An Eye for A Foot: Alarming Unawareness of Diabetic Retinopathy Among Diabetic Foot Patients.

This study aims to determine the awareness of diabetic retinopathy in patients hospitalized for diabetic foot ulcers, examine their clinical and demographic characteristics, and evaluate their treatment needs. In this prospective study, 62 consequent patients with diabetic foot ulcers who were hospitalized for further treatment in Diabetic Foot Department between June and August 2023 were subjected to ophthalmological examinations. Detailed anterior and posterior segment examinations were performed. Clinical and demographic characteristics and HbA1c levels were recorded. Thirty-nine patients (62.9%) were male and 23 (37.1%) were female. The mean age was 61 ± 11.4 years. The patients had diabetes mellitus (DM) for an average of 19.2 ± 9.6 years. The average HbA1c value of the patients was 9 ± 2.3%. Minor amputation was performed in 35 of 62 patients (56.5%) during treatment. Thirty-one patients (50%) were unaware of the risk of diabetic retinopathy. Of those "unaware" 31 patients, 26 (83.9%) had diabetic retinopathy. Diabetic retinopathy was detected in 57 patients (91.9%) and 3-month interval ophthalmological follow-up screening was recommended for 77 eyes. Eighty percent of the patients never had ophthalmological examination. Intravitreal (IV) injection was performed in 44 eyes, panretinal photocoagulation (PRP) in 2 eyes, and intravenous injection + PRP + vitreoretinal surgery in one eye. Diabetic foot ulcers and diabetic retinopathy are often accompanied by each other. Patients should be informed about this and strongly encouraged to undergo routine ophthalmological examinations, especially when they have advanced diabetic foot disease. Diabetic foot surgeons should keep in mind that a poor eye cannot detect diabetic foot problems.

Assessing the proficiency of artificial intelligence programs in the diagnosis and treatment of cornea, conjunctiva, and eyelid diseases and exploring the advantages of each other benefits.

PURPOSE: It was aimed to determine the knowledge level of ChatGPT, Bing, and Bard artificial intelligence programs related to corneal, conjunctival, and eyelid diseases and treatment modalities, to examine their reliability and superiority to each other. METHODS: Forty-one questions related to corneal, conjunctival, and eyelid diseases and treatment modalities were asked to the ChatGPT, Bing, and Bard chatbots. The answers to the questions were compared with the answer keys and grouped as correct or incorrect. Accuracy rates were compared. RESULTS: ChatGPT gave the correct answer to 51.2 % of the questions asked, Bing gave the correct answer to 53.7 %, and Bard gave the correct answer to 68.3 %. There was no significant difference in the rate of correct or incorrect answers to the questions asked for the 3 artificial intelligence chatbots (p = 0.208, Pearson's chi-square test). CONCLUSION: Although information about the cornea, conjunctiva, and eyelid diseases and treatment modalities can be accessed quickly and accurately using up-to-date artificial intelligence programs, the answers may not always be accurate and up-to-date. Care should be taken when evaluating this information.

Standard internal limiting membrane peeling versus internal limiting membrane abrasion technique for primary epiretinal membrane surgery / Remoção padrão da membrana limitante interna versus técnica de abrasão da membrana limitante interna em cirurgia primária de membrana epirretiniana

ABSTRACT Purposes: The purpose of this study is to compare the standard inner limiting membrane peeling technique to the inner limiting membrane abrasion technique with respect to visual outcomes and central retinal thickness in the primary epiretinal membrane surgery. Methods: A total of 59 eyes from 57 epiretinal membrane patients were separated into two groups including the standard inner limiting membrane peeling group and the inner limiting membrane peeling with abrasion technique group. At 6, 12, and 24 months of follow-up, the mean alteration in best-corrected visual acuity and central retinal thickness were assessed for each group. Results: The study includes 32 (54%) standard inner peeling and 27 (46%) inner limiting membrane peeling with abrasion technique patients. The mean preoperative logMAR best-corrected visual acuity for the standard inner limiting membrane peeling and inner limiting membrane peeling with abrasion groups was 0.73 (±0.29) and 0.61 (±0.3) respectively. At 6, 12, and 24 months of follow-up, the best-corrected visual acuity improved significantly in each group. At each period of observation, the alteration in best-corrected visual acuity was not statistically significant (p=0.54, p=0.52, p=0.67). When comparing the alterations between the standard inner limiting membrane peeling and inner limiting membrane peeling with abrasion technique groups at 6 months (p=0.26) and 24 months (p=0.06), no statistically significant differences were observed, but they were statistically different at 12 months (p=0.03), reflecting a greater reduction in central retinal thickness for the inner limiting membrane peeling with abrasion technique group after one year. Conclusion: Abrasion of the inner limiting membrane with a diamond-dusted membrane scraper during epiretinal membrane surgery demonstrates similar effectiveness to the standard inner limiting membrane peeling technique. At 12 months, retinal thinning was found to be more significant in inner limiting membrane peeling with abrasion technique patients in terms of central retinal thickness values. As a result, it may be argued that the inner limiting membrane abrasion technique eliminates the inner limiting membrane and related structures more effectively while inflicting less retinal damage.

