Does ranibizumab (Lucentis®) change retrobulbar blood flow in patients with neovascular age-related macular degeneration?

PURPOSE: To investigate the effects of intravitreal ranibizumab on retrobulbar blood flow in patients with neovascular age-related macular degeneration (AMD). METHODS: Thirty-one eyes of 30 patients with neovascular AMD were examined prospectively by both color Doppler imaging and fundus fluorescein angiography. Color Doppler imaging was used to measure the maximum and minimum velocities of the central retinal vein, peak systolic/end-diastolic velocities of blood flows, and pulsatility index and resistivity index values in the central retinal artery, nasal/temporal posterior ciliary arteries (NPCA/TPCA) and ophthalmic artery. The t test for paired samples was used for comparing retrobulbar blood flow values before and after intravitreal ranibizumab (Lucentis®) injection in the study and control groups. RESULTS: There was a statistically significant (p < 0.05) difference between the pre-injection and post-injection end-diastolic velocities of the NPCA and TPCA and resistivity index values of TPCA. The other parameters showed no statistically significant difference. CONCLUSION: Our results show that intravitreal ranibizumab injection increases retrobulbar blood flow.

Does phacoemulsification under topical anesthesia affect retrobulbar blood flow?

PURPOSE: To investigate with color Doppler imaging the effects of phacoemulsification surgery under topical anesthesia on retrobulbar vessels hemodynamics. METHODS: In this prospective study, color Doppler imaging was used to measure the maximum (Vmax) and minimum flow velocity (Vmin) of the central retinal vein, and the Vmax and Vmin, pulsatility index and resistance index of the central retinal artery, nasal, and temporal posterior ciliary arteries, and ophthalmic artery blood flow before and 1 day after phacoemulsification surgery under topical anesthesia. RESULTS: After phacoemulsification surgery under topical anesthesia, Vmin of the central retinal artery increased (p ≤ 0.05), whereas the other variables showed no significant change. CONCLUSIONS: Phacoemulsification surgery under topical anesthesia has a minor effect on retrobulbar blood flow. Therefore topical anesthesia should be suitable for patients with ocular perfusion disorders (eg, glaucoma).

Effects of intravitreal bevacizumab (Avastin) therapy on retrobulbar blood flow parameters in patients with neovascular age-related macular degeneration.

BACKGROUND: To investigate the effects of intravitreal bevacizumab on retrobulbar circulation in patients with neovascular age-related macular degeneration (AMD). METHOD: Thirty patients with neovascular age-related macular degeneration were assessed prospectively by both color Doppler imaging and fundus fluorescein angiography. Spectral Doppler analysis allowed the measurement of the maximum velocity (Vmax) and minimum velocity (Vmin) of the central retinal vein (CRV), and peak systolic (PSV), end-diastolic (EDV) velocities of blood flows, and pulsatility index (PI) and resistance index (RI) values in the central retinal artery (CRA), nasal and temporal posterior ciliary arteries (NPCA, TPCA), and ophthalmic artery (OA). The t test for paired samples was used to compare retrobulbar blood flow values before and after intravitreal bevacizumab injection. RESULT: PSV and EDV of the NPCA and PSV of the TPCA were significantly decreased after intravitreal bevacizumab injection (p < 0.05). There was no statistically significant difference in the other parameters. CONCLUSION: Our results suggest that intravitreal bevacizumab therapy has a measurable effect on retrobulbar blood flow.

Ophthalmic manifestations of 107 cases with hemolysis, elevated liver enzymes and low platelet count syndrome.

OBJECTIVE: To present various ophthalmologic disorders in a clinical series of hemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome cases. METHODS: This is a prospective clinical study performed between 2002 and 2005. One hundred seven HELLP patients attended in either Departments of Ophthalmology or Obstetrics and Gynecology, Medical School, Gaziantep University, Gaziantep, Turkey were evaluated. RESULTS: Mean age was 25.5 (22-36 years). Mean levels were 2.5 gravidity, 1.3 parity, 55,200/mm3 platelet counts, 308.7 U/l aspartate transaminase, 255.4 U/l alanine transaminase, and 1711.6 U/I lactate dehydrogenase. Four patients died (3.7%) despite the proper treatments. Cortical blindness was observed in 3 cases (2.7%), serous retinal detachments in 4 (3.7%), and mild hypertension changes in 18 (16%). CONCLUSION: Ophthalmic complications are possible during and after this syndrome. Almost all ophthalmologic changes recover after delivery by cesarean section, nevertheless, it is essential that ophthalmologists should be aware of retinal disorders when this fatal complication of pregnancy is encountered.

