Posterior Chamber Intraocular Lens Dislocation Into the Vitreous in Association With Descemet Stripping Lamellar Keratoplasty.

PURPOSE: The purpose of this study was to report 3 cases of a single-piece, acrylic, foldable, modified C loop posterior chamber intraocular lens (PCIOL) dislocated into the vitreous cavity after Descemet stripping automated endothelial keratoplasty (DSAEK). METHOD: We describe the clinical course and management of the 3 cases in which a previously implanted foldable, single-piece, acrylic posterior chamber intraocular lens with modified C loops dislocated into the vitreous in association with DSAEK. Surgical management consisted of pars plana vitrectomy in each case with either PCIOL repositioning (2 cases) or PCIOL exchange (1 case) and with different fixation methods, combined with repeated DSAEK in 1 case with previous primary graft failure. RESULTS: In 2 cases where the cornea cleared after the DSAEK, the cornea kept its clarity and the PCIOL remained stable. In the third case in which the PCIOL exchange was combined with DSAEK, the cornea only partially cleared up, both the PCIOL and the state of the eye remained stable. CONCLUSIONS: PCIOL dislocation is a possible and notable complication that requires attention while performing DSAEK on pseudophakic eyes. Not only plate-haptic silicone but also acrylic, single-piece PCIOLs with modified C loops may dislocate into the vitreous in association with DSAEK in cases with compromised capsular or zonular integrity.

Impact of the COVID‒19 pandemic on ophthalmic outpatient care at the Ophthalmology Department of the New St. John's Hospital, Budapest / A COVID-19-pandémia hatása a szemészeti járóbeteg-szakellátásra az Új Szent János Kórházban, Budapesten.

Összefoglaló. Bevezetés: Az új típusú koronavírus-járvány (COVID-19) az egészségügyi ellátóhálózatot egy eddig ismeretlen helyzet elé állította. A nemzetközi adatok alapján a szemészeti járóbeteg-ellátásban jelentos változások alakultak ki. Célkituzés: Felmérni a COVID-19-járvány okozta kvantitatív és kvalitatív változásokat az Észak-Közép-budai Centrum, Új Szent János Kórház és Szakrendelo Szemészeti Osztályának járóbeteg-szakellátásában. Módszer: A pandémia elso hullámában (2020. április 1-30.) mért járóbeteg-forgalmi adatokat hasonlítottuk össze a megelozo év azonos periódusában rögzített adatokkal. A betegek demográfiai jellemzoi mellett megvizsgáltuk a sürgosségi besorolásukat, valamint a panaszokhoz kötheto fodiagnózis-csoportok eloszlását. Rögzítettük a telemedicina keretein belül történt ellátások számát. Eredmények: 2020 vizsgált idoszakában 916, míg az elozo év azonos hónapjában 2835 járóbeteg-eset került rögzítésre. A 2020-as idoszakban a törvényi szabályozás szerint sürgos panaszokkal jelentkezo betegek aránya nem változott (p = 0,38), azonban a szakorvosi megítélés szerint sürgos panaszokkal érkezo betegek aránya nott (p<0,001) az elozo évhez viszonyítva. A zöld hályog, kötohártya-gyulladás, árpa, sérülés és nedves típusú maculadegeneratio miatt ellátásra jelentkezo betegek aránya szignifikánsan nott (p<0,001 mind), míg a szürke hályog, a száraz típusú maculadegeneratio, egyéb, a szemhéj és a könnyutak betegségei, utóhályog miatt és a szemészeti betegség nélkül érkezok aránya csökkent (p<0,001 mind). A telemedicina keretei között ellátott betegek száma 2020-ban közel a tizenötszörösére emelkedett 2019-hez képest (p<0,001). Következtetés: A COVID-19-pandémia elso hulláma során markáns betegszámcsökkenést regisztráltunk a szemészeti járóbeteg-szakellátásban. Több fodiagnózis-csoport esetén számolhatunk jelentos terápiavesztéssel és halasztott ellátási igény jelentkezésével. Az adatok kiértékelése segítséget nyújthat az elkövetkezo években az ellátási folyamat proaktív átszervezésében, a humáneroforrás-szükségletek jobb tervezésében, valamint a teleoftalmológiai ellátás fejlesztésében. Orv Hetil. 2021; 162(6): 203-211. INTRODUCTION: The COVID-19 pandemic put the healthcare network in a hitherto unknown situation. The ophthalmic outpatient care changed internationally. OBJECTIVE: To assess the quantitative and qualitative changes of the outpatient specialty care at the Ophthalmology Department of the North-Central-Buda Center, New St. John's Hospital and Clinic, through the pandemic. METHOD: Outpatient service data during the first wave of the pandemic (April 2020) were compared with those in April 2019. Patient demographics, emergency classification, distribution of the main diagnostic groups (associated with complaints) and services provided via telemedicine were collected. RESULTS: There were 2835 patient visits in 2019 and 916 in 2020. For 2020, the proportion of patients with emergency classification according to legal regulations did not change (p = 0.38), however, using the ophthalmologist's classification increased (p<0.001) significantly. The proportion of patients with glaucoma, conjunctivitis, chalazeon, injury and wet macular degeneration increased (p<0.001 all), while the proportion of patients with cataract, dry macular degeneration, other diseases, other adnexal diseases, secondary cataract and without ophthalmic pathology decreased significantly (p<0.001 for all). Patient number using telemedicine treatment was about 15× of those treated in 2019 (p<0.001). CONCLUSION: During the first wave of the pandemic, a marked decrease in ophthalmic outpatient care volume was recorded. In the case of several main diagnosis groups, significant therapy loss and a delayed need for care could be expected. Evaluation of the data helps in the upcoming years in proactive reorganization of the care process, in better planning of human resource needs, and in improvement of teleophthalmology care. Orv Hetil. 2021; 162(6): 203-211.