RESUMO Objetivo: Este estudo tem como objetivo comparar a técnica padrão de peeling da membrana limitadora interna com a técnica de abrasão da membrana limitadora interna com relação aos resultados visuais e à espessura central da retina na cirurgia primária de membrana epirretiniana. Métodos: Cinquenta e nove olhos de 57 pacientes com membrana epirretiniana foram divididos em dois grupos, incluindo o grupo de remoção padrão da membrana limitante interna e o grupo de remoção da membrana limitante interna com técnica de abrasão. A alteração média da melhor acuidade visual corrigida e da espessura central da retina foram medidas para cada grupo aos 6, 12 e 24 meses de acompanhamento. Resultados: O estudo incluiu 32 (54%) de padrão de membrana limitante e 27 (46%) de membrana interna com técnica de abrasão. A média de logMar pré-operatório de melhor acuidade visual corrigida foi de 0,73 (±0,29) e 0,61 (±0,3) para os grupos de remoção padrão da membrana limitante interna e de remoção da membrana limitante interna com técnica de abrasão, respectivamente. A melhor acuidade visual corrigida melhorou significativamente em cada grupo aos 6, 12 e 24 meses de acompanhamento. A alteração na melhor acuidade visual corrigida não foi estatisticamente significante (p=0,54, p=0,52, p=0,67) em cada período de observação. Quanto à espessura central da retina, diferenças estatisticamente significativas não foram observadas aos 6 meses (p=0,26) e 24 meses (p=0,06), mas foram estatisticamente diferentes aos 12 meses (p=0,03) quando comparadas às alterações entre os grupos de remoção padrão da membrana limitante interna e de remoção da membrana limitante interna com técnica de abrasão, refletindo uma maior redução da espessura central da retina para o grupo de remoção da membrana limitante interna com técnica de abrasão após um ano. Conclusão: A abrasão da membrana limitante interna com um raspador de membrana com pó de diamante em cirurgia de membrana epirretiniana demonstra eficácia semelhante com a técnica de remoção padrão de membrana limitante interna. Em relação aos valores de espessura central da retina, o afinamento da retina foi mais significativo em pacientes com remoção da membrana limitante interna com técnica de abrasão aos 12 meses. Assim, pode-se argumentar que a técnica de abrasão da membrana limitante interna remove a membrana limitante interna e as estruturas relacionadas de forma mais eficaz sem causar danos significativos à retina.

A comparative study on the knowledge levels of artificial intelligence programs in diagnosing ophthalmic pathologies and intraocular tumors evaluated their superiority and potential utility.

PURPOSE: This study aimed to test the knowledge levels of ChatGPT, Bing, and Bard artificial intelligence chatbots, which have been released by three different manufacturers, about ophthalmic pathologies and intraocular tumors, to test their usability and to investigate the presence of superiority to each other. METHODS: Thirty-six questions were obtained from the American Academy and Ophthalmology 2022-2023 Basic and Clinical Science Course Ophthalmic Pathology and Intraocular Tumor study questions section. Each question was asked separately for the ChatGPT, Bing, and Bard artificial intelligence programs. Answers to the questions were categorized as correct or incorrect. The statistical relationship between the correct and incorrect response rates of the artificial intelligence programs was determined. RESULTS: From the artificial intelligence chatbots, ChatGPT gave the correct answer to 58.6% of the questions asked, Bing gave the correct answer to 63.9%, and Bard gave the correct answer to 69.4%. No statistical significance was found between the rates of correct answers to the questions in all 3 artificial intelligence programs (p = 0.705, Pearson Chi-square test). CONCLUSION: Artificial intelligence chatbots can be used to access information related to ophthalmic pathologies and intraocular tumors. However, in the evaluation of the data, it should be noted that not all questions can be answered correctly. Care should be taken when examining the answers.

Off-Label Uses of Ranibizumab and Aflibercept for Age-Related Macular Degeneration in Turkey.

