THE EFFECT OF BOTULINUM TOXIN TYPE A IN PATIENTS WITH ESSENTIAL BLEPHAROSPASM.

The aim of this study was to determine the effect of botulinum toxin type A and satisfaction in patients with essential blepharospasm. The study included 12 subjects suffering from essential blepharospasm who received therapy with botulinum toxin type A injections. Respondents were given a Blepharospasm Disability Index (BSDI) survey before and three weeks after the procedure with questions related to quality of life. They were also given a Jankovic Rating Scale with questions related to the severity and frequency of symptoms. The overall level of difficulties was reduced, meaning the quality of life increased after the application of botulinum toxin, and the study found that the increase was statistically significant (p = 0.003). The severity of symptoms after the application of botulinum toxin was reduced, which meant that there was a decrease in the severity of the difficulties, and the study found a statistically significant difference (p=0.003). The frequency of symptoms was reduced after botulinum toxin administration, and the study revealed a statistically significant difference (p = 0.012). From the results of this study, we can determine that the use of botulinum toxin type A increases the quality of life and that the severity and frequency of symptoms are statistically significantly reduced.

PENETRATING ORBITOCRANIAL INJURY.

- A case of a 37-year-old female patient is presented. The patient was admitted to the Surgical Emergency Unit after accidental fall on a metal rod when she had sustained stab injury of the right orbit with penetration into the right frontal brain lobe. Multi-slice computed tomography (MSCT) showed penetrating injury and fracture of the right orbital roof without eyeball damage and endocranial impressed bone fragments into the right frontal brain lobe. Urgent surgical intervention was performed by a maxillofacial surgeon and neurosurgeon, including reposition of bone fragments of the orbital roof and cranioplasty. Reconstruction of Tenon's capsule of the right eyeball was performed by an ophthalmologist. From the intraoperative wound swab of the orbit, Bacillus cereus was isolated, therefore the patient was administered ciprofloxacin and rifampicin as recommended by an infectious disease (ID) specialist. Follow up brain MSCT at 15 days and magnetic resonance imaging of the brain at 25 days showed brain edema in the right frontal area and signs of local brain abscess. Intravenous administration of the ciprofloxacin and metronidazole antibiotics with corticosteroids for edema suppression were ordered by the ID physician. Fourteen weeks after this therapy, brain MSCT showed complete abscess regression and no neurologic deficit with only mild psychomotor changes.

Postoperative pain in complex ophthalmic surgical procedures: comparing practice with guidelines.

OBJECTIVE: To analyze the management of postoperative pain after complex ophthalmic surgery and to compare it to the guidelines. DESIGN: A retrospective study. SETTING: University Hospital Split, Croatia. SUBJECTS: Patients (N = 447) who underwent complex ophthalmic surgical procedures from 2008 to 2012. METHODS: The following data were extracted from patient medical records: age, gender, type and dosage of premedication, preoperative patient's physical status, type of procedure, duration of procedure-surgical and anesthesia time, type and dosage of anesthesia, the type and dosage of postoperative analgesia for each postoperative day. RESULTS: None of the patients had information about pain intensity in their records. There were 90% patients who did not receive any medication the night before surgery, 54% did not receive any premedication immediately before surgery, 19% did not receive any pain medication after the surgery in the operating room and 46% of patients did not receive any analgesics after being released to the ophthalmology department. Among those who received analgesia after surgery, 98% received only one dose of an analgesic, and 93% of patients received analgesia only on the day of the surgery. Furthermore, patients were returned to the department immediately after surgery, without intensive monitoring. During the analyzed five years there were no educational session organized by anesthesiologist to the ophthalmic surgeons. CONCLUSIONS: Postoperative pain management and perioperative care of patients undergoing major ophthalmic surgery indicates lack of attention towards pain intensity and postoperative analgesia. Appropriate interventions should be employed to improve postoperative pain management, to facilitate patient recovery.

Comparing two techniques of panretinal photocoagulation on visual acuity on patients with proliferative diabetic retinopathy.

We wanted to examine which of two panretinal photocoagulation (PRP) techniques, classical panretinal photocoagulation (CPRP) and modifield peripheral panretinal photocoagulation PPRP), causes less decline of visual acuity (VA) due to macular edema (ME) in patients with proliferative diabetic retinopathy (PRD). This clinical study includes 180 eyes with PDR with initial papillar neovascularization. The patients were divided into two groups according the RP. PPRP and CPRP showed the decline of VA in all patients, more pronounced in the CPRP group after one week. After three and six months, with CPRP and PPRP the values of VA was stabilized. The result suggests that eyes with PDR and starting epipapillar neovascularisation should be treated with PPRP with priority given to CPRP because it caused better VA.

[Famous doctors who stayed on the Croatian coast at the turn of the 20th century]. / Poznati lijecnici koji su boravili na hrvatskoj obali na prijelazu u 20. stoljece.

At the end of the 19th and the beginning of the 20th century many famous persons stayed on the Croatian coast mostly because of touristic and health reasons, than because of natural beauties, scientific or political reasons. Most often they came from Austro-Hungary, Germany or Russia but also from our homelands. Among them were also many famous doctors, some known worldwide. The most distinguished were the surgeon Theodor Billroth, the bacteriologist and a Nobel prize winner Robert Koch, the pathologist Rudolf Virchow, and the psychiatrist Sigmund Freud. They left a deep impression and a big benefit at the area they stayed in.

Association between Thyroid Function and Ocular Parameters.