Sutureless closure of the conjunctiva with a commercial fibrin sealant in extraocular muscle surgery for strabismus.

PURPOSE: Suturing is a time-consuming process and patients may suffer from sutures because of discomfort and tearing. This prospective study was done to determine the efficacy of an available commercial fibrin sealant for conjunctival wound closure following extraocular muscle surgery for strabismus. METHODS: Fibrin sealant (Beriplast) was used in 48 conjunctival wounds of 25 patients with strabismus during the period February 2004 to May 2005. There were 12 males and 13 females, whose mean age was 9.3 years. RESULTS: No allergic reactions, chemosis or infections were seen, but suturing was necessary a day after surgery in 3 wounds of 2 cases (3/48 eyes, 6%). All conjunctival wounds were healed at the end of the second week. CONCLUSION: The use of Beriplast for conjunctival wound closure is an effective method that is easy to apply and should be considered a solution in strabismus surgical practice.

The effect of age and gender on the anatomic structure of Caucasian healthy eyelids.

OBJECTIVES: To determine the normal values of the eyelid parameters in Caucasians and to describe the effects of age and gender on eyelid and eyebrow anatomy. METHODS: We evaluated the effects of age and gender on eyelid structures in 100 Caucasian volunteers in the Ophthalmology and Anatomy Departments, University of Gaziantep Medical School, Turkey between 2003 and 2004. Forty-five females with mean age of 36 years (5-80 years) and 55 males with mean age of 39 years (3-68 years) participated in the study. We divided subjects into 6 groups according to decades. We measured the palpebral fissure length (PFL), the distance between the pupil center and the upper eyelid (PC-UE) and lower eyelid margin (PC-LE), the eyebrow height (EH), the eye crease height (ECH) and the distance from the reference line to the pupil center (RL-PC), using a reference line through the medial canthus and vertical line through the pupil center of the frontal slides. RESULTS: The measurements of PFL were between 23.5 mm and 29 mm in females, 24.8 mm and 29.1 mm in males and showed a gradual decrease with age. The PC-UE, PC-LE, ECH and RL-PC remained stable throughout life and were identical for both gender. However, EH ranging from 10.7-12 mm in females and 6.5-11 mm in males appeared to have a significant association with gender, which was higher in females than males, but was not effected with age. CONCLUSION: These results demonstrate the importance of providing a normal anatomic relationship that relates to the patient's age and gender.

Cell division and cellular morphology of the chick retinal pigmented epithelial cells in culture: a time-lapse analysis.

OBJECTIVE: To investigate the patterns of cell division, movement and shape during early stages of development of the chick embryo retinal pigmented epithelial (RPE) cells and to evaluate the morphology of dissociated embryonic cells with regard to their proliferation capacity. METHODS: We conducted this study at the Department of Histology and Embryology, Celal Bayar University, Manisa, Turkey, between 2002 and 2003. We isolated the cells from chick embryos. We analyzed the images of the embryonic cells originated from neuroepithelia using a computer-based time-lapse acquisition system attached to a differential interference contrast microscope. RESULTS: Retinal pigmented epithelial cells, despite being dissociated, depict a colony-type growth. Cells in the periphery of the colony and those outside the colony showed a tendency to proliferate and migrate and retained contact with the neighboring cells during division. Characteristics of cytokinesis were separation from the neighboring cell while retaining an attachment point, became rounded, moved up and started to shake and ascend to disseminate to the substrate to complete the division. The round-up stage was non-significantly shorter when the cell was closer to the center of the colony. Cells that were in the periphery of, or outside the colony had a round-up time of over one hour while cytokinesis-to-adhesion time was around 5 minutes. However, when we found the cells in the center of the colony, the times were half-an-hour and 1.5 hours for the daughter cells, a 2-fold difference between daughter cells with regard to the duration of attachment. CONCLUSION: Cell division, migration and proliferation are complex procedures influenced by growth factors, cell adhesion, matrix molecules underneath and the signal mechanisms and can be studied in detail using time-lapse microscopy, immunohistochemistry and confocal microscopy.