Purpose: To evaluate the clinical and demographic aspects of off-label drug use applications for age-related macular degeneration (AMD) in Turkey. Methods: Applications for off-label drug use in the treatment of AMD to the Turkish Medicines and Medical Devices Agency (TITCK) in 2018 were retrospectively analyzed. Demographic characteristics, requested drugs, previous treatment regimens, and reasons for applications were evaluated. Results: The mean age of the patients (n = 209) was 64.9 ± 15.7 years, of which 48.8% were male and 51.2% were female. Ranibizumab (n = 113) comprised 54.1% and aflibercept (n = 96) 45.9% of off-label use applications. No application was made for bevacizumab. The most frequent reasons for application were switchback (49.3%), nonreimbursement of indicated drugs in cases under 50 years of age (24.4%), and failure to complete the loading dose (14.4%). Conclusions: Ranibizumab was the most requested off-label drug for AMD. There was no application for off-label bevacizumab since its use does not require approval from TITCK. In Turkey, new rules were established for the reimbursement of intravitreal drugs for AMD in 2019. Three doses of intravitreal bevacizumab were required initially for aflibercept and ranibizumab to be covered for reimbursement. There is not enough data in the English literature regarding the off-label use of ranibizumab and aflibercept for AMD. This study provides information about drug regulations and the off-label treatment options preferred by physicians for AMD in Turkey.

Evaluation of retinal vascular and structural alterations in pediatric idiopathic intracranial hypertension patients without papilledema.

PURPOSE: The aim of this study was to evaluate retinal structural and microvascular alterations using optical coherence tomography-angiography (OCTA) in pediatric idiopathic intracranial hypertension (IIH) patients with regressed papilledema. METHODS: This study included 40 eyes of 21 IIH patients and 69 eyes of 36 healthy controls. Radial peripapillary capillary (RPC) vessel density and peripapillary retinal nerve fiber layer (RNFL) thickness were evaluated by XR Avanti AngioVue OCTA (Optovue, Fremont, CA, USA). The data were obtained from measurement zones that are automatically divided into two equal hemispheres (superior and inferior) and eight quadrants (superior-temporal, superior-nasal, inferior-temporal, inferior-nasal, nasal-superior, nasal-inferior, temporal-superior, temporal-inferior). Initial cerebrospinal fluid (CSF) pressure, grade of papilledema, and duration of follow-up were recorded. RESULTS: There were significant differences in RPC vessel densities and RNFL thicknesses between the study groups (p Ëƒ 0.05). Significantly higher RPC vessel density measurements were observed in the patient group for the whole image, peripapillary, inferior-hemi, and whole nasal quadrants (p < 0.05). Except for the temporal-superior, temporal-inferior, inferior-temporal, and superior-temporal quadrants, the RNFL in all regions was significantly thicker in the IIH group than in the control group (p Ë‚ 0.001). CONCLUSIONS: RNFL thickness and RPC vessel density were significantly different between the IIH patient and control groups, suggesting that retinal microvascular and subclinical structural changes that were potentially secondary to CSF pressure can persist after the resolution of papilledema. However, our results should be confirmed by further longitudinal studies investigating the progress of these alterations to determine their effects on peripapillary tissues.

Non-damaging retinal laser therapy in chronic central serous chorioretinopathy.

PURPOSE: To investigate the functional and anatomical outcomes of non-damaging retinal laser therapy (NRT), in cases with chronic central serous chorioretinopathy (CSCR). METHODS: Twenty-three eyes of 23 treatment-naïve chronic CSCR patients were included in this study. The irradiation of 577 nm yellow light was conducted on the serous detachment area after switching over to the NRT algorithm. Anatomical and functional changes after treatments were investigated. RESULTS: The mean age of the subjects was 48.68 ± 5.93 years (41-61). The mean best-corrected visual acuity (BCVA) and the mean central macular thickness (CMT) values were 0.42 ± 0.12logMAR (0.20-0.70) and 315.69 ± 61.25 µm (223-444) before NRT; and 0.28 ± 0.11logMAR (0.10-0.50) and 223.26 ± 60.91 µm (134-336) at the 2nd month follow-up visit (p < 0.001, for both). At the 2nd-month follow-up visit after NRT, complete resorption of subretinal fluid was observed in 18 eyes (78.3%) and incomplete resorption in five eyes (21.7%). Worse values of BCVA and CMT before NRT were found as increased risk for incomplete resorption (p = 0.002 and ρ = 0.612 for BCVA, and p < 0.001 and ρ = 0.715 for CMT). CONCLUSION: Significant functional and anatomical improvements can be observed in the early period after NRT in patients with chronic CSCR. Patients having worse baseline BCVA and CMT have increased risk for incomplete resorption.

Real Life Multicenter Comparison of 24-Month Outcomes of Anti-VEGF Therapy in Diabetic Macular Edema in Turkey: Ranibizumab vs. Aflibercept vs. Ranibizumab-Aflibercept Switch.

