 mL 2% lidocaine without any adjuvant. No sedation was administered. Demographics of the patients, duration of the procedure, analgesia, akinesia, duration of the procedure intraoperative chemosis, and postoperative subconjunctival haemorrhage were compared. RESULTS: Both groups were comparable for demographic data, duration of the procedure, analgesia, and akinesia (p > 0.05). The severity of chemosis and postoperative subconjunctival haemorrhage were significantly lower in Group LD (n = 32) in comparison to Group WS (n = 31) (p < 0.001). CONCLUSIONS: Incisionless lacrimal dilator-facilitated STB decreases intraoperative chemosis and postoperative conjunctival haemorrhage in comparison to standard STB. Analgesia and akinesia are comparable in both techniques.

Effect of diluted povidone iodine in adenoviral keratoconjunctivitis on the rate of subepithelial corneal infiltrates.

AIM: To evaluate the clinical characteristics of adenoviral keratoconjunctivitis, the management modalities, as well as the incidence of subepithelial corneal infiltrates (SEI). METHODS: Patients with characteristic clinical symptoms and signs, who presented to our clinic within the first week of symptoms and received the diagnosis of adenoviral keratoconjunctivitis between January 2013 and April 2016, were included in the study. A total of 211 patients were included in the study. Patients were evaluated for the incidence of clinical signs, late complications, management preferences, and the effect of diluted povidone-iodine (d-PVP-I) 2%. RESULTS: Patients' mean age was 33.03±14.76y. We observed an increase in the number of cases according to the years. At presentation and/or early follow-up, the clinical signs were conjunctival hyperemia (100%), conjunctival follicules (79.1%), edema of the eyelids (39.3%), chemosis (16.1%), pseudomembrane formation (16.6%), and corneal epitheliopathy (29.9%). During late follow-up 13.3% patients developed conjunctival subepithelial fibrosis, and 39.8% developed SEI. A significant decrease in the incidence of SEI development was observed in patients who used d-PVP-I 2% (P=0.032; 33.3% vs 45.9%, respectively in patients who received d-PVP-I 2% and who did not). CONCLUSION: Adenoviral keratoconjunctivitis has a tremendous effect on patient's comfort and abilities in short-term. Additionally, almost half of the patients develop visual problems related to SEI. According to our clinical experience, using d-PVP-I 2% in the first days of adenoviral keratoconjunctivitis might be helpful in reducing the risk of SEI as a complication.

Possible Association of Papillophlebitis with Guillain-Barré Syndrome: Case Report.

In this case report, we presented a patient with visual deterioration as a result of papillophlebitis in the right eye who was later diagnosed with Guillain-Barré syndrome (GBS). Upon systemic and laboratory work-up to determine the etiology of papillophlebitis, the diagnosis of GBS was made and treatment was initiated immediately. The ocular and systemic symptoms resolved quickly after starting intravenous immunoglobulin therapy. We present this case to emphasize the importance of etiological diagnosis in papillophlebitis and the unusual presentation of GBS.

Influence of glycosylated hemoglobin on the choroidal thickness.

PURPOSE: The aim of the study reported here was to assess the influence of serum HbA1c levels on foveal choroidal thickness in diabetic patients. METHODS: A total of 122 eyes from 122 patients who had type 2 DM were studied in this prospective, cross-sectional study. Patients were divided into three groups: 43 patients (43 eyes) without diabetic retinopathy (NDR), 39 patients (39 eyes) with diabetic retinopathy and no macular edema (DR/ME-), 40 patients (40 eyes) with diabetic retinopathy and macular edema (DR/ME+). Central foveal thicknesses and subfoveal choroidal thicknesses were noted. Subfoveal choroidal thickness measurement was taken perpendicularly from the outer part of the retinal pigment epithelial layer to the line corresponding to the choroidal-scleral junction. Serum glycosylated hemoglobin (HbA1c) levels were evaluated. RESULTS: No significant differences in age, gender, pseudophakia were observed between the groups. There was no significant difference in HbA1c value among the three diabetic groups. Mean foveal choroidal thickness was 270.09 ± 42.41 in NDR group, 243.18 ± 30.21 in DR/ME- group and 250.90 ± 40.06 in DR/ME+ group. Mean foveal choroidal thickness in NDR group was significantly different from DR/ME- group. There was no statistically significant difference between the other groups among foveal choroidal thicknesses. There was no correlation between HbA1c and foveal choroidal thickness. Multiple regression analyses of two diabetic retinopathy groups showed no significant correlation between foveal choroidal thickness and HbA1c and also no significant correlation between foveal choroidal thickness and duration of diabetes. CONCLUSIONS: Serum HbA1c levels were not correlated with foveal choroidal thickness. Choroidal thickness is effected by several factors as axial length, age and systemic diseases.

