Primary heavy silicone oil usage in inferior rhegmatogenous retinal detachment.

PURPOSE: To evaluate the efficacy and complications of heavy silicone oil (Densiron 68) in primary inferiorly located retinal detachment. METHODS: Sixty-seven eyes of patients aged 24-79 years with inferior primary rhegmatogenous retinal detachment with/without proliferative vitreoretinopathy grades C and lower were included in the study. The mean duration of the Densiron endotamponade was 87 days (range, 60-180 days), with a mean follow-up after removal of 110 +/- 41 days. RESULTS: Anatomical success was achieved in 64 of 67 eyes with completed follow-up. The mean visual acuity was changed significantly (p < 0.05). Partial superior redetachment occurred in 3 cases during endotamponade. No redetachment occurred after removal of the silicone oil. Postoperative best corrected visual acuity was better than 20/40 in 43 of cases at the end of follow-up. The mean intraocular pressure was 19.2 mm Hg during endotamponade follow-up. Mild to moderate intraocular inflammation was detected in 7 eyes. In 6 cases, adherence of residual bubble or bubbles was present after removal of the heavy silicone oil. Other complications, like elevated intraocular pressure (n = 6), emulsification (n = 8), temporary lens opacities (n = 14) or early cataract (n = 9), were detected after the operation. CONCLUSION: Long-term endotamponade with Densiron in inferior retinal detachment appears to be a safe and useful option.

Posterior-segment surgeries with a two-port modified multiport illumination system.

PURPOSE: The purpose of this study was to evaluate the safety and efficacy of a modified two-port multiport illumination system (MIS) in different vitreoretinal surgeries. PATIENTS AND METHODS: Sixty-one patients had undergone pars plana vitrectomy for complications of retinal diseases with the modified MIS. Only two-port pars plana vitrectomy was performed with the MIS. Visual acuity, intraoperative and postoperative complications, intraocular pressure and the retinal reattachment rate were evaluated. The mean follow-up time was 3 months (range 1-6 months). RESULTS: Visual acuity was stabilized in 40 (65.5%) of 61 eyes, improved in 15 eyes (24.5%) and deteriorated in 6 eyes (9.8%). No intraoperative complications occurred. Postoperative complications were hypotony in 12 eyes, rehemorrhage in 2 eyes and choroidal detachment in 1 eye. Five cases required conversion to standard three-port vitrectomy. Mean overall preoperative and postoperative intraocular pressures were 17.4 and 11.9 mm Hg, respectively. CONCLUSION: Despite some limitations the modified MIS with two-port sclerotomy is a good, comfortable and safe option for posterior-segment surgeries.

Inhibition of experimental proliferative vitreoretinopathy with protein kinase C inhibitor (chelerythrine chloride) and melatonin.

PURPOSE: To investigate whether a protein kinase C (PKC) inhibitor and melatonin prevent proliferative vitreoretinopathy (PVR). METHODS: Twenty pigmented rabbits were used in this study. All rabbits except controls received an intravitreal injection of 0.15 ml (75,000 units) of platelet-rich plasma into their left eye. The animals were divided into four groups: group I was treated with intravitreal injection of 0.1 ml (100 micromol/ml) of PKC inhibitor (chelerythrine chloride), group II received 1 ml (4 mg/kg) of intraperitoneal melatonin for 3 days, group III received nothing (blank group), and group IV (control group) received only 0.5 ml of 1% ethanol intraperitoneally for 3 days. Proliferative changes were graded in a masked fashion by indirect ophthalmoscopy for a 15-day follow-up period. The malondialdehyde (MDA), reduced glutathione (GSH) and total nitrite levels were measured in the vitreous humor. RESULTS: The grades of PVR were A and B in group I and II, treated with PKC inhibitor and melatonin, respectively. The PVR grade in the blank group was C-D. The mean MDA level in group I (4.2 +/- 0.9 micromol/l) was significantly lower than in the blank group (6.0 +/- 1.0 micromol/l; p < 0.05). The mean GSH level in group I (66.3 +/- 8.8 micromol/l) was not significantly different from that in the blank group (p > 0.05). The MDA and GSH levels in group II were 3.2 +/- 0.7 and 70.1 +/- 13.3 micromol/l, respectively. Both these levels were significantly different from those of the blank group (p < 0.05). The NO levels in both treatment groups were significantly lower than in the blank group (p < 0.001). CONCLUSION: These findings suggest an inhibitory effect of PKC inhibitor and melatonin on PVR. The inhibition of PVR development was associated with lower MDA and NO levels with higher GSH levels in the treatment groups.