The aim of this study was to compare the outcomes of diabetic macular edema (DME) treated with aflibercept (AFB) or ranibizumab (RNB) only, and after switching from RNB to AFB. This was a retrospective, real-world, multicenter (7 cities) 24 month study. Overall, 212 eyes in the AFB group, 461 in the RNB group, and 141 in the RNB to AFB group were included. The primary endpoints were differences in visual acuity (VA) and central macular thickness (CMT) from baseline to the final visit. The secondary outcomes were the percentage of eyes that achieved ≥10 letters gain and ≥10 letters loss in vision at month 12 and 24, and the percentage of eyes that achieved a thinning of ≥20% in CMT at month 3 and month 6. The results showed that VA did not significantly differ at baseline (AFB: 0.62 ± 0.38, RNB: 0.61 ± 0.36, RNB to AFB: 0.61 ± 0.38), at checkpoints, or at the final visit (AFB: 0.46 ± 0.38, RNB: 0.5 ± 0.37, RNB to AFB: 0.53 ± 0.36) (p > 0.05). Though the mean CMT at baseline was significantly thicker in the RNB to AFB group (479 ± 129.6 µm) when compared to the AFB (450.5 ± 122.6 µm) and RNB (442 ± 116 µm) groups (p < 0.01), similar measurements were obtained after 12 months. The percentages of eyes that gained or lost ≥10 letters in the AFB, RNB, and RNB to AFB groups at year 1 and 2 were similar, as was the percentages of eyes that demonstrated ≥20% CMT thinning at month 3 and 6. Our study showed similar visual improvements in non-switchers (AFB and RNB groups) and switchers (RNB to AFB group) through 2 years follow-up, however, AFB patients required fewer injections, visits, or need for additional treatments.

Long-term Outcomes of Submacular Perfluorocarbon Liquid Removal with Internal Limiting Membrane Peeling and Transretinal Aspiration.

BACKGROUND: An important complication associated with perfluorocarbon liquid (PFCL) use during pars plana vitrectomy (PPV) is its retention in the submacular area. The aim of this study was to present the long-term outcomes of the surgical method used in this study to remove submacular PFCL and to shed light on the advantages and disadvantages compared to other methods. MATERIAL AND METHODS: This is a retrospective, single-center, observational study. Patients who underwent surgical intervention due to submacular PFCL were included in this study. The surgical procedural includes internal limiting membrane (ILM) peeling, transretinal aspiration of submacular PCFL with a 25/27-gauge soft-tipped cannula, then perfluoropropane (C3F8) gas tamponade, and facedown positioning for 5 days. The long-term anatomical and functional outcomes were evaluated with an ophthalmological examination and optical coherence tomography (OCT). OUTCOMES: A total of 15 patients with submacular PFCL were included in this study, and the mean age of the patients was 64.33 ± 10.36 years (47 - 83). The localization of submacular PFCL was subfoveal in nine patients (60.00%), non-subfoveal in four patients (26.67%), and both subfoveal and non-subfoveal in two patients (13.33%). The mean time of submacular PFCL diagnosis was 4.86 ± 1.02 weeks (2 - 8) and the mean time of the surgery was 9.80 ± 1.17 weeks (8 - 14). Complete removal of submacular PFCL was achieved in all cases (100%) and no significant treatment-associated complications were observed. The mean follow-up time was 37.60 ± 14.00 months (18 - 60) and the best-corrected visual acuity was significantly improved (p = 0.001). At the end of the follow-up time, prominent ellipsoid zone disruption was observed in six patients (40.00%), while in nine patients (60.00%), there was no prominent ellipsoid zone disruption. CONCLUSIONS: The surgical procedural for submacular PFCL removal is a reasonable option and improves visual acuity in the long term without any significant treatment-associated complications.

Assessment of the Retinal Nerve Fibre Layer, Retina, and Choroid in Osteogenesis Imperfecta.

BACKGROUND: Osteogenesis imperfecta (OI) is a genetic disorder in which there are problems in tissues containing type I collagen, predominantly the cornea and sclera in the eye. Although there are many studies on problems with the anterior segment of the eye in patients with OI, studies on posterior structures are limited. Involvement of the sclera may affect the retinal nerve fibre layer (RNFL), which is indirectly related to intraocular pressure. In addition, the retina and choroid containing type I collagen may be affected. The aim of the study was to compare the posterior segment structures of the eye, including the RNFL, retina, and choroid, in patients with OI to those of healthy control subjects. METHODS: This cross-sectional study recruited 19 patients with OI, as well as 22 age- and gender-similar healthy control subjects. Measurements of the RNFL, retina, and choroid were obtained with optical coherence tomography (Spectralis SD-OCT, Heidelberg Engineering, Heidelberg, Germany). RESULTS: Patients with OI (mean age 14.32 ± 5.08 years) and the control group (mean age 13.73 ± 3.56 years) had similar age, refractive error, and intraocular pressure values (p > 0.05). There was no difference between groups in terms of RNFL thickness, including the superonasal, nasal, inferonasal, inferotemporal, temporal, and superotemporal sectors, retinal thickness, and choroidal thickness from five different locations (p > 0.05, for all). CONCLUSION: According to these results, OI does not clinically affect the RNFL, retina, and choroid in childhood.