Measurements of Retinal Nerve Fiber Thickness and Ganglion Cell Complex in Neurofibromatosis Type 1, with and Without Optic Pathway Gliomas: A Case Series.

PURPOSE: The aim of this study was to investigate differences in retinal nerve fiber layer (RNFL) and ganglion cell complex (GCC) thicknesses in neurofibromatosis 1 (NF1) cases, with and without optic pathway gliomas (OPGs). MATERIALS AND METHODS: In total, 33 eyes of 33 subjects were evaluated in this prospective observational case series. Twenty-one patients with a diagnosis of NF1 were enrolled. Patients with NF1 and OPGs were included in Group 1 (n = 9), and patients with NF1 without OPGs were included in Group 2 (n = 12). The control group (Group 3) was comprised of 12 age- and sex-matched subjects with no history of ophthalmic or systemic diseases. All of the subjects underwent complete ophthalmic examinations, including best-corrected visual acuity (BCVA), slit lamp microscopy, and indirect ophthalmoscopy. Additionally, optical coherence tomography (OCT) measurements were obtained. RESULTS: There were no statistically significant between-group differences in age and sex (p = 0.227 and 0.986, respectively). The average RNFL thickness in Group 1 (NF1 patients with OPGs) was significantly lower than in Groups 2 and 3 (86.6 ± 22.5, 107.4 ± 6.65, and 108.4 ± 5.05 µm, respectively; p = 0.001). Furthermore, the average GCC thickness in Group 1 was significantly lower than in Groups 2 and 3 (78.6 ± 16.3, 94.8 ± 3.55, and 94.9 ± 3.82 µm, respectively; p < 0.001). CONCLUSIONS: Both RNFL and GCC thicknesses were significantly lower in NF1 patients with OPGs. The use of OCT to quantify damage to the visual pathway may enable earlier detection of OPGs in NF1 patients.

Spindle cell carcinoma of the conjunctiva: A rare entity.

An 85-year-old male presented with painless bulging lesion over the cornea. Clinical history, diagnostic imaging studies, and histopathologic sections were evaluated. The patient clinically displayed an vascularized conjunctival lesion located at the superior bulbar conjunctiva with extension onto cornea covering 2/3 of his pupillary aperture superiorly. His visual acuity was counting fingers at 4 m. The patient underwent a total excision of the lesion including conjunctival and corneal parts. Histopathologic evaluation revealed spindle cell carcinoma which involves the whole conjunctival squamous epithelium with significant polarity loss, nuclear enlargement with hyperchromasia and pleomorphism, and mitotic activity. Diagnosis of spindle cell carcinoma is challenging because of overlapping histopathological features with other spindle cell tumors. The detailed pathologic examination is very important for the decision of proper treatment.

Choroidal thickness measurements with optical coherence tomography in branch retinal vein occlusion.