Intravitreal cortisone injection for refractory diffuse diabetic macular edema.

PURPOSE: The purpose of this study was to evaluate the safety and efficacy of intravitreal triamcinolone acetonide injection in patients with diffuse diabetic macular edema. We also compared the effect of intravitreal triamcinolone with macular grid laser photocoagulation in macular edema. PATIENTS AND METHODS: Thirty patients with diabetic diffuse macular edema unresponsive to grid laser photocoagulation for at least 4 months received 0.1 ml (4 mg/ml) intravitreal triamcinolone acetonide (Kenakort-A) injection as treatment. This study group was compared with a control group of 30 patients (30 eyes) who had undergone grid laser macular coagulation. Mean follow-up time was 17 months (range 14-24 months) in the study group and 19 months (range 16-24 months) in the control group. RESULTS: In the study group, mean improvement in visual acuity measured 3.8, 3.4, 0.9 and 0.2 Snellen lines at the follow-up intervals of 1, 3, 6 and 12 months, respectively. Improvement in visual acuity was statistically significant only at 1 month (p = 0.002) and 3 months (p = 0.003) after injection. Visual acuity was significantly (p < 0.05) better in the study group than the control group at 1 and 3 months. Overall, 6 of 30 eyes (20%) required a second injection and 3 eyes (10%) a third due to regression in visual acuity. Towards the end of the follow-up period, the visual acuity decreased to almost baseline levels. Elevation of intraocular pressure was found in 4 patients and controlled with topical antiglaucomatosis treatment. Sterile endophthalmitis was detected in only one eye. No eye exhibited cataract progression during the follow-up period. CONCLUSION: Intravitreal injection of triamcinolone may be beneficial for temporarily increasing visual acuity in patients with diabetic diffuse macular edema who are unresponsive even to grid laser photocoagulation. But the regression of visual acuity looks inevitable in the long term after injection. Therefore, repeated injections with/without increasing doses might be required for the stabilization of visual acuity.

Adrenomedullin and leptin levels in diabetic retinopathy and retinal diseases.

PURPOSE: Proliferative and vascular retinal diseases are important cause of irreversible blindness. Consistent features of these diseases are endothelial dysfunction and angiogenesis. Adrenomedullin (ADM) is a multifunctional vasorelaxant peptide. Leptin is a recently discovered metabolic peptide that regulates energy metabolism in human. In the present study, we aimed to investigate the possible roles of adrenomedullin and leptin in the pathophysiology of diabetic and proliferative diseases. METHODS: Ten patients with proliferative diabetic retinopathy (57.1 years, 5 female and 5 male) and 8 patients (51 years, 5 female and 3 male) with other retinal diseases including macular hole and epiretinal membrane were included in this study. All the patients had undergone pars plana vitrectomy for complications of the diseases. Vitreous samples were collected by vitreous tap during the vitrectomy. Adrenomedullin analysis was made by using reverse-phase high-performance liquid chromatography (HPLC). Leptin was measured by enzyme-linked immunosorbent assay (ELISA). Body mass index (BMI) [weight (kg)/height (m2)] was calculated for each group. The Mann-Whitney U test was used for statistics. RESULTS: The age, gender ratio and BMI were not substantially different between the two groups. The mean vitreous adrenomedullin levels (63.9+/-7.1 pmol/l) were significantly higher (p<0.05) in group I than in group II (34.25+/-3.0 pmol/l). Leptin levels in vitreous (4.54+/-1.6 ng/ml) were also significantly higher (p<0.05) in patients with diabetic retinopathy than in those without diabetes (1.83+/-0.5 ng/ml). CONCLUSION: Increased adrenomedullin and leptin levels in vitreous humor might be a possible newly associated factor in the course of vascular and proliferative retinal diseases.