Biological therapy for ocular Behçet's disease with off-label drug prescription in Turkey.

OBJECTIVE: The use of biological agents in the treatment of ocular Behçet's disease has recently become more frequent. The use of two agents, infliximab (IFX) and adalimumab (ADA), for the treatment of Behçet's disease requires prior approval by the Turkish Medicines and Medical Devices Agency. We report on a review of such applications with a view to informing on how such agents are used off-label in Turkey. METHODS: Prescriptions for off-label use of IFX or ADA sent from hospitals in Turkey to the Turkish Medicines and Medical Devices Agency in 2018 were evaluated. Demographic data, previous treatment regimens and reasons for referral were extracted from the files of the cases. RESULTS: A total of 662 patients were considered for off-label use of IFX or ADA for the treatment of ocular Behçet's disease. The mean age of the patients was 35.7±10.8 years (range 12-76); 61.5% of patients were men and 38.5% were women. Of the applications, 345 (52.1%) were for IFX and 317 (47.9%) for ADA. Among the referring hospitals, the public university hospitals ranked first, accounting for 77.9% of IFX and 88.6% of ADA prescriptions. Most applications were made after the failure of conventional therapy, which included steroids and immunosuppressive agents. CONCLUSION: IFX and ADA are rarely used as initial therapy. Stepwise treatment is still preferred in the treatment of ocular Behçet's disease in Turkey. Our report informs on the management of this difficult-to-treat condition.

Peripapillary and Macular Structural and Vascular Parameters in Age-Related Choroidal Atrophy.

PRCIS: The macular and peripapillary structural and vascular alterations in elderly patients with age-related choroidal atrophy may mimic glaucomatous degeneration. PURPOSE: To evaluate the peripapillary retinal nerve fiber layer (pRNFL), macular nerve fiber layer (mNFL), ganglion cell layer (mGCL), inner plexiform layer (mIPL) thicknesses, and choroidal vascularity index (CVI) values in patients with age-related choroidal atrophy (ARCA) and to compare with the those of age and sex-matched healthy controls. METHODS: The cross-sectional, observational study included 95 eyes of 95 patients. The patients were divided into 2 groups according to subfoveal choroidal thickness (sCT) values. Forty eight eyes with sCT<125 µm constituted ARCA group (group 1), and 47 eyes with sCT>125 µm constituted control group (group 2). Peripapillary RNFL, mNFL, mGCL, mIPL, sCT values and fundus autofluorescence images were acquired with spectral domain-optical coherence tomography. Enhanced depth imaging mode spectral domain-optical coherence tomography images were binarized to show the luminal and stromal areas of choroid. CVI (%) was defined as the ratio of the luminal area to the total choroidal area with defined borders. RESULTS: The mean age was 78.47±6.07 years in group 1 and 76.95±6.68 years in group 2. The mean, superior and inferior quadrants pRNFL thicknesses were significantly lower in group 1 than in group 2 ( P <0.05 for all). The mean mNFL, mGCL, mIPL thickness values were also statistically lower in group 1 than group 2 ( P <0.05 for all). The CVI value was 61.29±4.52 in group 1, and 64.81±3.80 in group 2 ( P <0.001). CONCLUSION: The patients with ARCA had decreased pRNFL, inner macular layer thickness and CVI values when compared with healthy control eyes. These findings should be considered in the differential diagnosis and the follow up of eyes with glaucoma.

Assessing the Competence of Artificial Intelligence Programs in Pediatric Ophthalmology and Strabismus and Comparing their Relative Advantages.

Objective: The aim of the study was to determine the knowledge levels of ChatGPT, Bing, and Bard artificial intelligence programs produced by three different manufacturers regarding pediatric ophthalmology and strabismus and to compare their strengths and weaknesses. Methods: Forty-four questions testing the knowledge levels of pediatric ophthalmology and strabismus were asked in ChatGPT, Bing, and Bard artificial intelligence programs. Questions were grouped as correct or incorrect. The accuracy rates were statistically compared. Results: ChatGPT chatbot gave 59.1% correct answers, Bing chatbot gave 70.5% correct answers, and Bard chatbot gave 72.7% correct answers to the questions asked. No significant difference was observed between the rates of correct answers to the questions in all 3 artificial intelligence programs (p=0.343, Pearson's chi-square test). Conclusion: Although information about pediatric ophthalmology and strabismus can be accessed using current artificial intelligence programs, the answers given may not always be accurate. Care should always be taken when evaluating this information.

