Assessment of Schlemm's canal with swept-source optical coherence tomography in Graves' ophthalmopathy.

PURPOSE: To evaluate the Schlemm's canal (SC) parameters obtained by swept-source optical coherence tomography (OCT) different in Graves' ophthalmopathy (GO) eyes compared to healthy eyes. METHODS: This cross-sectional observational study evaluated 64 eyes of 32 GO cases and 56 eyes of 28 healthy controls. The study was conducted between October 2020 and June 2021. SC images were obtained from the temporal limbus of individuals using swept-source OCT. SC length (SCL) and SC area (SCA) were measured. The relationship between SC parameters in the patient group and intraocular pressure (IOP), retinal nerve fiber layer (RNFL) thickness, Graves' disease (GD) duration, and clinical activity score (CAS) was evaluated. RESULTS: In the GO group, 64 eyes of 32 patients were evaluated, and in the age and gender-matched healthy control group, 56 eyes of 28 individuals were assessed. SC images from 4 eyes of 4 patients in the patient group and 1 eye of 1 patient in the control group were not clear, preventing SCL and SCA measurements for these eyes. SCL and SCA measurements were found to be lower, and IOP and Hertel values were higher in the GO group compared to the healthy controls. However, no significant correlation was observed between SCL and SCA with IOP, RNFL thickness, GD duration, GO duration, or CAS in the GO group. In the GO group, the mean value of SCA was found to be higher in eyes with glaucoma or OHT compared to those without. CONCLUSION: These findings indicate that SC in GO-affected eyes is shorter and has a smaller area than in healthy individuals. Additionally, higher IOP and Hertel values were observed in the GO group compared to healthy controls. This study suggests that assessing SC using anterior segment OCT could provide valuable insights into the regulation of IOP and the development of glaucoma in GO-affected eyes.

Unlocking the secrets of success in probing for congenital nasolacrimal duct obstruction: investigating the factors that matter.

PURPOSE: The objective of this study was to analyze the impact of different factors on the success rate of probing for congenital nasolacrimal duct obstruction (CNLDO). METHODS: A retrospective analysis was conducted on 239 eyes of 202 patients who underwent probing for CNLDO between 2014 and 2019. Patients were divided into three age groups (12-24 months, 25-36 months, and over 36 months) and two groups based on the type of membranous obstruction (MO) and incomplete complex obstruction (ICO), with complete complex obstruction (CCO) cases being excluded. The study involved administering general anesthesia (GA) to all participants during the probing procedure. The patients were then monitored at scheduled intervals for up to 6 months after the surgery. Success was defined as an improvement in symptoms and signs, and logistic regression and Fisher's exact test were used for statistical analysis. RESULTS: The mean age of the patients was 25.48 ± 13.38 months, and the total success rate was 86.61%. The success rate for MO was 92.8%, 95.87%, and 97% in age groups 1, 2, and 3, respectively. The success rate for ICO was 91.17%, 80%, and 23.52% in age groups 1, 2, and 3, respectively. The success rate for MO was significantly higher than ICO in all age groups. The success rate for ICO was significantly lower in age group 3 (p = 0.009). CONCLUSION: The study found that probing performed within the first 36 months had high success rates regardless of age and type of obstruction. However, the success rate significantly decreased in patients undergoing probing for ICO at 36 months or later.

Modified Horner-Duverney's muscle plication in the treatment of functional epiphora.

