Treatment of the lower eyelid with the CO2 laser: transconjunctival or transcutaneous approach?

PURPOSE: To compare the effects of CO(2) laser transcutaneous blepharoplasty with CO(2) laser transconjunctival blepharoplasty with simultaneous resurfacing for the treatment of lower lid dermatochalasis. METHODS: Thirteen men and 23 women, between 42 and 67 years of age, participated in this study. Patients were divided into two groups: (1) CO(2) laser transconjunctival blepharoplasty with resurfacing or (2) CO(2) laser transcutaneous blepharoplasty by the skin-muscle approach without resurfacing. The two operative techniques were compared with regard to the patient's satisfaction, complications and effectiveness on lower lid bulging and wrinkles. RESULTS: Transconjunctival blepharoplasty with simultaneous laser resurfacing yielded satisfactory results with improvement of the lower lid bulging in 92% of the 20 subjects. Persistent erythema was seen in only 5% and hiperpigmentation in 10% of this group, but 80% of the patients complained of long postoperative care. On the other hand, with the transcutaneous approach, lower lid bulging was perfect in 98% of the 16 subjects; although the rate of complications such as lateral canthal rounding (3.2%) and ectropion (6.25%) was higher, the patients had no problems with the period of postoperative care. Fourteen of 16 subjects in this group also demonstrated a better appearance of the lower lid wrinkles. CONCLUSION: Although transconjunctival blepharoplasty with laser resurfacing is now the most common surgical procedure for lower eyelid dermatochalasis and orbital fat herniation, postoperative care after laser resurfacing can be a problem in a certain group of patients. Transcutaneous blepharoplasty via the skin-muscle approach may be preferable in certain cases because of the short recovery period.

Comparison of corneal thickness of long-term contact lens wearers for different types of contact lenses.

PURPOSE: To compare the central corneal thickness (CCT) values of long-term wearers of different types of contact lenses with those of each other and a normal control group. METHODS: Twenty-three healthy eyes with no history of contact lens wear were used for the control group. Forty-eight eyes were evaluated in four different groups according to the type of contact lens worn; each group comprised 12 eyes. Group 1 (SofLens 38) and group 2 (Contact Day 30) had worn daily-wear frequent-replacement soft contact lenses with a 38% and 55% water content, respectively, and they had worn their lenses for an average of 4.28 +/- 1.70 years and 3.71 +/- 1.11 years, respectively. Group 3 (Wöhlk A90) and group 4 (Conflex-air) had worn daily-wear rigid gas-permeable (RGP) contact lenses with a Dk/t value of 68 and 22, respectively, and they had worn their lenses for an average of 3.00 +/- 0.63 years and 3.25 +/- 1.17 years, respectively. CCT values in micrometers were measured by optical coherence tomography. RESULTS: When comparing the CCT between the control group and the contact lens groups, the CCT was significantly thinner in the group wearing Conflex-air RGP contact lenses with a low Dk/t value (P = 0.010). In comparing the CCT among the four contact lens groups, the CCT was significantly thinner in the group wearing SofLens 38 contact lenses with a water content of 38% than in the group wearing Contact Day 30 contact lenses with a water content of 55% (P = 0.004). There was also significant thinning in the group wearing Conflex-air RGP contact lenses versus the group wearing Contact Day 30 soft contact lenses (P = 0.0005). CONCLUSIONS: CCT was significantly thinner in patients wearing long-term low-Dk/t RGP contact lenses compared to no contact lens wear and soft contact lenses with a water content of 55%. CCT was also decreased significantly in long-term soft contact lens wear with a water content of 38% compared to 55%.

Upper lid blepharoplasty in patients with LASIK.