Functional benefits and patient satisfaction with upper blepharoplasty - evaluated by objective and subjective outcome measures.

PURPOSE: To investigate the functional benefits and patient satisfaction with upper blepharoplasty in patients meeting the Danish visitation guidelines for upper blepharoplasty from the Danish Health and Medicines Authority (Sundhedsstyrelsen). METHODS: Before and 3 months after upper blepharoplasty, the following investigations were made: (i) a standard eye examination, (ii) photographic documentation with a normal camera and the infrared camera of a Spectralis Optical Coherence Tomograph and (iii) measurements of the upper visual fields using the blepharoptosis test of Octopus 900. Along with the pre- and postoperative examinations, the patients completed a questionnaire concerning the functional and psychosocial impact of their eyelids. RESULTS: Ninety eyelids of 45 patients were studied, 34 females and 11 males. The mean age was 56.9 years (SD: 12.8). The mean change in the distance between the upper eyelid skin fold and the visual axis or the marginal reflex distance (MRD), depending on which was lowest, was 1.6 mm (SD: 0.8 mm) for the right eyelids and 1.2 (SD: 0.9 mm) for the left eyelids. The mean improvement in the upper visual field was 31.3% points for the right eyelids (SD: 21.4% points) and 28.3% points for the left eyelids (SD: 24.9% points). A statistically significant correlation between the preoperative distance from skin fold to visual axis/MRD and the pre- and postoperative visual field was found. The patients reported an improvement in their symptoms postoperatively. All subjects were satisfied with the postoperative result and would undergo the surgery again if they had to make the choice again. CONCLUSION: Patients meeting the Danish visitation guidelines for upper blepharoplasty experience a measurable improvement in function and alleviation of symptoms after blepharoplasty.

Long term follow-up of persistent choroidal folds and hyperopic shift after complete removal of a retrobulbar mass.

BACKGROUND: Hyperopic shift and chorioretinal folds are common findings with intraorbital masses compressing the posterior pole of the globe. These signs usually regress after complete tumour excision. To the best of our knowledge this is the first reported case, where optical coherence tomography was used to document persistent chorioretinal folds after complete excision of a retrobulbar mass. CASE PRESENTATION: A 47-year-old Caucasian woman was referred to our department with long-documented hyperopic shift and gradually decreasing vision in her left eye. Optical coherence tomography showed chorioretinal folds. Magnetic resonance imaging revealed a retrobulbar mass which caused flattening of the posterior pole of the globe. The tumour was successfully removed, and was confirmed to be a cavernous haemangioma on histological assessment. 3 years after surgery the patient still has a similar amount of hyperopia and chorioretinal folds. CONCLUSION: Choroidal folds and hyperopic shift may persist after complete tumour removal. Long term follow-up is advised to rule out recurrence of the intraorbital mass.