BACKGROUND: The orbicularis oculi muscle, especially its part (Horner-Duverney's muscle), which is surrounded by the pericanalicular and located deep in the lacrimal sac, is of primary importance in all stages of tear fluid flow. PURPOSE: This study aimed to demonstrate that tightening the pretarsal-preseptal orbicularis oculi and Horner-Duverney muscles may improve the function of the lacrimal pump and may be a surgical alternative for treating functional epiphora. MATERIAL AND METHODS: This was a prospective interventional case series of 28 patients with functional epiphora. During surgery, sutures were used to perform the intervention, and these were first passed through the upper and lower eyelid pretarsal-preseptal orbicular muscles, through the Horner-Duverney's muscle, and finally, through the dacriocystorhinostomy incision and tightened. Each patient completed the Lac-Q questionnaire and Munk scale prior to surgery, as well as six weeks and six months later. Before surgery, a fluorescein dye disappearance test was performed, which was repeated at follow-up appointments. Pre- and post-operative data were analyzed and compared at the most recent visit. RESULTS: Twenty-eight patients (10 males and 18 females) with a mean age of 59 ± 35 years were included in this study. The severity of epiphora and its tearing effect on daily life significantly improved following the operation. The fluorescein dye disappearance test result was significantly improved after 6 weeks of followup in %89.3 of eyes and at 6 months followup in 92.9% of eyes. The Lac-Q questionnaire's mean social impact scores improved significantly postoperatively, from 3.76 to 0.77 (p < 0.001). The changes in total scores (7.29 before surgery to 1.71 after 6 months) were statistically significant (p < 0.001). The Munk score success rate was 64.3% and 85.7%, respectively. No significant complications or adverse effects were observed. CONCLUSION: Our findings suggest that a beneficial and seemingly simple, safe, and easy procedure to reduce functional epiphora is to tighten the preseptal-pretarsal orbicularis and Horner-Duverney's muscles.

Evaluating the quality, utility, and reliability of the information in uveitis videos shared on YouTube.

BACKGROUND: This study aimed to analyze the quality of videos on YouTube as educational resources about uveitis. METHODS: An online YouTube search was performed using the keyword "uveitis". Total view counts, duration of videos, publishing dates, likes and dislikes, numbers of comments, and source of videos were recorded. The quality and accuracy of the video's educational content were evaluated using the DISCERN score, Global Quality Score (GQS), and Journal of the American Medical Association (JAMA) score. Video power index (VPI) was used to evaluate both the view and the like ratio of the videos. All videos were classified according to publishers and types of categories. RESULTS: From among the 200 videos analyzed, 94 were included. The mean DISCERN score was 38.5 ± 13.2 (poor), the mean JAMA score was 1.8 ± 0.6 (fair), and the GQS was 2.5 ± 0.9 (fair). There were positive correlations between the three checklists (p < .001). VPI was not correlated with each score (p > .05). The most common upload sources were ophthalmologists (24.4%) and YouTube channels about health (20.2%). Regarding content, we identified 47 (50%) medical education, 26 (27.6%) patient education, 16 (17%) patient experience, and five (5.3%) surgical procedure videos involving patients with uveitis. While the most popular videos were uploaded by doctors other than ophthalmologists, the videos uploaded by academic institutions and associations of healthcare professional were found to have higher educational quality and reliability scores. CONCLUSIONS: Uveitis videos on YouTube are of poor quality and reliability and are not adequately educational for patients. Therefore, physicians must be aware of the limitations of YouTube and ensure the flow of correct medical information to patients.

Importance of etiology in canalicular obstruction surgery.

PURPOSE: The treatment options for canalicular obstruction remain controversial, and there are different approaches. In this study, we aimed to evaluate the success of balloon dilatation and silicon tube intubation according to the etiology in patients with canalicular obstruction. METHODS: The files of 91 patients with isolated monocanalicular obstruction were retrospectively reviewed. Patients were grouped according to surgical methods (Group A: both balloon dilatation and silicon tube intubation; Group B: Only balloon dilatation) and etiologies (topical anti-glaucomatous usage-related, inflammatory, chemotherapy-related, radiotherapy-related, trauma-related, idiopathic). Preoperative and postoperative Munk scores and lacrimal irrigation results were noted in all cases. RESULTS: Munk score was found to be statistically significantly lower in the 1st year in both groups. The patency rate with lacrimal syringing was found to be statistically significantly higher in group A. Success rates both in the munk score and lacrimal passage patency were found to be statistically significantly lower in inflammatory etiology than other etiologies. CONCLUSIONS: Both techniques can be used as first-line therapies for canalicular obstruction. It should be considered that recurrence may develop in stenosis of inflammatory origin and more invasive surgery may be required.