PURPOSE: To investigate the changes in tear secretion and tear film stability after upper lid blepharoplasty in patients that had previously undergone excimer laser in situ keratomileusis (LASIK). METHODS: We performed carbon dioxide (CO2) laser upper lid blepharoplasty to 18 eyes of 9 patients that had undergone bilateral LASIK at least 18 months before the surgery. Six women and 3 men aged 35 to 52 were included in this group. An additional control group of 18 eyes of similar age patients with no history of LASIK, contact lens usage or dry eye symptoms were studied. We studied the Schirmer tear test values without anesthesia at 5 minutes in both groups before and after the upper lid blepharoplasty procedure. Tear break-up time values were also measured before and 4 weeks after (CO2) laser upper lid blepharoplasty. The Schirmer tear test and tear break-up time values were analyzed statistically using the independent t-test. RESULTS: The mean Schirmer tear test value was 19.07 +/- 4.03 mm in both eyes of the patients who had undergone LASIK and upper lid blepharoplasty, and it was 21.07 +/- 7.03 mm in the eyes of the control group that only had (CO2) laser upper lid blepharoplasty. The mean tear break-up time value was 21.0 +/- 3.55 seconds in the eyes that had LASIK treatment, and it was 21.27 +/- 6.79 seconds in the eyes of the control group. There was no statistical difference between the two groups. CONCLUSION: Because LASIK and blepharoplasty both may cause dry eye symptoms, the possible cumulative effect of these surgeries is a serious consideration. However, dry eye symptoms after LASIK is usually temporary, and we may perform upper lid blepharoplasty to these patients after a certain time interval by closely monitoring their preoperative and postoperative tear function.

Microbial changes in conjunctival flora with 30-day continuous-wear silicone hydrogel contact lenses.

PURPOSE: To determine the effect of 30-day continuous-wear silicone hydrogel contact lenses on the conjunctival flora in asymptomatic wearers. METHODS: The authors studied 29 eyes of 15 patients wearing Focus NIGHT & DAY silicone hydrogel contact lenses for up to 30 nights of continuous wear. The average age of the patients was 25.54 +/- 8.98 years. Cultures of the inferior cul-de-sac were taken bilaterally from all eyes, before and after lens wear in asymptomatic patients. The isolation and identification of bacteria were made by standard clinical laboratory methods. RESULTS: The number of eyes whose conjunctival cultures were sterile before using the lenses significantly decreased (P = 0.0005), and the number of eyes with a growth of coagulase-negative staphylococci and diphtheroid rods in their conjunctival cultures significantly increased after using these lenses (P = 0.001 and P = 0.031, respectively). Conversely, a statistically significant difference was not found in the number of eyes that carried Propionibacterium acnes and Fusobacterium nucleatum in their conjunctival cultures before and after using the 30-day continuous-wear silicone hydrogel lenses (P = 0.998 and P = 0.488, respectively). CONCLUSIONS: The results suggest that the sterility of the conjunctiva significantly decreased after using 30-day continuous-wear silicone hydrogel contact lenses. In addition, the number of bacteria of the normal conjunctival flora significantly increased after the use of these lenses. Contamination by the bacteria of the eyelids may be a possible colonization factor in this study group. Therefore, it is appropriate to examine the patients who wear these lenses more frequently.

Failure to detect hepatitis B virus in vitreous by polymerase chain reaction.

PURPOSE: To assay the vitreous of asymptomatic hepatitis B virus (HBV) carriers for the presence of HBV DNA using polymerase chain reaction (PCR). METHODS: Vitreous and serum specimens were collected from 13 carriers of HBV. The presence of HBV DNA was investigated by using PCR and Digene's Hybrid Capture System. The presence of hepatitis B surface antigen (HBsAg) in vitreous was also investigated by using the enzyme immunoassay (EIA). RESULTS: The serum was positive for HBV DNA in3 of the 13 asymptomatic carriers using PCR. Vitreous samples of all the patients, including 3 patients who were positive for HBV DNA in serum, were negative for HBV DNA with PCR and were negative for HBsAg with EIA. CONCLUSION: There is no evidence of HBV in the vitreous of asymptomatic HBV carriers.

Treatment of xanthelasma palpebrarum with argon laser photocoagulation. Argon laser and xanthelasma palpebrarum.