AIM: To evaluate central macular thickness (CMT) and mean choroidal thickness (MCT) in eyes with branch retinal vein occlusion (BRVO), before and after ranibizumab treatment using spectral domain-optical coherence tomography (SD-OCT). METHODS: Forty-two patients with unilateral BRVO and macular edema were included in this study. There were 25 men and 17 women. Using SD-OCT, choroidal thickness was measured at 500 µm intervals up to 1500 µm temporal and nasal to the fovea. MCT was calculated based on the average of the 7 locations. All the eyes with BRVO were treated with intravitreal ranibizumab (0.5 mg/0.05 mL). Comparisons between the BRVO and fellow eyes were analyzed using Mann-Whitney U test. Pre-injection and post-injection measurements were analyzed using Wilcoxon test and repeated measure analysis. RESULTS: At baseline, there was a significant difference between the BRVO and fellow eyes in MCT [BRVO eyes 245 (165-330) µm, fellow eyes 229 (157-327) µm] and CMT [BRVO eyes 463 (266-899) µm, fellow eyes 235 (148-378) µm (P=0.041, 0.0001, respectively)]. Following treatment, CMT [295 (141-558) µm] and MCT [229 (157-329) µm] decreased significantly compared to the baseline measurements (P=0.001, 0.006, respectively). Also BCVA (logMAR) improved significantly (P=0.0001) in the BRVO eyes following treatment. After treatment CMT [BRVO eyes 295 (141-558) µm, fellow eyes 234 (157-351) µm] and MCT [BRVO eyes 229 (157-329) µm, fellow eyes 233 (162-286) µm] values did not reveal any significant difference in BRVO eyes and fellow eyes (P=0.051, 0.824, respectively). CONCLUSION: In eyes with BRVO, CMT and MCT values are greater than the fellow eyes, and decrease significantly following ranibizumab injection.

Optic neuritis as a presenting symptom of Mycoplasma pneumoniae infection.

A broad range of neurologic disorders has been described in children infected with Mycoplasma pneumoniae, of which encephalitis is among the most common. In contrast, the association between optic neuritis and Mycoplasma pneumoniae infection has been rarely described in children. We report a case of a 12-year-old girl who was seropositive for antibodies against Mycoplasma pneumoniae and presented with optic neuritis without respiratory symptoms or other neurologic findings.

Ischemic retinopathy and neovascular proliferation secondary to severe head injury.

We report a case with severe head trauma and perforating globe injury in one eye and ischemic retinopathy and neovascular proliferation in the other eye. A 37-year-old male was brought to the emergency department after a motor vehicle accident with severe maxillofacial trauma. Ophthalmic examination revealed hematoma of the left eyelids as well as traumatic rupture and disorganization of the left globe. On the right eye, anterior segment and fundoscopic examination were normal. Primary globe repair was performed. At postoperative one-month visit, the right eye revealed no pathology of the optic disc and macula but severe neovascularization in the temporal peripheral retina. The patient was diagnosed as ischemic retinopathy and neovascular proliferation due to head trauma.

Interexaminer reproducibility of optical coherence tomography for measuring the tear film meniscus.

PURPOSE: New optical coherence tomography (OCT) devices with anterior segment module are able to measure the tear meniscus height (TMH) and tear meniscus area (TMA). Since the borders of the area and the height are to be marked by an examiner, the measurements are prone to be subjective. Herein, we aimed to evaluate the interexaminer reproducibility of the tear meniscus measurements with OCT. MATERIALS AND METHODS: In this prospective cross-sectional study, both eyes of 300 consecutive patients with and without dry eye were studied. Following routine ophthalmologic examination, tear-film OCT images were obtained. Two examiners, who were unaware of the other examiner's results, measured the TMH (i.e. the line connecting the intersection of the meniscus with the cornea/sclera and eyelid) and cross-sectional TMA. The reliability and correlation of the two examiners' results were assessed. RESULTS: Four right and six left eyes were excluded from the final analysis, so a total of 590 eyes were evaluated. The mean difference of the two examiners' measurements of both eyes was -0.001 ± 0.027 mm(2) in TMA, and -21.29 ± 39.95 µm in TMH. An agreement between the two examiners was found regarding TMA and TMH measurements for right and left, as well as both eyes (Cronbach's alpha > 0.900, for all). Also, the correlation between both variables was high (inter item correlation matrix > 0.840, for all). CONCLUSIONS: We showed a strong statistical agreement for both TMA and TMH measurements. According to our results, we believe that FD-OCT device is dependable in measuring the TMA and TMH values, given that its results are reproducible.