Surgical excision, cryotherapy, autolimbal transplantation and mitomycin-C in treatment of conjunctival-corneal intraepithelial neoplasia.

PURPOSE: To report surgical excision, cryotherapy, autologous conjunctival-limbal transplantation and topical mitomycin C (MMC) in the patient with extensive conjunctival-corneal intraepithelial neoplasia. METHODS: Case report and literature review. RESULTS: A 75-year-old woman was referred to our department with the diagnosis of conjunctival-corneal neoplasia. Slit-lamp microscopic examination revealed an extensive papilliform tumoral mass invading the limbus at 360-degrees, and bulbar conjunctiva and cornea. Visual acuity was finger counting from 2 m in the right eye and 20/20 in the left eye. We performed total surgical excision, cryotherapy and autologous conjunctival-limbal transplantation in the right eye. Mitomycin-C 0.02% eye drops four times a day were prescribed for 4 weeks after the surgery. After the treatment, the visual acuity increased to 0.7 in the right eye. Corneal epithelium completely healed within 1 week after the surgery. No corneal epithelium-related problem or neoplasia recurrence were noted during the 2-year follow-up period. CONCLUSIONS: This technique may be useful in reconstruction of eyes with extensive neoplastic involvement of the conjunctiva, limbus, and cornea. In addition, mitomycin C drops may be useful in preventing postoperative recurrence of conjunctival-corneal intraepithelial neoplasia.

Use of caffeic acid phenethyl ester and cortisone may prevent proliferative vitreoretinopathy.

PURPOSE: To investigate whether caffeic acid phenethyl ester (CAPE) and cortisone prevent proliferative vitreoretinopathy (PVR). METHODS: Twenty pigmented rabbits were used in this study. All rabbits except controls received an intravitreal injection of 0.15 ml (75,000 U) of platelet-rich plasma into their left eye. The animals were divided into four groups: group I was treated with intraperitoneal injection of 0.5 ml (15 micromol/kg) of CAPE for 3 days, group II received 0.15 ml (4 mg/kg) of intravitreal cortisone, group III received nothing (blank group), and group IV (control group) received only 1 ml of 1% ethanol intraperitoneally daily for 3 days. Proliferative changes were graded in a masked fashion by indirect ophthalmoscopy for a 15-day follow-up period. The malondialdehyde (MDA), reduced glutathione (GSH) and total nitrite (NO) levels were measured in the vitreous humor. RESULTS: The grades of PVR were B-C in group I, and C-D in group II. The PVR grade in the control group was C-D. The mean MDA level in group I (4.0+/-0.8 micromol/l) was significantly lower than in the blank group (6.0 micromol/l) (p < 0.05). The mean GSH level in group I (71.0+/-11.2 micromol/l) was significantly different than in the blank group (p < 0.05). The MDA and GSH levels in group II were 4.7+/-0.6 micromol/l and 53.8+/-7.8 micromol/l, respectively. Both these levels were not significantly different from the blank group (p > 0.05). The NO levels in both treatment groups were significantly lower than in the blank group (p < 0.001). CONCLUSION: These findings suggest an inhibitory effect of CAPE on PVR. The inhibitory effect was supported by lower MDA and NO with higher GSH levels in treatment groups than in the blank group. There was no detected significant effect of cortisone for preventing PVR experimentally.