PURPOSE: We report the results of argon laser coagulation of xanthelasma lesions. METHODS: Forty eyelids of 24 patients with xanthelasma were treated in 1 to 4 sessions at 2-3 week intervals, using an argon green laser. The laser parameters were as follows: wavelength 514 nm; spot size 500 microns; energy 900 mW; the duration of the laser pulse 0.1-0.2 seconds. The procedure was done on outpatient basis. A gauze pad soaked in topical anaesthetic eye drops was applied to the surface of the lesion. RESULTS: The therapy was well tolerated, and all lesions responded to the therapy. There were no complications and no functionally relevant scar developed. The cosmetic outcome was considered to be good in 85% of the cases. CONCLUSION: Argon laser photocoagulation represents an alternative treatment in selected cases. It is easy to perform and well tolerated by the patients.

Structural features of attached retina in rhegmatogenous retinal detachments.

PURPOSE: To examine the thickness and structural features of the ophthalmoscopically normal-appearing, attached retina in rhegmatogenous retinal detachments by optical coherence tomography (OCT) and compare them with those of the fellow eye. METHODS: Seventy eyes of 35 patients with rhegmatogenous retinal detachments were included in this study. The retinal detachments were not total. None of the patients had pathologic myopia or a history of ocular surgery. The fellow eyes were ophthalmoscopically normal and used as controls. Attached retinal sites of the eyes with a retinal detachment and the corresponding retinal sites of the fellow eyes were examined by OCT. Three OCT sections were taken from each eye, and thicknesses of three reflective zones corresponding to the inner part of the neurosensory retina (partial neurosensory retina), photoreceptor-photoreceptor outer segment, and total retinal thickness on each OCT section were measured and compared with those of the fellow eye. These three measurements were taken as the main outcome measures and performed on five different sites of each OCT section taken from each eye. RESULTS: The mean partial neurosensory retinal thickness of the attached retina in the eyes with a retinal detachment and the corresponding retinal sites in the fellow eyes was 172.74 +/- 14.23 microm and 170.60 +/- 16.51 microm, respectively. There was no statistically significant difference between these two values. The mean photoreceptor outer segment thickness of the attached retina in the eyes with a retinal detachment and the corresponding retinal sites in the fellow eyes was 62.74 +/- 12.02 microm and 58.23 +/- 15.14 microm, respectively. There was a statistically significant difference between these two values. The mean total retinal thickness of the still-attached retina in the eyes with a retinal detachment and the corresponding retinal sites in the fellow eyes were 293.23 +/- 27.87 microm and 277.06 +/- 19.12 microm, respectively. There was a statistically significant difference between these two values. CONCLUSIONS: The main difference between the two groups of eyes was at the level of the thickness of the black hyporeflective zone, corresponding anatomically to the photoreceptor and photoreceptor outer segment that enlarges in the retinal detachments. Therefore, there may be a subclinical retinal detachment or a global retinal relaxation even in the ophthalmoscopically normal-appearing, still-attached retina. This may be the underlying cause of preoperative and postoperative signs and symptoms. Additional studies are required to confirm these findings.

Microvascular blood flow of the optic nerve head and peripapillary retina in unilateral exfoliation syndrome.

PURPOSE: To measure microvascular blood flow in patients with unilateral exfoliation syndrome (XFS) without glaucoma or ocular hypertension and to compare the values in the eyes with clinically detected exfoliation, their nonexfoliative fellow eyes of the same patients and control eyes. METHODS: Twenty-two patients with clinically detected unilateral XFS and 30 age-matched healthy subjects were included in this study. Group 1 consisted of 22 eyes with clinical XFS, and the nonexfoliative fellow eyes of the same patients formed Group 2. The control group (Group 3) comprised te randomly selected eyes of 30 age-matched healthy subjects. Ocular blood flow values (volume, flow and velocity) were recorded from the opti nerve head (ONH) and peripapillary retina (PPR) using the Heidelberg retinal flowmeter (HRF). The difference between the three groups were compared statistically. RESULTS: The mean values of blood flow obtained from the ONH and PPR in eyes with clinically detected exfoliation (Group 1) and their nonexfoliative fellow eyes (Group 2) were both significantly lower than the values for the control eyes (Group 3). The differences in ocular blood flow between the eyes with exfoliation and the nonexfoliative fellow eyes were not statistically significant [one-way analysis of variance (ANOVA), Dunnett's T3 test, p >/= 0.05]. CONCLUSION: These findings suggest that the eyes with clinically detected unilateral XFS were associated with reduced blood flow values in both the ONH and the PPR. The nonexfoliative fellow eyes also have lower blood flow values than the control eyes.