The effects of facial mask use on ocular surface parameters and tear film cytokine profile in prolonged use.

OBJECTIVE: To compare tear fluid levels of matrix metalloproteinase 9 (MMP-9) and IL-1ß cytokines between healthcare workers wearing facial masks and controls with correlations in clinical findings. METHODS: In a prospective, controlled clinical trial tear fluid was analyzed for MMP-9 and IL-1ß levels using a commercially available test (Invitrogen; Thermo Fisher Scientific Inc. Waltham, Massachusetts, USA). Symptoms and signs of dry eye disease (DED) were evaluated using the ocular surface disease index (OSDI), noninvasive tear break-up time (NIBUT), tear meniscus height (TMH), Oxford corneal staining, meibomiography, and clinical findings of meibomian gland dysfunction (MGD). RESULTS: In the 38 eyes of healthcare workers and 30 eyes of controls, there was no statistically significant difference between the groups in terms of age and sex (p > 0.05). The mean OSDI score, daily mask wear time, meibomiography degree, and rate of positive clinical findings of MGD were higher in group 1 than in group 2, and the mean NIBUT was higher in group 2. (p > 0.05). The mean values of IL-1ß and MMP-9 were higher in group 1 (p = 0.036 and p = 0.001, respectively). The TMH and Oxford score percentages were similar between the two groups (p > 0.05). CONCLUSIONS: Elevated levels of IL-1ß and MMP-9 in the basal tear fluid reveal increased ocular inflammation in healthcare professionals. Lower NIBUT values with higher OSDI and meibomian gland loss scores support ocular surface disturbance depending on regular mask use.

Surgical Outcomes in Congenital Nasolacrimal Duct Obstruction After Probing Failure: A One-Stage Approach.

Objectives: This study evaluates the outcomes of a one-stage obstruction-based strategy for congenital nasolacrimal duct obstruction (CNLDO) in children who have prior probing failure. The objective is to assess the success rates of probing, balloon dacrioplasty (BDP), monocanalicular intubation (MCI), and external dacryocystorhinostomy (external DCR) performed in the same anesthesia session. Methods: A retrospective analysis included 55 eyes (45 patients, aged 12-120 months) with initial probing at another center. Procedures involved probing, probing plus BDP, MCI, and external DCR. For membranous obstruction (MO), the procedure concludes after probing; for incomplete complex obstruction (ICO) it includes BDP or MCI; and for complete complex obstruction (CCO), external DCR is performed. Success rates were assessed based on obstruction types and age groups, with improvement in symptoms and signs as the measure of success. Statistical analysis utilized Kruskal-Wallis, Fisher's exact test, and logistic regression. Results: The overall success rate for all procedures was 72.7%. Success rates were 77.8% for MO, 66.7% for ICO, and 100% for CCO, introducing a promising perspective for the management of different CNLDO types. External DCR exhibited a 100% success rate, highlighting its effectiveness in cases of CCO. Success rates for interventions were 77.8% for probing, 61.5% for probing plus BDP, and 73.1% for MCI, emphasizing the feasibility and success of one-stage obstruction-based treatments. Age did not significantly correlate with success rates. Conclusion: The one-stage obstruction-based approach, which demonstrated favorable success rates in treating CNLDO and introduced a paradigm shift in the treatment strategy after probing failure, underscores the importance of tailoring interventions to the specific obstruction type. The study also highlights the feasibility and cost-effectiveness of performing multiple BDP, MCI, or external DCR procedures concurrently during the same anesthesia session, further emphasizing the crucial role of customizing treatments based on the nature of the obstruction.

Efficacy of pyridostigmine (Mestinon) in the relief of patients with epiphora.