Normal Value Ranges for Central Retinal Thickness Asymmetry in Healthy Caucasian Adults Measured by SPECTRALIS SD-OCT Posterior Pole Asymmetry Analysis.

PURPOSE: To determine the normal variation in central retinal thickness asymmetry in healthy Caucasian adults using the posterior pole asymmetry analysis (PPAA) of a SPECTRALIS spectral-domain optical coherence tomography (SD-OCT) device. METHODS: Healthy Caucasian individuals aged between 18 and 45 years with a visual acuity of minimum 20/20 and a spherical equivalent between -1.5 and +1.5 diopters were recruited. Retinal thickness and retinal nerve fiber layer thickness (RNFL) were using measured SPECTRALIS SD-OCT. Inter- and intraocular differences in central retinal thickness were calculated using the PPAA. The association between age, sex, and interocular asymmetry was evaluated by a linear model with Gaussian correlation structure. RESULTS: A total of 105 individuals, 30 men and 75 women, were studied. The mean age ± SD was 28.8 ± 7.87 years. The grand mean interocular retinal thickness asymmetry was 5.6 µm (95% confidence interval [CI]: 4.6-6.5) and the grand mean intraocular retinal thickness asymmetry was 8.3 µm (95% CI: 6.8-9.9) in the right eye and 8.4 µm (95% CI: 6.7-10.0) in the left eye. The highest local asymmetries were found in the nasal corners of macula were the posterior pole thickness map overlaps the temporal vascular arches. A slight general age and sex effect on the mean interocular retinal thickness asymmetry was found to be respectively 0.04 µm/year (95% CI: 0.02-0.06 µm) and 0.54 µm (95% CI: 0.19-0.88 µm) for men compared with women. CONCLUSIONS: Statistically significant physiological asymmetries in inter- and intraocular central retinal thickness exist. This must be considered when early signs of glaucoma or other pathologies are evaluated based on the retinal thickness asymmetry. (http://www.controlled-trials.com/isrctn/ number, ISRCTN09017572.).

Comparing the efficacy of mydriatic cocktail-soaked sponge and conventional pupil dilation in patients using tamsulosin - a randomized controlled trial.

BACKGROUND: A strong association exists between the use of tamsulosin and the occurance of intraoperative floppy iris syndrome. Several methods were advocated to overcome the progressive intraopertive miosis.Our purpose was to investigate the effect of a mydriatic-cocktail soaked cellulose sponge on perioperative pupil diameter in tamsulosin-treated patients undergoing elective cataract surgery. METHODS: Patients using tamsulosin were dilated either with mydriatic-cocktail soaked sponge (group 1) or with conventional eyedrop regimen (group 2). Control patients not taking any α1 adrenergic receptor inhibtors were also dilated with mydriatic sponge (group 3).In all groups oxybuprocain 0.4%, cocain 4%, tropicamide 1%, phenylephrine 10%, diclophenac 0.1% along with chloramphenicol 0.5% were used preoperatively.Pupil diameter (mm) was measured preoperatively, after nucleus delivery, and before IOL implantation. Adverse effects associated with the use of sponge, minor and major intraoperative complications, the use of iris retractors and operation time were recorded.Differences in general between groups were analyzed with a one way analysis of variance (ANOVA); differences between groups in proportions were assessed by Fisher's exact test. RESULTS: Mean pupil diameter (mm) was preopertively: 7.52 ± 1.21, 7.30 ± 1.55 and 7.99 ± 0.96 (ANOVA: p = 0.079); after nucleus delivery: 6 ± 1.20, 6.29 ± 1.12 and 6.52 ± 0.81 (ANOVA: p = 0.123); before IOL implantation: 5.46 ± 1.06, 5.83 ± 1.09 and 6.17 ± 0.89 (ANOVA: p = 0.0291).No adverse effect related to sponge use was detected. Frequency of minor complications, and iris hook use was similar in the two tamsulosin treated group. Operation time did not differ significantly in the three groups. CONCLUSION: We have found that using a mydriatic cocktail-soaked wick - an alternative way to achieve intraoperative mydriasis for cataract surgery - was as effective and safe as the conventional repeated eyedrops regiment for tamsulosin treated patients. TRIAL REGISTRATION: Current Controlled Trials ISRCTN37834752.