Interleukin-8, nitric oxide and glutathione status in proliferative vitreoretinopathy and proliferative diabetic retinopathy.

PURPOSE: To evaluate interleukin-8 (IL-8), nitric oxide (NO) and glutathione (GSH) profiles in vitreous humor and blood samples in patients with proliferative diabetic retinopathy (PDR) and in patients with proliferative vitreoretinopathy (PVR) and to compare the levels with those of controls. PATIENTS AND METHODS: NO concentrations were determined by using the Greiss reaction in plasma and vitreous humor samples. GSH levels were determined in both blood and vitreous humor samples, using DTNB, a disulfide chromogen. Vitreous IL-8 were assayed by ELISA. Twenty-three patients with PDR, 18 patients with PVR and 21 cadavers as the control group were included in the study. RESULTS: Plasma and vitreous NO levels were found to be 25.6 +/- 2.1 and 36.9 +/- 3.0 micromol/l in patients with PDR, 27.0 +/- 4.7 and 34.3 +/- 2.9 micromol/l in patients with PVR and 17.4 +/- 2.7 and 15.9 +/- 1.4 micromol/l in controls, respectively. Vitreous humor and plasma NO levels did not show any statistically significant difference between PDR and PVR groups. However, the values for vitreous in both groups were significantly higher than those of controls (p < 0.0001). Although IL-8 levels in vitreous samples of patients with PDR were not significantly different (79.6 +/- 9.7 pg/ml) from those of patients with PVR (42.2 +/- 7.3 pg/ml) (p = 0.06), the levels in both groups were significantly higher than those of controls (19.0 +/- 3.9 pg/ml) (p < 0.0001 and p < 0.05, respectively). Blood and vitreous GSH levels were found to be 5.3 +/- 0.4 micromol/g. Hb and 0.58 +/- 0.16 micromol/l in patients with PDR and 8.4 +/- 0.5 micromol/g. Hb and 15.7 +/- 2.2 micromol/l in patients with PVR and 12.0 +/- 1.1 micromol/g. Hb and 0.26 +/- 0.03 mmol/l in controls, respectively. Vitreous and blood GSH levels were significantly lower in patients with PDR compared to those with PVR (p < 0.0001 for both). CONCLUSION: Elevated levels of vitreous and plasma NO and vitreous IL-8 in PDR and PVR implicate a role for these parameters in the proliferation in these ocular disorders. GSH concentrations both in vitreous and blood samples of the PVR and PDR patients were much less than those observed in the control group. Lower GSH concentrations detected in PDR in comparison with those in PVR in vitreous humor and to a lesser degree in blood may play an important role in pathogenesis of new retinal vessel formation in patients with PDR. This also suggests that oxidative stress may be involved in the pathogenesis of PVR and particularly that of PDR.

Long term follow-up of retinal nerve fiber layer thickness in eyes with optic nerve head drusen.

PURPOSE: To investigate the effect of optic nerve head drusen (ONHD) on the retinal nerve fiber layer (RNFL) thickness during follow-up period. METHODS: Twenty-three non-glaucomatous eyes having clinically visible ONHD confirmed by colored disc photos were studied. RNFL thickness was determined with Optical Coherence Tomography (OCT). Eyes were re-examined after average of 18 months (ranging between 14 and 22 months). Mean RNFL thickness of each quadrant was compared with previous results at each follow-up visit. RESULTS: Mean RNFL thickness was 88.43 +/- 10.2 micron at first visit and 90.35 +/- 6.9 micron at follow-up in eyes with clinically visible ONHD. The difference between the mean RNFL thickness measured from inferior, superior, nasal and temporal quadrant at first and follow-up visits was not significant (paired t-test, p > 0.05). CONCLUSION: The presence of drusen was found to have no effect on RNFL thickness at follow-up visits. OCT may provide a useful means to evaluate and follow up the RNFL thickness in these patients.