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.

Ocular anterior segment pathologies and tear film changes in patients with psoriasis vulgaris.

Ocular manifestations in patients with psoriasis vulgaris have been investigated in only a small number of studies. Our purpose was to identify tear film function and ocular pathologies associated with psoriasis vulgaris in patients who had received neither oral retinoids nor phototherapy. We examined 62 eyes of 31 patients with psoriasis and 60 eyes of 30 age-and-sex matched healthy volunteers. In addition to complete ocular and dermatological examination, tear film function (i.e., tear secretion and tear film stability) were assessed by the Schirmer-I test, as well as by tear film break-up time. None of the controls had any ocular abnormalities, whereas 67.74% of patients with psoriasis had various anterior segment pathologies (P<0.00009). The most prevalent finding was chronic blepharoconjunctivitis (64.5%), as the only pathology (n=9) or in association with other findings, including nonspecific corneal opacities (n=4), cataract (n=3), both corneal opacities and cataract (n=2), and corneal pigment dispersion (n=2). The Schirmer-I test results revealed comparable mean values in the patient group (9.8+-4.2 mm) and in the controls (11.2+-3.7 mm; P=0.078). However, mean tear film break-up time was significantly shorter in the patients (7.2+-2.5 sec) than in the healthy persons (11.7+-3.1 sec; P=0.001). In agreement with some previous reports, our findings clearly demonstrated that early ocular involvement occurs in patients with psoriasis vulgaris, irrespective of the history of previous therapeutic modalities (e.g., retinoid therapy and phototherapy). Thus, the present findings are suggestive of the contributory role of primary etiologic factors of psoriasis in the pathogenesis of ocular changes in patients with psoriasis vulgaris.

Decreased central corneal thickness in children with Down syndrome.

PURPOSE: A cross-sectional, masked, case-control study was undertaken to investigate whether central corneal thickness is affected in children with Down syndrome and to focus on its clinical significance. PARTICIPANTS AND METHODS: Twenty-eight children with Down syndrome (15 boys and 13 girls) aged 5 to 15 years and 20 age-matched and gender-matched healthy control subjects (11 boys and 9 girls) from a similar ethnic background were enrolled in the study. Central corneal thickness was measured by ultrasound pachymetry. Only the right eye of each child in each group was included in the statistical analysis. The Mann-Whitney U test was used and a P value of less than .05 was considered significant. RESULTS: The mean ages of the children with Down syndrome (9.28 +/- 3.47 years) and the healthy control subjects (8.75 +/- 3.30 years) were comparable (P > .05). Central corneal thickness values were below 500 microm in 19 (67.8%) of the 28 children with Down syndrome, 4 of which were less than 450 microm. However, all central corneal thickness measurements in the control eyes were more than 500 microm. The mean central corneal thickness in the children with Down syndrome was significantly (P < .001) less (488.39 +/- 39.87 microm) than that in the healthy control subjects (536.25 +/- 20.70 microm). Mean keratometric values were significantly (P < .001) higher in the eyes of the children with Down syndrome (46.35 +/- 1.28 D) than in the eyes of the control subjects (43.32 +/- 1.15 D). CONCLUSIONS: Children with Down syndrome had a decreased central corneal thickness compared with healthy control subjects. Decreased central corneal thickness may give an artificially low intraocular pressure measurement by applanation tonometry. Central corneal thickness must be considered when developing approaches for keratorefractive treatment of patients with Down syndrome.

Effectiveness of retroequatorial recession surgery in congenital nystagmus.