Assessment of tear meniscus with optical coherence tomography in thyroid-associated ophtalmopathy.

PURPOSE: To evaluate the tear-film meniscus with optical coherence tomography (OCT) in patients with Graves' disease (GD). MATERIALS AND METHODS: Patients with GD without clinical features of thyroid-associated ophthalmopathy (TAO) (Group 1, n=35), patients with signs of TAO (Group 2, n=31) and healthy participants (Group 3, n=31) were enrolled. Palpebral fissure width, Schirmer test, tear break-up time (TBUT) test and tear-film meniscus height and area obtained with Fourier-domain-OCT were analyzed. RESULTS: TBUT test scores were 8 s (2-25) in Group 1, 8 s (2-15) in Group 2 (p=0.380); and 10 s (5-17) in Group 3 (p=0.000 Group 1 versus 3, and 0.000 for Group 2 versus 3). Tear-film meniscus height did not significantly differ between Groups 1 and 2 (257.5 µm (86-962) and 258 µm (99-1340), respectively, p=0.980). In Group 3, tear-film meniscus height was 316 µm (122-720) (p=0.005 Group 1 versus 3 and 0.004 for Group 2 versus 3). Tear-film meniscus area did not significantly differ between Groups 1 and 2 (0.025 mm(2) (0.004-0.250) and 0.024 mm(2) (0.003-0.316), respectively, p=0.850). In Group 3, tear-film meniscus area was 0.048 mm(2) (0.006-0.75) (p=0.000 Group 1 versus 3 and 0.000 for Group 2 versus 3). CONCLUSION: Tear function is significantly disturbed in GD. OCT is an effective way to assess the tearing function also in patients with GD.

Efficacy of topical 0.05% cyclosporine treatment in children with severe vernal keratoconjunctivitis.

We aimed to determine the efficacy of topical cyclosporine in children with vernal keratoconjunctivitis refractory to topical mast cell stabilizer and antihistamine therapy. Thirty-one patients, 24 boys and 7 girls younger than 16 years of age, were included in the study. All patients were scored on a four-point scale from 0 to 3 for symptoms and signs. Each patient received topical cyclosporine 0.05% emulsion (Restasis, Allergan Inc., Irvine, CA, USA) four times daily in addition to preservative-free artificial tears and was followed for 6 months. The data was recorded before the initiation of treatment (day 0) and at the 1st, 3rd, and 6th months following treatment. After six months of treatment, severity of all symptoms and signs showed a statistically significant decrease (p<0.05). Patients did not report any serious adverse effects. Topical cyclosporine 0.05% emulsion treatment is a safe and effective treatment option for controlling the symptoms and signs of vernal keratoconjunctivitis in children.

Risk factors for intraocular pressure rise following phacoemulsification.

PURPOSE: This study was designed to analyze the risk factors resulting in high intraocular pressure (IOP), which was accepted as IOP higher than 22 mmHg, following uncomplicated phacoemulsification. MATERIALS AND METHODS: The records of 812 eyes of 584 patients who underwent uncomplicated phacoemulsification were evaluated. There were 330 men and 254 women ranging between the age of 26 and 89 years (65.4 ± 9.8 years). The preoperative, postoperative first day (day 1), first week (day 7), and first month (day 30) IOP values were analyzed. Data on history of diabetes, glaucoma, pseudoexfoliation (PXF), incision site, capsular staining with trypan blue, and surgeon were recorded. A multinomial regression analysis was performed to analyse the relationship of the factors with postoperative high IOP. RESULTS: The mean IOP was 15.6 ± 4.3 mmHg preoperatively. Postoperatively that were changed to 19.7 ± 9.0 mmHg at day 1, 12.7 ± 4.5 mmHg at day 7, and 12.8 ± 3.7 mmHg at day 30. The factors such as surgeon, presence of PXF, diabetes, surgical incision site, and trypan blue were not related to the postoperative high IOP (P > 0.05, in all). The only factor that related to high IOP at all visits was glaucoma (P < 0.005). CONCLUSION: According to our results, preoperative diagnosis of glaucoma seems to be the only factor to affect the postoperative IOP higher than 22 mmHg.