Truncation of retinoschisin protein associated with a novel splice site mutation in the RS1 gene.

PURPOSE: To present the ocular findings of a Hungarian family with X-linked juvenile retinoschisis (XLRS) and to reveal a novel putative splice mutation leading to serious truncation of retinoschisin (RS1) protein. Our genetic results were compared to a mouse model of XLRS. METHODS: Complete ophthalmic examinations were performed on five members (two male patients, two female carriers, and one healthy fraternal male twin) of the family. The examinations included optical coherence tomography (OCT) and full-field and multifocal electroretinography (mfERG). OCT and ERG results were compared to the normative database of our laboratory. All exons and the flanking intronic regions of the RS1 gene were amplified by polymerase chain reaction and directly sequenced in all family members and in 50 male controls. RESULTS: Typical microcystic foveal changes were found on fundoscopy and OCT in two male patients. Large foveal and smaller perifoveal cysts were detected by OCT in the inner nuclear layer and another deeper retinal cleavage in the photoreceptor layer. The standard combined b-wave amplitudes and b/a amplitude ratios of full-field ERGs of the male patients were decreased compared with controls, but the typical "negative-type" ERG was not observed. The amplitudes of mfERGs were reduced in all rings but mainly in the central part of the examined retina. Implicit times were delayed across almost the whole testing field. Female carriers and the healthy fraternal twin brother were without any symptoms and had normal clinical examination results, but the implicit times of female carriers were delayed in all rings. DNA sequence analyses revealed a novel putative splice mutation (c.78+1G>C) in the splice donor site of intron 2 in RS1 of two male patients and two female carriers. Mutations were absent in the 50 control samples. CONCLUSIONS: Male patients exhibited typical bilateral foveal retinoschisis in two retinal layers and characteristic ERG changes. The inheritance of the novel putative splice mutation (c.78+1G>C) followed the classic inheritance of an X-linked recessive disease in two male patients and two female obligate carriers. There are two possible ways the c.78+1G>C splice site mutation may lead to frameshift and introduce a premature termination codon at the beginning of exon 3: after activation of the next cryptic splice site by a 10 bp insertion or after exon skipping by a 26 bp deletion. The splice site mutation in the second intron of RS1 identified in these XLRS patients is practically identical to the N-ethyl-N-nitrosourea (ENU) induced splice site mutation in the mouse model of XLRS described by the Tennessee Mouse Genome Consortium. The genetic findings of the mutant mouse model confirm and support our human results.

Correlation of clinical and genetic findings in Hungarian patients with Stargardt disease.

PURPOSE: Autosomal recessive Stargardt disease (arSTGD) presents with substantial clinical and genetic heterogeneity. This study was conducted to correlate foveolar thickness (FT) and total macular volume (TMV), measured by optical coherence tomography (OCT), with other clinical characteristics and with specific genetic variation in Hungarian patients with arSTGD. METHODS: After a standard ophthalmic workup, both eyes of 35 patients with STGD from Hungary and of 25 age-matched healthy control subjects were tested with OCT. FT and TMV were measured automatically with the OCT mapping software in the nine Early Treatment Diabetic Retinopathy Study areas of 3500 microm in diameter. All patients were screened for mutations by a combination of the ABCR400 microarray and direct sequencing. RESULTS: The patients with STGD presented with markedly thinned retina in the foveola and decreased macular volume, 72 microm and 1.69 mm3, respectively, compared with 169 microm and 2.48 mm3 in the normal subjects, respectively. Statistically significant correlation was observed between visual acuity (VA) and TMV and between VA and FT. Disease-associated mutations were detected in 23 (65.7%) of 35 patients, including 48.5% with both alleles and 17.2% with one allele. The most frequent ABCA4 alleles in Hungarian patients with STGD were L541P/A1038V (in 28% of all patients), G1961E (20%) and IVS40+5G-->A (17%). Specific genotypes correlated with some phenotypic features and allowed for predictions of the disease progression. CONCLUSIONS: Hungarian patients with STGD presented with extensive foveolar thinning and macular volume loss. Genetic analysis detected several ABCA4 alleles at high frequency in the cohort of patients, suggesting founder effect(s). Unusually homogeneous distribution of disease-associated mutations aided genotype-phenotype correlation analyses in this population.