Evaluation of Structural Retinal Layer Alterations in Retinitis Pigmentosa.

Objective: This study aimed to analyze retinal layers in the macular region using spectral-domain optical coherence tomography (SD-OCT). Additionally, we examined the retinal vascular plexus densities of the eyes using optical coherence tomography angiography (OCT-A), specifically in patients with retinitis pigmentosa (RP). Methods: In the study, 36 eyes from patients with retinitis pigmentosa (RP) and 36 eyes from healthy controls were included. Measurements involved assessing the thicknesses of each retinal layer at the central fovea, parafoveal, and perifovea using spectral domain optical coherence tomography (SD-OCT). Moreover, the study involved the evaluation of retinal capillary plexus densities (RCPD), encompassing deep capillary plexus density values, superficial capillary plexus, and radial peripapillary capillary plexus. This assessment was performed using optical coherence tomography angiography (OCT-A). Results: No statistically significant difference in retinal thickness was found in the central fovea between the two groups. The thicknesses of the INL, OPL, and PRL in the parafoveal regions as well as the RPE in the perifoveal regions increased in the RP group. Nonetheless, the ONL, IPL, GCL, and RNFL demonstrated reduced thickness in both the perifoveal and parafoveal areas. The OCT-A findings indicated that patients with RP exhibited lower values for all RCPD. Conclusion: The retinal layers and RCPD were significantly impacted at varying rates of RP. It is essential to acknowledge that this alteration may be significant in the context of the retinal findings in patients with RP. Abbreviations: SD-OCT = Spectral-domain optical coherence tomography, OCT-A = Optical coherence tomography angiography, RP = Retinitis pigmentosa, ETDRS = Early Treatment Diabetic Retinopathy Study, SD = standard deviation, TRT = Total Retinal Thickness, IRT = Inner Retinal Thickness, ORT = Outer Retinal Thickness, RNFL = Retinal Nerve Fiber Layer, GCL = Ganglion Cell Layer, IPL = Inner Plexiform Layer, INL = inner nuclear layer, OPL = Outer Plexiform Layer, ONL = Outer Nuclear Layer, PRL = Photoreceptor layer, RPE = Retinal Pigment Epithelium, µm = micrometer, PaFoSu = parafovea superior, PeFoSu = perifovea superior, PaFoNa = parafovea nasal, PeFoNa = perifovea nasal, PaFoTe = parafovea temporal, PeFoTe = perifovea temporal, PaFoIn = parafovea inferior, PeFoIn = perifovea inferior.

Evaluation of off-label anti-vascular endothelial growth factor and steroid implant medication uses in macular edema due to retinal vein occlusion in Turkey.

WHAT IS KNOWN AND OBJECTIVE: Retinal vein occlusion (RVO) is one of the most common causes of vision loss. Anti-vascular endothelial growth factor (anti-VEGF) drugs, ranibizumab and aflibercept, and corticosteroid implants are approved treatment options for RVO-related macular edema (ME) in Turkey. To the best of our knowledge, there is no data regarding the off-label use of these drugs for RVO in English literature. We aimed to evaluate the clinical and demographic characteristics of off-label drug use applications in Turkey for RVO. METHODS: Applications made to the Turkish Medicines and Medical Devices Agency between January 1 and December 31, 2018, for the use of off-label drugs (ranibizumab, aflibercept, dexamethasone implant) for the diagnosis of RVO from hospitals across Turkey were retrospectively analysed. Data of the applications, such as demographic characteristics, previous treatment regimens, reasons for applications, applicant hospitals and their regions, were recorded. RESULTS: There were 291 approved applications for RVO. The mean age of the patients was 64.88 ± 10.78 years, 48.8% were male, and 51.2% were female. Of these applications, 44.7% were for aflibercept, 35.7% for ranibizumab and 19.6% for dexamethasone implant. No application was made for bevacizumab since it could be used without needing for an application. The most common reasons for applications were due to dose limitations, failure to complete loading doses, and glaucoma, respectively. In terms of the distribution of the applicant hospitals, public university hospitals ranked first with 72.5%, training and research hospitals ranked second with 14.7% and foundation university hospitals ranked third with 13.1% rates. WHAT IS NEW AND CONCLUSION: The practice of drug use in RVO in Turkey has changed as of the beginning of 2019. Stepwise therapy has been accepted by the drug regulatory agency Turkish Medicines and Medical Devices Agency. Utilization of licensed drugs, aflibercept, ranibizumab and dexamethasone has been allowed only after administration of 3 doses of intravitreal bevacizumab. After 3 doses of bevacizumab, the physician may continue either with bevacizumab again or a dexamethasone implant. If there is a reason such as the presence of glaucoma, the physician may skip dexamethasone and switch to aflibercept and ranibizumab, but in this case, dexamethasone cannot be administered to the patient for life. The evaluation of the off-label treatments of RVO, which is one of the most frequently followed diseases in retina clinics, not only contributes to the literature but also provides information regarding the most frequently applied treatments and the physicians' off-label drug preferences for RVO.