BACKGROUND: Although the mechanism is not clear, the inability of the orbicularis oculi muscle, especially the deeper segment (Horner muscle), is thought to be responsible in epiphora. This study evaluates the effect of the anticholinergic drug pyridostigmine (Mestinon) in patients with patent but dysfunctional lacrimal drainage system. MATERIAL AND METHODS: Twenty patients with bilateral epiphora (mean age:60.78 ± 6.49 yrs) were included in this study. Patients with a patent lacrimal irrigation test based on persistent and symptomatic epiphora, wiping >10 times daily or continuous tearing and grade 4-5 epiphora according to Munk scale, showing neuropathic involvement in the orbicularis oculi muscle by the quantitative motor unit potential (MUP) analysis method were evaluated prospectively. Fluorescein dye disappearance test (a semi-quantitative assessment of delayed tear outflow) together with a Schirmer test reading were performed in order to detect dry eye. The patients were evaluated for tear meniscus measurements by anterior segment optical coherence topography (OCT) and non-invasive tear break-up time (NI-BUT) was measured by Oculus Keratograph 5 M. Those with a NI-BUT value above 10 s, without eyelid laxity, previous ocular surgery or ocular surface disease, or nasolacrimal duct obstruction, and who agreed to use the drug were included in the study. Each subject underwent OCT measurements of the lower tear meniscus of both eyes before and 15 mins after taking Mestinon (1 × 60 mg tablet). Upon measurement of the positive effect of the drug on tear meniscus height (TMH), the patients were asked to continue this regime daily for 1 month and then evaluated for relief in their epiphora complaints and any systemic drug side effects. RESULTS: A total of 20 patients (40 eyes) with bilateral epiphora were included in the study. All eyes had grade 4 Munk-score epiphora, Schirmer's test was within the normal range in all eyes (mean, 14 ± 4 mm), and patent lacrimal irrigation test. The lower mean TMH reductions 15 min after Mestinon in the right and left eyes were 135.41 ± 85.47 and 55.44 ± 61.56 mm, respectively, a statistically significant decrease in both eyes (p = 0.001, p < 0.01). The mean tear meniscus area (TMA) in the right and left eyes was 131.83 ± 68.27 mm2 and 62.72 ± 50.57 mm2, respectively; 15 mins after administration of Mestinon, the mean TMA in the right and left eyes was 77.27 ± 48.34 and 59.18 ± 44.74 mm2, respectively (p = 0.001, p < 0.01). The mean decreases of 54.56 ± 39.34 mm2 in the right eye area and 3.53 ± 42.32 mm2 in the left eye area were statistically significant (p = 0.041, p < 0.05). CONCLUSION: Symptomatic relief for epiphora cannot be achieved with known treatment options due to lacrimal pump dysfunction. We found that pyridostigmine (Mestinon) provided relief in patients' complaints of epiphora consistent with a significant reduction in TMH levels.

Treatment Adherence Effect on the Visual Acuity of Behçet's Uveitis Patients.

PURPOSE: This study aimed to explore the relationship between treatment adherence, visual acuity, quality of life (QoL), depression, and anxiety levels in individuals with Behçet's uveitis (BU). METHODS: A total of 55 BU patients and 55 healthy controls completed sociodemographic questionnaires, the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), World Health Organization Quality of Life Questionnaire-BREF version (WHOQOL-BREF), Self-reported Questionnaire About Treatment Compliance, and the Morisky Medication Adherence Scale (MMAS). The scores obtained from these scales were analyzed to assess the relationship between treatment adherence, visual acuity, QoL, depression, and anxiety levels. RESULTS: The results revealed that 36 (65.4%) of the 55 BU patients exhibited depressive symptoms, while 45 (81.8%) of them experienced symptoms of anxiety. Patients with BU demonstrated significantly higher BAI and BDI scores compared to the healthy control group (p < 0.001). Furthermore, the patient group reported lower mean scores across multiple domains of the WHOQOL-BREF questionnaire, including general health, psychological health, social relationships, and environment (p < 0.05). Moreover, a significant association was observed between low treatment adherence and lower values of best-corrected visual acuity (BCVA) (p < 0.05), as well as a higher frequency of uveitis attacks (p = 0.005). CONCLUSION: Poor treatment adherence in BU patients has a negative effect on final visual acuity outcomes. Moreover, BU patients experience lower QoL and higher rates of depression and anxiety compared to the healthy control group. These findings highlight the importance of addressing treatment adherence and psychological well-being in the management of BU.