Nitric oxide and lipid peroxidation are increased and associated with decreased antioxidant enzyme activities in patients with age-related macular degeneration.

BACKGROUND: Nitric oxide (NO), hydroxyl radical (OH*), superoxide anion (O2-) and hydrogen peroxide (H2O2) are free-radicals released in oxidative stress. Superoxide dismutase (SOD), glutathione peroxidase (GSHPx) and catalase (CAT) are antioxidant enzymes, mediating defense against oxidative stress. Excess NO and/or defective antioxidants cause lipid peroxidation, cellular dysfunction and death. Age-related maculopathy (ARM) or degeneration (ARMD) is the leading cause of irreversible blindness in developed countries. The etiology is unclear and the molecular factors contributing this disease remain to be specified. AIMS: This multicenter, double-blind, cross-sectional study aimed to investigate plasma NO and lipid peroxidation levels with relation to antioxidant enzyme activities in erythrocyte and plasma of patients with ARMD compared with healthy control subjects. METHODS: NO, lipid peroxidation (measured as plasma malondialdehyde [MDA] levels) and the catalytic activity of SOD, GSHPx and CAT were measured in a group of 41 patients with maculopathy (19 men, 22 women; 67.12 +/- 3.70 years) and compared with 25 age- and sex-matched healthy control subjects without maculopathy (12 men, 13 women; 68.04 +/- 3.02 years). NO and MDA levels were measured in plasma, CAT in red blood cells (RBCs), and SOD and GSHPx in both plasma and RBCs. Color fundus photographs were used to assess the presence of maculopathy, and the patients were divided into two groups using clinical examination and grading of photographs; early-ARM (n = 22) and late-ARMD (n = 19). RESULTS: All patients with maculopathy had significantly (p < 0.001) higher plasma NO levels over control subjects (mean +/- SD, 48.58 +/- 8.81 vs. 28.22 +/- 3.39 micromol/l). Plasma MDA levels in patients and control subjects were 4.99 +/- 1.00 and 2.16 +/- 0.24 micromol/l, respectively, and the difference was significant (p < 0.001). On the other hand, SOD and GSHPx activities were significantly lower in both RBCs and plasma of patients with maculopathy than in control subjects (RBCs-SOD, 3509.30 +/- 478.22 vs. 5033.30 +/- 363.98 U/g Hb, p < 0.001; plasma-SOD, 560.95 +/- 52.52 vs. 704.76 +/- 24.59 U/g protein, p < 0.001; RBCs-GSHPx, 663.43 +/- 41.74 vs. 748.80 +/- 25.50 U/g Hb, p < 0.001; plasma-GSHPx, 98.26 +/- 15.67 vs. 131.80 +/- 8.73 U/g protein, p < 0.001). RBCs-CAT levels were not different between groups (131.68 +/- 12.89 vs. 133.00 +/- 13.29 k/g Hb, p = 0.811). Late-ARMD patients had significantly lower antioxidant enzyme levels and higher MDA levels when compared with early-ARM patients (for each, p < 0.001). In addition, plasma NO and MDA levels were negatively correlated with SOD and GSHPx activities. CONCLUSIONS: This study demonstrated for the first time that NO, the most abundant free-radical in the body, might be implicated in the pathophysiology of ARMD in association with decreased antioxidant enzymes and increased lipid peroxidation status.

Comparison of secondary implantation of flexible open-loop anterior chamber and scleral-fixated posterior chamber intraocular lenses.