OBJECTIVE: The aim of this retrospective study was to evaluate the effectiveness of the retroequatorial recession technique in the surgical treatment of nystagmus and associated strabismus. METHOD: The effect of large recessions of four horizontal extraocular muscles was analyzed qualitatively in seven patients with congenital nystagmus. RESULTS: The ages of the patients ranged between 12 and 42 years (mean, 21.5 years). Of the seven patients, four had motor and three had sensory nystagmus. Visual acuity increased in five (71.4%) patients. Planned recovery of associated strabismus was attained in six patients (85.7%). In five patients who had abnormal head position, the head positions and nystagmus intensities were found to be decreased. No postoperative complication, such as diplopia, was encountered. CONCLUSION: The retroequatorial recession technique is preferable in patients who have congenital nystagmus, especially in the presence of horizontal squint associated with low visual acuity, because of its success in increasing visual acuity and decreasing the amplitude of nystagmus, its reversibility, making posssible new operations in the future, as well as the absence of any significant complications.

Unilateral nystagmus in an infant with acrocallosal syndrome.

Acrocallosal syndrome (ACS), is an extremely rare disorder characterized by the absence of corpus callosum (CC), macrocephaly, hypertelorism, pre- and postaxial polydactyly and severe motor and mental retardation. There are only 3 reports of ACS associated with ocular findings, including optic atrophy, esotropia and anophthalmus. We report on the first known Turkish case of ACS associated with unilateral nystagmus in addition to several neurologic abnormalities such as absence of the adhesio interthalamica and many others. A physically and mentally underdeveloped one year-old girl was evaluated for macrocephaly, polydactyly and left-sided nystagmus, which was not recognized until the fourth month. Magnetic resonance imaging revealed external hydrocephaly, triventricular hydrocephaly, midline brain abnormalities including partial agenesis of the CC, cavum septi pellucidi, cavum vergae, and absence of the adhesio interthalamica. The following anomalies were also noted; high arched palate, short nose with broad nasal bridge and anteverted nostrils, macrocephaly, frontal bossing, open and down turned angles of the mouth, hypertelorism, postaxial polydactyly of the left foot, hypertrichiasis, and hypertrichosis. On the basis of these findings, a diagnosis of ACS was made. In addition to neuroimaging, systemic research is needed in all patients presenting with asymmetric nystagmus as such a nystagmus may be associated with various external developmental abnormalities in addition to central nervous system involvement. Our case indicates that asymmetric nystagmus and midline brain abnormalities may also be included in the diagnostic criteria of ACS.

Central corneal thickness is lower in osteogenesis imperfecta and negatively correlates with the presence of blue sclera.

BACKGROUND: Osteogenesis imperfecta (OI) is a rare, autosomal-inherited, connective tissue disorder characterised by bone fractures, deafness and blue sclera. Additional ocular findings are decreased ocular rigidity, myopia, glaucoma, keratoconus, corneal opacity, small corneal diameter and congenital Bowman's layer agenesis. PURPOSE: This cross-sectional, masked, case-control study aimed to assess whether central corneal thickness (CCT) is affected in patients with OI and to focus on the clinical significance of scleral blueness. MATERIALS AND METHODS: Twenty-three children with OI (13 boys, 10 girls) and 15 age-, sex- and refraction-matched healthy control subjects (eight boys, seven girls) were assessed for CCT by ultrasound pachymetry. The CCT was compared between two different patient subgroups (type-I OI with blue sclera, n = 12; type-IV OI without blue sclera, n = 11). Mann-Whitney U-test or analysis of variance was used as indicated and only right eyes of each subject were included in statistical analysis. Results were expressed as mean +/- S.D. and statistical significance was taken as p < 0.05. RESULTS: Mean age and sex distribution was similar between the groups (10.1+/-2.5 vs 9.8+/-1.8 years, p > 0.05). Patients with OI had significantly lower CCT (459.5+/-24.6 microm) than in control subjects (543.6+/-21.4 microm; p < 0.001). The CCT was below 500 microm in 22 of 23 children (95.6%) with OI, 15 of which (65.2%) were below 450 microm. In contrast, CCT was over 500 microm in all eyes in the control group. Type-I OI eyes with blue sclera had significantly (p = 0.005) lower CCT readings (446.5+/-16.3 microm) than type-IV OI eyes without blue sclera (473.6+/-25.0 microm). Mean keratometric values were similar between the groups (44.2+/-1.7 vs 43.8+/-1.6 dioptre, p > 0.05). Mean cycloplegic refraction was similar between the groups (-0.32+/-0.5 vs -0.18+/-0.4 dioptre; p > 0.05), although five of 23 OI patients had myopia, and mean intraocular pressure was lower in OI patients than controls (12.7+/-1.8 mmHg vs 15.6+/-1.9 mmHg; p < 0.001). CONCLUSIONS: The CCT is thinner and negatively correlated with the blueness of the sclera in patients with OI. The CCT readings may therefore be of utmost importance in the diagnosis of OI. An ophthalmologist should be aware of an artificially low intraocular pressure measurement in such patients. In addition, when considering a keratorefractive treatment, CCT must be evaluated carefully to avoid unexpected results or complications. Sturdy protective spectacles should be prescribed to those who are not bed bound. Possible correlation of low CCT with biochemical changes in scleral collagen or systemic parameters awaits further investigation.