Evaluation of corneal endothelium and correlation with disease severity in patients with Graves' ophthalmopathy: A specular microscopy-based study.

PURPOSE: To investigate the possible corneal endothelial damage in Graves' ophthalmopathy (GO) and its relationship with GO activity. METHODS: This cross-sectional study included 101 eyes of 55 patients with GO. Each eye was assigned a specific clinical activity score (CAS). Accordingly, they were classified as active (CAS ≥ 3) or inactive (CAS< 3). The corneal endothelium was measured using a non-contact specular microscope (Tomey EM-4000; Tomey Corp.). Endothelial cell density (ECD), average cell area (ACA), standard deviation of cell area (SD), coefficient of variation in cell area (CV), hexagonal cell ratio (HEX), and central corneal thickness (CCT) were recorded. RESULTS: Among the eyes included in the study, 71 had inactive GO and 30 had active GO. ACA and HEX levels were lower (p<0,001) and CV values were higher (p<0.001) in patients with GO than in healthy subjects. Corneal endothelial cell morphology was altered in active GO compared to inactive GO. The SD (p = 0,009) and CV (p<0,001) were significantly higher in active GO than in inactive GO. When the parameters examined were correlated with CAS, a statistically significant positive correlation was observed between proptosis (p = 0,036, r = 0,385) and CV (p = 0,001, r = 0,595). CONCLUSION: Our study confirmed that morphological changes occur in the corneal endothelium of patients with GO. CV and SD values, in conjunction with CAS, can be used as non-invasive and quantitative indices to examine the activity status of GO. The demonstration of endothelial changes even in GO eyes with low CAS may be considered an incentive to include non-contact specular microscopy in the routine clinical evaluation of all patients with GO.

Changing trends in the corneal transplantation and the impact of the COVID-19 pandemic on corneal transplant recipient selection.

PURPOSE: The aim of this study was to analyze the trends in the major indications and types of keratoplasty over a 15-year period and to determine the effect of the coronavirus disease-2019 (COVID-19) pandemic on the selection of corneal transplant recipients at a tertiary referral center in Turkey. METHODS: We retrospectively reviewed the data of patients who underwent keratoplasty at the center from January 2006 to March 2021. The keratoplasty indications and types of surgery were evaluated after classification into three groups (period I - January 2006-December 2012; period II - January 2013-March 2020; COVID-19 period - April 2020-March 2021). RESULTS: A total of 5016 corneal transplants were performed in 3862 patients. Lamellar keratoplasty (LK) techniques were found to demonstrate a statistically significantly increasing trend compared to penetrating keratoplasty in the period between 2006 and 2021 (χ2 = 240.55, P < 0.001). The top 4 indications over the 15-year period were aphakic/pseudophakic bullous keratopathy (BK) (1105, 22%), keratoconus (1085, 21.6%), regraft (1084, 21.6%), and keratitis (645, 12.8%). The most common keratoplasty indication during the COVID-19 period was regraft (27, 54.0%), followed by BK (13, 26.0%) and corneal perforation (5, 10%). CONCLUSION: BK was the most common keratoplasty indication at our clinic during the 15-year period. LK rates have been found to increase in recent years, although still not reaching the rates of developed countries. There was a marked decrease in the number of keratoplasties during the COVID-19 pandemic and patients requiring urgent keratoplasty or those who suffered from a painful eye were prioritized.

The electromyographic analysis of orbicularis oculi muscle in epiphora.