Standard internal limiting membrane peeling versus internal limiting membrane abrasion technique for primary epiretinal membrane surgery.

PURPOSES: The purpose of this study is to compare the standard inner limiting membrane peeling technique to the inner limiting membrane abrasion technique with respect to visual outcomes and central retinal thickness in the primary epiretinal membrane surgery. METHODS: A total of 59 eyes from 57 epiretinal membrane patients were separated into two groups including the standard inner limiting membrane peeling group and the inner limiting membrane peeling with abrasion technique group. At 6, 12, and 24 months of follow-up, the mean alteration in best-corrected visual acuity and central retinal thickness were assessed for each group. RESULTS: The study includes 32 (54%) standard inner peeling and 27 (46%) inner limiting membrane peeling with abrasion technique patients. The mean preoperative logMAR best-corrected visual acuity for the standard inner limiting membrane peeling and inner limiting membrane peeling with abrasion groups was 0.73 (±0.29) and 0.61 (±0.3) respectively. At 6, 12, and 24 months of follow-up, the best-corrected visual acuity improved significantly in each group. At each period of observation, the alteration in best-corrected visual acuity was not statistically significant (p=0.54, p=0.52, p=0.67). When comparing the alterations between the standard inner limiting membrane peeling and inner limiting membrane peeling with abrasion technique groups at 6 months (p=0.26) and 24 months (p=0.06), no statistically significant differences were observed, but they were statistically different at 12 months (p=0.03), reflecting a greater reduction in central retinal thickness for the inner limiting membrane peeling with abrasion technique group after one year. CONCLUSION: Abrasion of the inner limiting membrane with a diamond-dusted membrane scraper during epiretinal membrane surgery demonstrates similar effectiveness to the standard inner limiting membrane peeling technique. At 12 months, retinal thinning was found to be more significant in inner limiting membrane peeling with abrasion technique patients in terms of central retinal thickness values. As a result, it may be argued that the inner limiting membrane abrasion technique eliminates the inner limiting membrane and related structures more effectively while inflicting less retinal damage.

Quantitative OCT angiography of the retinal and choroidal vascular circulation in pediatric patients with neurofibromatosis type 1.

PURPOSE: To investigate retinal and choroidal microvascular changes in neurofibromatosis type 1 (NF1) pediatric patients using optical coherence tomography angiography (OCTA). METHODS: This study was performed on 21 eyes of 21 NF1 patients and 30 eyes of 30 healthy subjects. Foveal avascular zone (FAZ) parameters, including area, perimeter, acircularity index, and foveal density, were measured using OCTA. Superficial (SCP) and deep (DCP) capillary plexus and radial peripapillary capillary (RPC) vessel densities and choriocapillaris flow were also evaluated. Choroidal nodules and thickness were detected using infrared reflectance and enhanced-depth imaging OCT. RESULTS: No significant differences were observed for FAZ parameters or SCP and RPC vessel densities between groups. DCP vessel densities in the perifovea were significantly lower in the NF1 group than in the control group (P = 0.001). A significantly lower choriocapillaris flow area (P < 0.001) and increased subfoveal and nasal perifoveal choroidal thickness (P < 0.001) were observed in the NF1 group. Choriocapillaris flow area tended to be inversely related to the number of choroidal nodules in the NF1 group. CONCLUSIONS: Perifoveal DCP vessel density and choriocapillaris flow significantly differed between NF1 patients and controls, suggesting that retinal and choroidal vascular microcirculation is affected in the former, potentially by choroidal nodules. Further longitudinal studies are required to determine the effects of these differences on circulation in the posterior segment of the eye.

Anti-vascular endothelial growth factor therapy in diabetic macular edema: real-life outcomes from a multicenter study in Turkey over 36 months.