Transient immunosuppression stops rejection of virus-transduced enhanced green fluorescent protein in rabbit retina.

The expression of lentivirus-transduced enhanced green fluorescent protein (EGFP) was detectable in rabbit retinal pigment epithelium (RPE) within 3 to 5 days after subretinal injection of the vector. Within 2 to 3 weeks, EGFP-expressing cells were eliminated by rejection. In the current experiments, we monitor serum antibody titers for EGFP before and after transduction and determine whether systemic immunosuppression prevents recognition of EGFP by the immune system. While all control rabbits developed antibodies against EFGP and showed signs of rejection, no such evidence was observed with animals which received immunosuppression. One month of systemic immunosuppression permanently prevented rejection of RPE with EGFP expression. Fluorescence has been maintained for more than a year. If a control eye was injected with the same virus after terminating immunosuppression, both eyes showed signs of rejection. The lack of rejection is not due to tolerance but to a failure of the animals to detect the foreign protein. Detection must depend upon a brief window of time after surgery needed to introduce the vector, perhaps related to a concurrent but transient inflammation. This strategy may be useful in managing other types of rejection in the retina.

Auto-immune-like cone dystrophy.

PURPOSE: To describe rapid loss of cone vision in an adult due to putative auto-immune rejection. METHODS: Clinical and electrophysiological examination, including full-field and multi-focal electroretinograms (ERGs), were used to assess retinal function. Serum was analyzed for antibodies to retinal antigens. RESULTS: The patient lost cone vision in the course of several months while rod vision remained unaffected. Initially short wavelength (S) cone function appeared more resistant to the degeneration. Cancer associated retinal antibodies were present in the sera of the patient but no cancer has been found. CONCLUSION: Rapid loss of cone function can occur in an adult without a concomitant neoplasm although serum antibodies to retinal antigens suggest an autoimmune cause.

Macular pigment and visual acuity in Stargardt macular dystrophy.

PURPOSE: To test the hypothesis that macular pigment reflects foveal cone function and possibly the presence of foveal cones in recessive Stargardt macular dystrophy. METHODS: Sixteen patients (32 eyes) diagnosed to have Stargardt macular dystrophy by clinical criteria were studied with a scanning laser ophthalmoscope (SLO) comparing argon laser blue (488 nm), green (514), helium-neon laser red (633 nm) and infrared diode laser (780 nm) images for the presence or absence of macular pigment in the fovea. Fifteen of the patients were screened for mutations in the ABCR gene. Eyes were graded into three categories: those without foveal macular pigment, those with partial pigment and those with normal amounts of macular pigment. These categories were compared with visual acuity determined by the Snellen chart. RESULTS: All patients with a visual acuity of 20/200 or worse had no macular pigment in the fovea. All patients with visual acuity of 20/40 or better had a normal amount of macular pigment in the fovea. Patients with partial macular pigment had intermediary acuity values except for two eyes, one with 20/20 and another with 20/200 acuity. Infrared light revealed more retinal abnormalities than blue light at early stages of the disease. CONCLUSION: Foveal macular pigment is related to foveal cone acuity in Stargardt macular dystrophy and may be a marker for the presence of foveal cones. Infrared light is a sensitive monitor of early Stargardt macular dystrophy.

Co-expression of murine opsins facilitates identifying the site of cone adaptation.

Murine cones contain two opsins in the same cone, one ultraviolet (UV) and the other middle-wavelength sensitive (M). A long-wavelength flash only affecting M-opsin suppresses the cone electroretinogram (ERG) produced by light absorption of UV-cone opsin raising the hypothesis that activation of M-cone opsin suppresses UV-cone opsin responses in the same cone. Here we show that pharmacologic blockade of synaptic transmission in the superfused murine retina, which eliminates interaction from second-order neurons, fails to prevent suppression of the UV-opsin driven pathway by long-wavelength stimuli. This proves that the antagonism must be occurring in the same cone, co-expressing both opsins. Our results show that UV-opsin suppression successively ceases in presence of the M-opsin activating background light, which implies that cone light adaptation is controlled at the opsin stage, before activation of transducin. It also reveals the time course of a transient desensitization of cones due to post-opsin factors in the transduction cascade.