Angiotensin-converting enzyme insertion-deletion polymorphism in primary open-angle glaucoma.

PURPOSE: To investigate the hypothesis that primary open-angle glaucoma (POAG) is associated with a common insertion-deletion (I/D) polymorphism in the angiotensin-converting enzyme (ACE) gene. METHODS: ACE I/D polymorphism was investigated in a control group of healthy subjects (n = 101) and in a group of patients diagnosed with POAG (n = 104). Polymerase chain reaction detection of I/D polymorphism was used to determine the presence of the two ACE alleles in the groups. RESULTS: Neither the I/D genotype distributions nor the allele frequencies differed significantly between POAG and control subjects (DD genotype 34.6 vs. 39.6%; ID genotype 53.9 vs. 40.6%; II genotype 11.5 vs. 19.8%, p = 0.1; D allele 61.5 vs. 60%; I allele 38.5 vs. 40%, p = 0.8). CONCLUSION: We could not identify a possible association of the I/D polymorphism in the ACE gene with POAG, however further studies with larger patient numbers in different populations are required to clarify the role of ACE gene in susceptibility to POAG.

Beta 2-adrenergic receptor polymorphism and susceptibility to primary congenital and primary open angle glaucoma.

OBJECTIVE: It has been shown that arginine to glycine (Arg16Gly), glutamine to glutamic acid (Gln27Glu) and threonine to isoleucine (Thr164Ile) exchanges in codons 16, 27 and 164, respectively, of the beta 2-adrenergic receptor (B2AR) gene significantly alter receptor function. As B2ARs are located on the afferent blood vessels supplying the ciliary body and trabecular meshwork cells, which control aqueous humour dynamics, polymorphisms of B2AR may be involved in the pathophysiology of certain eye diseases, such as glaucoma. Therefore, the aim of the present study was to investigate the distribution of B2AR polymorphisms in patients with primary congenital and primary open angle glaucoma. METHODS: A group of 30 patients with primary congenital glaucoma, 105 with primary open angle glaucoma and 92 control patients were analysed for the Arg16Gly, Gln27Glu, and Thr164IIe polymorphisms of the B2AR by polymerase chain reaction-restriction fragment length polymorphism. RESULTS: The allelic frequencies of Gly16, Glu27 and IIe164 variant alleles were 66.7, 38.3 and 3.3% in patients with congenital glaucoma, 59.5, 31.0 and 1.0% with glaucoma, and 54.9, 26.6 and 0.5% in controls, respectively. Although statistically non-significant, the frequencies of variant alleles were slightly higher in both groups of the glaucoma patients. CONCLUSIONS: These results suggest no evidence of an association between the Arg16Gly, Glu27Gln and Thr164Ile polymorphisms of the B2AR gene and risk of developing primary open angle glaucoma or primary congenital glaucoma. However, further studies are needed to understand the role of B2AR polymorphisms in patients with eye disease.