PURPOSE: This study aimed to report the visual and anatomical outcomes of intravitreal anti-VEGF treatment for diabetic macular edema (DME) in a real-world clinical setting from Turkey over 36 months. METHODS: This is a retrospective, multicenter (7 sites) study. The medical records of 1072 eyes (both previously treated and naive eyes) of 706 consecutive patients with visual impairment due to center-involving DME treated with intravitreal anti-VEGF injections between April 2007 and February 2017 were reviewed. The eyes were divided into mutually exclusive three groups based on the duration of follow-up (12, 24, or 36 months). Primary outcome measures were changes in visual acuity (VA) and central macular thickness (CMT) from baseline to final visit in each cohort, frequency of visits and intravitreal anti-VEGF injections. As secondary endpoints, VA outcomes were assessed in subgroups stratified by baseline VA [<70 ETDRS letters and ≥70 ETDRS letters] and loading dose status of anti-VEGF injections. RESULTS: VA increased by a mean of 8.2 letters (12-month cohort, p < 0.001), 5.3 letters (24-month cohort, p < 0.001), and 4.4 letters (36-month cohort, p = 0.017) at final visits. The eyes with <70 VA letters achieved more significant VA improvement at final visits in all cohorts compared with eyes with >70 VA letters (p < 0.001). The mean decreases in CMT from baseline to last visits at 12-, 24-, and 36- month cohorts were -100.5 µm, -107.7 µm, and -114.3 µm, respectively (p < 0.001). The mean number of injections given were 4.6, 2.3, and 1.8 during years 1 to 3, respectively. Patients who received loading dose showed greater VA gains than those who did not in all follow-up cohorts. CONCLUSION: Our study revealed that anti-VEGF treatment improved VA and CMT over a follow-up of 36 months. Although these real-life VA outcomes following anti-VEGF therapy for DME were similar to other real-life studies, they were inferior to those noted in randomized controlled trials, mainly due to undertreatment.

Evaluation of the radial peripapillary capillary density in unilateral branch retinal vein occlusion and the unaffected fellow eyes.

Background: Given that unilateral branch retinal vein occlusion (BRVO) and glaucoma share common systemic vascular risk factors, the fellow eyes of patients with BRVO may be at increased risk of glaucoma. Objectives: To analyze the radial peripapillary capillary density (RPCD) in eyes with unilateral BRVO and their unaffected fellow eyes using optical coherence tomography angiography (OCTA). Design: Cross-sectional, prospective study. Methods: The study included 120 eyes of 80 patients: 40 affected eyes of BRVO, 40 fellow eyes of BRVO, and 40 control eyes. The RPCD, retinal nerve fiber layer thickness (RNFLT) were analyzed using OCTA. Results: RPCDs in the whole image, peripapillary region, all the hemispheres, and quadrants were statistically lower in the affected eyes than in both the fellow and control eyes (p < 0.05 for all). RPCD values in the whole image and the peripapillary region were significantly lower in the fellow eyes than in the control eyes (p = 0.013, and p = 0.021, respectively). RNFLTs in the peripapillary region, inferior hemisphere and inferior quadrant were significantly lower in the affected eyes than in the control eyes (p < 0.05 for all). No significant differences were detected between the fellow eyes and the control eyes in term of RNFLT values in any regions (p > 0.05 for all). Conclusion: Lower RPCD values despite similar RNFLT values were observed in the fellow eyes of patients with unilateral BRVO compared with healthy controls. These results may indicate the shared vascular mechanisms and risk factors that account for the development of BRVO and glaucoma.

Association between ocular trauma and attention-deficit/hyperactivity disorder in adult patients.

Purpose: To investigate the potential relationship between ocular trauma and attention-deficit/hyperactivity disorder (ADHD)-related clinical outcomes in adults. Methods: This prospective case-control study included 108 ocular trauma patients and 90 age-sex-matched healthy control. The ocular trauma group was separated into the subgroups home accident, outdoor activity, and work related in terms of the reasons for ocular trauma, and as ocular surface problems, blunt trauma-related, and open globe injury in terms of the clinical findings. The ADHD-related clinical outcomes were evaluated using the Wender-Utah Rating Scale (WURS). The outcomes were compared between ocular trauma and control groups, and ocular trauma subgroups. Results: The demographic characteristics of ocular trauma groups and controls were similar (P > 0.05, for all). In comparison to the control group, the ocular trauma group had higher total WURS score and WURS subscale scores, but not significantly (P > 0.05, for all). According to comparisons of the subgroups separated by the reasons, there was significant difference in the mean behavioral problems/impulsivity scores in favor of outdoor activities (P = 0.015). On the other hand, the mean scores for WURS subscales of the subgroups separated by the clinical findings were similar (P > 0.05, for all). Conclusion: WURS scores in ocular trauma patients are similar to control; however, the score in behavioral problems/impulsivity subscales is higher for ocular trauma caused by outdoor activities.