Early surgery for dysthyroid orbitomyopathy based on magnetic resonance imaging findings.

PURPOSE: To investigate the value of magnetic resonance imaging (MRI) in the determination of the fibrotic phase in dysthyroid orbitopathy, which may be an indication for early surgery. PATIENTS AND METHODS: Thirteen patients with dysthyroid orbitopathy who had vertical deviation in excess of 20 PD and associated diplopia in the primary position that did not respond to medical treatment were included in the study. On MRI, the absence of high-intensity foci in the T2 sequence, especially in the coronal planes, indicated that the extraocular muscles were not edematous. These muscles were evaluated as being in the fibrotic phase, and surgery was performed without waiting the recommended 6 months for the stabilization of the angle of deviation. RESULTS: The complaint of diplopia disappeared after a single operation in 8 patients, and after a second operation in 4. Thus, success was obtained in 12 of the 13 patients. One patient with persistent vertical diplopia refused a second operation. CONCLUSION: Our results indicate that MRI is an effective and reliable method for the determination of the fibrotic phase in patients with dysthyroid orbitopathy who have diplopia in the primary position, and that MRI results have an important role in determining whether early surgery is appropriate.

The capillary blood flow in ischaemic type central retinal vein occlusion: the effect of laser photocoagulation.

PURPOSE: To determine the effect of photocoagulation on retinal blood flow (RBF) in eyes with ischaemic type central retinal vein occlusion (CRVO). PATIENTS AND METHODS: Retinal blood flow was measured in 12 eyes with CRVO, 12 fellow eyes and 12 eyes of 12 age-matched healthy subjects using the Heidelberg retinal flowmeter (HRF). Microvascular blood flow values (volume, flow, velocity) were recorded from the upper temporal retina and macula. Eyes were re-examined 1 month after photocoagulation. We investigated whether there was a difference in RBF measurements before and after photocoagulation treatment. RESULTS: In eyes with CRVO, mean RBF values (volume, flow and velocity) obtained from the upper temporal retina increased significantly after treatment (paired t-test, p < 0.05). In contrast, mean RBF values from the macula were unaffected by photocoagulation (paired t-test, p > 0.05). Retinal blood flow values from the upper temporal retina obtained from control subjects were significantly higher than the values in eyes with CRVO before and after photocoagulation (unpaired t-test, p < 0.05), but there was no significant difference between control subjects and CRVO patients in RBF values from the macula (unpaired t-test, p > 0.05). Mean RBF values were significantly higher in CRVO patients' fellow-eyes before photocoagulation in the eyes with CRVO (paired t-test, p < 0.05) but were lower than in age-matched healthy control eyes (unpaired t-test, p < 0.05). Macular blood flow did not differ between the eyes with CRVO and fellow eyes (paired t-test, p > 0.05). CONCLUSION: Laser photocoagulation increased retinal blood flow in eyes with CRVO, but RBF did not reach normal values. Photocoagulation was found to have no effect on RBF in the macular area.

Intravitreal penetration of cefepime after systemic administration to humans.

PURPOSE: To investigate the penetration of cefepime (a fourth-generation cephalosporin) into the vitreous after single-dose intravenous administration to human subjects. METHODS: Thirty phakic patients about to undergo vitreous surgery received 1 g (group 1, 15 patients) or 2 g cefepime (group 2, 15 patients) in a single intravenous injection before surgery. The indications for vitreous surgery were retinal detachment with proliferative vitreoretinopathy (24 patients), retinal detachment associated with giant retinal tear (4 patients), macular hole (1 patient) and intraocular foreign body (1 patient). Samples of vitreous and serum were obtained at 0.5, 1, 2, 4 and 12 h after injection. Three patients were used for each sampling time and for 1 g and 2 g of cefepime. Samples were assayed for cefepime concentrations with high-performance liquid chromatography (HPLC). RESULTS: All the patients had detectable cefepime in their vitreous and serum measurable by HPLC. The level of cefepime in the vitreous peaked at 2 h and reached a minimum at 12 h after intravenous injection in both groups. A mean peak vitreous level of cefepime was 1.91 +/- 0.13 microg/ml in group 1 and 2.86 +/- 0.37 microg/ml in group 2. The level of cefepime in the vitreous at 12 h after injection was 0.89 +/- 0.14 microg/ml in group 1 and 0.97 +/- 0.30 microg/ml in group 2. CONCLUSION: The vitreous level of cefepime after intravenous injection was below the minimum inhibitory concentration (MIC(90)) against Staphylococcus aureus, Staphylococcus epidermidis and Pseudomonas aeruginosa, but was over the MIC(90) against Proteus mirabilis, Klebsiella spp., Haemophilus influenzae, Streptococcus pneumoniae, Streptococcus pyogenes and Enterobacter spp.