Purpose: Functional epiphora is a clinical condition that presents with the complaint of watery eyes, but without anatomical stenosis in the lacrimal drainage system. Although the mechanism is not clear, there are various possibilities involving the movement of the orbicularis oculi muscle, especially its deeper segment (Horner's muscle). We aimed to evaluate the function of the orbicularis oculi muscle in patients with patent, but dysfunctional lacrimal drainage system using a quantitative motor unit potential (MUP) analysis. Methods: Twenty-eight patients with functional epiphora (mean age = 59 years) and a control group of 28 volunteers were included in the study. Inclusion criteria were persistent and symptomatic epiphora or wiping >10 times per day and diagnosis confirmation by lacrimal irrigation test. Electromyography (EMG) was performed on the deeper segment of the orbicularis oculi muscle (medial and lateral parts). MUP parameters (duration time, amplitude, number of phases, number of turns, area, rise time, and thickness) were evaluated in both groups. Any increase in amplitude, prolongation time (>14 ms), number of turns, and satellite potential was taken as characteristic of the neurogenic type of epiphora, whereas shortened motor unit duration time, increased phase number, and low amplitude are the features of myopathic type. Results: Upon MUP analysis of the medial and lateral orbicularis oculi muscle, the increase in duration and thickness values in the medial part and the increase in duration, amplitude, area, and thickness values of the lateral part were found to be statistically significant in the patient group compared to the control group (P < 0.001). In the evaluation of the patients' medial and lateral orbicularis oculi muscle, the increase in phase values and decrease in amplitude, area, and rise time values were found to be statistically significant (P = 0.024, P < 0.001, P < 0.001, and P = 0.010, respectively). Conclusion: These data show that functional epiphora is due to neurogenic damage of the orbicularis oculi muscle and should be investigated in more detail.

A Case Report of Conjunctival Extranodal Marginal Zone Lymphoma Treated with Intralesional Rituximab Injection Therapy.

PURPOSE: To describe the safety and efficacy of intralesional rituximab (anti-CD 20 monoclonal antibody) therapy in a patient with conjunctival extranodal marginal zone lymphoma. METHODS: A single case report from a tertiary referral center. RESULTS: A 43 years old female patient with low-grade conjunctival extranodal marginal zone lymphoma who was completely and safely treated with intralesional rituximab therapy was presented. After four injections per week, intralesional rituximab injections were given monthly, and the treatment was completed in 6 months. Near-total regression was achieved at the end of the tenth cycle. No recurrence was observed during the 20-month follow-up period. CONCLUSION: The intralesional rituximab is a cost-effective and well-tolerated treatment for low-grade conjunctival lymphoma. The intralesional rituximab therapy may be prefer in the patients with low grade conjunctival lymphoma instead of radiotherapy. There will be needed further researches in this area.

Peripapillary retinal nerve fiber layer and ganglion cell-inner plexiform layer changes on optical coherence tomography in patients with unilateral hypertensive cytomegalovirus anterior uveitis.

PURPOSE: To investigate whether peripapillary retinal nerve fiber layer (pRNFL) and macular ganglion cell-inner plexiform layer (GCIPL) thinning are present in patients with unilateral hypertensive Cytomegalovirus anterior uveitis (hCMV AU). METHODS: We included 19 eyes with unilateral hCMV AU and their unaffected fellow eyes as the control group in this study. Peripapillary RNFL and macular GCIPL changes were determined using spectral-domain (SD) - optical coherence tomography (OCT). RESULTS: The overall calculated mean pRNFL thickness was significantly lower in the effected eyes with hCMV AU than in the uneffected fellow eyes (p = 0.012). The mean macular GCIPL thickness in the affected eyes was also significantly lower than in the normal eyes (p < 0.001). CONCLUSION: Measurement of pRNFL and macular GCIPL thickness with OCT may detect signs of damage before the visual field changes in patients with hypertensive CMV AU. Early aggressive treatment in these patients may prevent further glaucomatous damage.

A Rare Cause of Hypopyon Anterior Uveitis: Relapsing Polychondritis.

Relapsing polychondritis (RP) is a rare multisystemic disease. It affects cartilage and proteoglycan-rich structures. Ocular findings are the most frequent systemic involvement of the disease. The most common ocular manifestations are episcleritis and scleritis. During the course of the disease, uveitis may also be seen. However, as far as we know, nongranulomatous anterior uveitis with hypopyon is an uncommon ocular finding. In this article, we report a 27-year-old male patient who presented with hypopyon anterior uveitis as a revealing manifestation of RP.