Optical coherence tomography for measuring the tear film meniscus: correlation with schirmer test and tear-film breakup time.

PURPOSE: To compare tear meniscus height (TMH) and area (TMA) values obtained by optical coherence tomography (OCT) with the Schirmer test and tear-film break-up time (TBUT) values. MATERIALS AND METHODS: In this prospective cross-sectional study, the right eyes of 300 consecutive patients were studied. All patients underwent routine ophthalmologic examination. Schirmer and TBUT measurements were taken, and tear-film OCT images were obtained. Using OCT, the TMH (i.e. the line connecting the intersection of the meniscus with the cornea and eyelid) and cross-sectional TMA were calculated. Patients were divided into Groups 1 (Schirmer values ≤5 mm) and 2 (Schirmer values >5 mm). Data were analyzed using SPSS 13.0 software. The Mann-Whitney U-test was used for the comparison of groups. Correlations between tear parameters were analyzed. RESULTS: There were no significant differences in age, logMAR, or IOP values (p = 0.480, 0.077 and 0.146, respectively) between the two groups. Mean TBUTs were 5.1 ± 2.9 and 9.5 ± 4.2 s for Groups 1 and 2, respectively (p < 0.001). Mean TMHs were 237.9 ± 108.9 and 324.3 ± 158.9 µm for Groups 1 and 2, respectively (p < 0.001). Mean TMAs were significantly lower in Group 1 compared to Group 2 (p < 0.001; 0.027 ± 0.028 versus 0.055 ± 0.059 mm(2), respectively). Correlations between Schirmer values and TMH, and between Schirmer values and TMA, were significant (p = 0.001 and <0.001, respectively). CONCLUSIONS: OCT values were significantly lower in patients with Schirmer values of <5 mm. Tear meniscus measurements obtained by OCT are reliable for establishing a diagnosis of dry eye.

Purtscher-like retinopathy related to drug-induced hypersensitivity syndrome.

PURPOSE: To report a case with Purtscher-like retinopathy related to drug-induced hypersensitivity syndrome (DIHS). DESIGN: Case report. METHODS: A 31-year-old male with fever, macula-papular rash, lymphadenopathy, and hepatitis was hospitalized. RESULTS: Eosinophilic leukocytosis, as well as cotton wool spots around the optic disc, was observed. Viral, bacteriologic, and parasitologic tests and rheumatologic markers were all negative. Given his history of antibiotic use, he was diagnosed as DIHS. On the seventh day he lost consciousness and and on the tenth day he died. CONCLUSION: Purtscher-like retinopathy might be a sign of DIHS, and should be considered in the differential diagnosis where early intervention is needed.

Management of facial disfigurement in orbitotemporal neurofibromatosis.

A 19-year-old woman with type I neurofibromatosis requested reconstruction of her severe facial disfigurement caused by the plexiform neurofibroma of the right upper eyelid. Previously, she had glaucoma surgery for buphthalmus and enucleation with dermis fat transplantation. She was unable to wear prosthesis in the last year. Transverse palpebral resection of the lesion, lateral canthal reconstruction, and frontal sling ptosis surgery were performed at the same session. Postoperatively, the cosmetic appearance of the patient was markedly improved. No complication or progression was observed during 2 years follow-up. We believe that an individual-based surgical plan may give acceptable results in these challenging cases.