Repair of Descemet's membrane detachment after viscocanalostomy.

We report an alternative descemetopexy technique in a case of Descemet's membrane detachment after viscocanalostomy, possibly caused by high-molecular-weight viscoelastic material.

Determining the lowest trypan blue concentration that satisfactorily stains the anterior capsule.

PURPOSE: To determine the lowest concentration of trypan blue that will stain the anterior capsule satisfactorily to perform a safe continuous curvilinear capsulorhexis and to describe a staining technique using a dispersive viscoelastic material. SETTING: Cerrahpasa School of Medicine, University of Istanbul, Istanbul, Turkey. METHODS: Trypan blue 0.1% (Vision Blue) was diluted by half by adding an equal volume of balanced salt solution (BSS) in a stepwise pattern continuously until the concentration failed to stain the anterior capsule satisfactorily. After the dilution, 4 concentrations of the dye were obtained: 0.050%, 0.025%, 0.0125%, and 0.00625%. The volume of dye used for staining was 0.1 cc at all concentrations. Each concentration of the dye was applied using a classic air-bubble technique or a technique in which the dye was injected under sodium hyaluronate 3.0%-chondroitin sulfate 4.0% (Viscoat) onto the anterior lens surface without using an air bubble to reform the anterior chamber. Each diluted concentration was used in 10 eyes by the same surgeon, with 5 eyes having the air-bubble technique and 5 having the viscoelastic technique. The 0.1% concentration was used in 5 eyes, all having the viscoelastic technique. RESULTS: Trypan blue in concentrations as low as 0.0125% stained the anterior capsule satisfactorily. In addition, staining was possible under the Viscoat. The viscoelastic technique was faster, safer, and easier to perform than the air-bubble technique. CONCLUSIONS: As trypan blue is a potentially carcinogenic vital dye and its possible long-term side effects are unknown, the lowest effective concentration should be used. A concentration lower than 0.1% was effective in staining the anterior capsule even under dispersive viscoelastic material.

The effect of artificial tears on corneal surface regularity in patients with Sjögren syndrome.

PURPOSE: To evaluate the effect of artificial tears on the topographic parameters associated with corneal surface regularity in patients with Sjögren syndrome. METHODS: A total of 38 eyes of 20 patients with Sjögren syndrome were evaluated prospectively. The mean age of the patients was 50.5 +/- 15.3 years (range, 28-76). Corneal topography with the Topographic Modeling System (TMS-2, Tomey) was performed before and after the instillation of artificial tears. The surface regularity index (SRI), surface asymmetry index (SAI), potential visual acuity (PVA) and mean astigmatism were compared in dry eyes before and after the instillation of artificial tears. RESULTS: Before the instillation of artificial tears SAI, SRI, PVA and mean antigmatism values were found to be 1.37 +/- 1.47, 0.74 +/- 0.42, 20/30.92 +/- 20/8.12 and 1.53 +/- 1.47 D, respectively. In corneal topography performed after the instillation of artificial tears SAI, SRI, PVA and mean astigmatism values were 0.71 +/- 0.82, 0.43 +/- 0.36, 20/25.92 +/- 20/5.55 and 1.08 +/- 1.18, respectively. When compared statistically, the SRI, SAI, and mean astigmatism all decreased significantly and the PVA improved (p = 0.0001). CONCLUSION: Irregular corneal surface in dry eye patients affects optical quality. The statistically significant improvement observed in SRI and SAI values after the instillation of artificial tears also improves the PVA that is especially related to SRI.