PURPOSE: To analyze and compare the outcomes and complication rates of secondary implantation of flexible, open-loop, anterior chamber intraocular lenses (AC IOLs) and single-piece, scleral-fixated, posterior chamber IOLs (PC IOLs). SETTING: Departments of Ophthalmology, Gaziantep University Medical Faculty, Research Hospital, Gaziantep, and Inönü University Medical Faculty, Research Hospital, Malatya, Turkey. METHODS: This study comprised 124 eyes of 113 aphakic patients (61 men, 52 women) with insufficient capsule support who had secondary IOL implantation from January 1997 to June 2001. In Group 1 (n = 73 eyes), a flexible, open-loop AC IOL was implanted and in Group 2 (n = 51 eyes), a single-piece, scleral-fixated PC IOL. The mean follow-up was 34 months (range 6 to 53 months) and took place at several different clinical settings. The mean interval between the initial cataract operation and secondary IOL implantation was 63 months (range 6 months to 12 years). The postoperative outcomes, safety, efficacy, and complication rates were analyzed, and the preoperative and postoperative best spectacle-corrected visual acuities (BSCVAs) were compared. RESULTS: The postoperative mean BSCVA was 20/34.8 +/- 45.2 (SD) in Group 1 and 20/32.1 +/- 33.7 in Group 2; the difference was not significant (P =.718). A BSCVA of 20/40 or better was achieved in 62 eyes (84.9%) in Group 1 and 45 eyes (88.2%) in Group 2. A BSCVA of 20/25 or better was achieved in 40 eyes (54.8%) and 33 eyes (64.7%), respectively. The difference between the 2 groups was not significant (P =.472). Complications occurred in 25 eyes (34.2%) in Group 1 and 13 eyes (25.5%) in Group 2 (P >.05). The most frequent complications in Group 1 were early transient corneal edema, intraocular pressure elevation, cystoid macular edema, hyphema, secondary glaucoma, and iris capture or pupil decentration and in Group 2, suture erosion, a tilted or decentered IOL, fibrin reaction, and vitreous prolapse into the anterior chamber. CONCLUSIONS: The AC IOLs and PC IOLs were safe and effective for secondary implantation to correct aphakia. Secondary implantation of the scleral-fixated PC IOL seemed to provide a more favorable outcome and a lower complication rate than the open-loop AC IOL in complicated cataract cases with inadequate capsule and zonular support. As scleral-fixated PC IOL implantation is technically more difficult than AC IOL implantation, the decisive factor in choosing a secondary IOL is surgical experience. Long-term comparison of both techniques is required.

Urinary nitric oxide levels are increased and correlated with plasma concentrations in patients with Behçet's disease: is it a new urinary activity marker?

Nitric oxide (NO) is a free radical and serves many functions within the kidney. Excess NO causes glomerular injury. Behçet's disease (BD) is a systemic immunoinflammatory vasculitis, affecting every organ in the body including the kidneys (subclinic glomerulonephritis). We investigated the role of urinary total nitrite levels (end product of NO) in BD and evaluated whether urinary concentrations were correlated with its plasma levels or disease activity. Thirty-six consecutive Behçet's patients (19 men, 17 women; 35.9 years), and 20 age- and sex-matched healthy control volunteers (12 men, eight women; 33.2 years) were divided into an active (n = 16) and inactive (n = 20) period. Urinary and serum NO levels ( micromol/mg urinary creatinine) were higher in BD patients (4.1 +/- 0.3) than control subjects (1.7 +/- 0.2; P < 0.001). Serum NO levels in Behçet's patients and control subjects were 51.3 +/- 9.8 and 21.7 +/- 7.3 micromol/L, respectively (P < 0.001). Active patients had higher urinary NO excretion (4.9 +/- 0.3) than inactive patients (3.3 +/- 0.3; P < 0.01). Urinary NO levels were correlated with its serum levels (r2 = 0.69, P < 0.001). Higher urinary NO levels found in BD may be produced by the kidney as a result of an inflammatory stimulation. As excess NO is toxic to the tissues, increased NO levels may play a role in mediating subclinic glomerular injury of such patients. However, we could not determine the exact site(s) of NO synthesis by the kidney, such as the glomeruli, blood vessels and/or the tubular cells. Whatever the source, urinary NO levels may be used as a new activity marker in the diagnosis and follow up of BD by serial measurements.