During development, thyroid hormones play an important role in eye development, while in adults, some pathological thyroid conditions can affect the normal functioning of the eyes. Thyroid eye disease is the most well-known eye pathology caused by a pathological thyroid condition. Few studies have investigated the association between ocular parameters and thyroid function. Thus, in this study, we aimed to examine whether thyroid activity affects ocular parameters. This cross-sectional study included 4633 healthy adults recruited within the 10,001 Dalmatians project of the Croatian Biobank. The plasma levels of thyroid-stimulating hormone (TSH), free triiodothyronine (fT3), free thyroxine (fT4), thyroglobulin (Tg), thyroglobulin antibodies (TgAb), and thyroid peroxidase antibodies (TPOAb) were measured by an immunoassay. We determined 20 ocular parameters for each participant (10 for each eye, including corneal radius, corneal thickness, anterior chamber depth, anterior chamber angle, lens thickness, posterior chamber length, axial length, intraocular lens power (IOL), spherical power, and cylinder power). Patients with hyperthyroidism had thicker corneas compared to euthyroid individuals. Corneal thickness was also negatively associated with plasma TSH levels. Intra-ocular lens power was higher in patients with clinical hypothyroidism, while spherical power was higher in euthyroid individuals with positive antibodies compared to euthyroid individuals. Intra-ocular lens power negatively correlated with fT4 levels, while spherical power positively correlated with TgAb, TPOAb, and Tg levels and negatively correlated with TSH levels. The anterior chamber angle was positively associated with plasma TSH levels and TPOAb levels and negatively associated with plasma fT4 levels. These findings suggest an interesting interplay between ophthalmic measures and thyroid status, detectable even in the general adult population.

The role of oxidative stress after retinal laser photocoagulation in nonproliferative diabetic retinopathy.

Diabetic retinopathy (DR) represents the most common chronic complication of diabetes, and it is the leading cause of new cases of blindness in patients between 20-74 years old in developed countries. Laser photocoagulation (LF) represents an efficacious approach to the treatment of DR. Oxidative factors, such as free radicals (FR), are continuously generated in aerobic organisms as a result of different metabolic processes. It is well known that oxidative stress plays a role in the development of DR. The aim of this study was to evaluate the thermal effects of the scatter retinal laser photocoagulation technique on the production of FR. A total of 90 patients were enrolled in this study. They were divided in 3 groups: 30 diabetic patients with DR, 30 diabetic patients without DR, and 30 control individuals without diabetes mellitus (DM). Full scatter retinal LF was performed in all patients with DR. We measured the concentrations of superoxide dismutase (SOD), glutathione peroxidase (GPOD), catalase, and total antioxidative status (TAS). Of the 30 DR patients, 13 showed the appearance or worsening of macular edema after LEF, whereas the other 17 patients showed no change. Thirty days after LF, improvement in visual acuity was observed, but this change was not statistically significant. The mean plasma or erythrocyte lysate concentrations of various antioxidants were significantly lower in the diabetic patients without DR compared to the individuals without DM and in the diabetic patients with DR compared to the individuals without DM; the diabetic patients with DR did not show lower concentrations of the antioxidants compared to the diabetic patients without DR. The concentrations of SOD, GPOD, catalase, and TAS were significantly lower in the diabetic patients with DR after retinal scatter LF, which could be the consequence of retinal oxidative stress caused by the LF thermal effect.

Importance of circulating platelet aggregates and haemodynamic changes in ophthalmic artery and progression of visual field loss at pseudoexfoliation glaucoma.

The aim of this work is to examine the role of circulating platelet aggregates (CPA) at pseudoexfoliation glaucoma (PXG), haemodynamic changes in the ophthalmic artery by ultrasonic color Doppler, searching for visual field progression. Vascular component at PXG and its role in VF progression dynamics has not been sufficiently explained, as well as CPA influence to ischaemic events related to optic nerve damage and VF progression. The examination included 80 patients, where of 35 (44%) men average age 68.3 +/- 7.0 and 45 (56%) women average age 65.7 +/- 7.0 (t = 1.66; p = 0.101). Forthy of them suffered from primary open angle glaucoma (POAG) as a control group (healthy), and 40 from pseudoexfoliative glaucoma (PXG) as an experimental group. All the examinees underwent complete ophthalmological examination: visual acuity, ocular fundus, intraocular pressure measured, anterior eye segment biomicroscopy with gonioscopy performed. Also VF examination was performed three times at 6 months intervals. Laboratory testing of CPA proportion values was performed by means of Wu an Hoak method and ultrasonic measurement of blood perfusion in the carotid tree, particularly concerning ophthalmic artery by means of color Doppler. Obtained decreased values of CPA proportion resulted in hypercoagulability of blood in PXG group. At PXG were also found increased blood flow resistivity indexes in ophthalmic artery (RI AO) and internal carotid artery (RI ACI), resulting with ischemia and hypoxia and finally progression of the visual filed damage. In conclusion, our study shows that examining CPA and ultrasonic monitoring of vascular parameters in ophthalmic artery with color Doppler may be the way of better understanding the vascular role in PXG prognosis.

[Clinico-epidemiological analysis of choroidal melanoma in Split Area, Croatia]. / Klinicko-epidemioloska analiza melanoma zilnice u splitskom podrucju u Hrvatskoj.

Choroidal melanoma is the most common primary intraocular malignant tumour in adults. The aim of the study was to examine epidemiological characteristics of choroidal melanoma in Split-Dalmatia County from 1990 to 2009. In this retrospective study, data on 46 patients from medical documentation of the University Department of Ophthalmology, Split University Hospital Center, were analyzed. According to 2001 census, the Split-Dalmatia County population was 467,676 inhabitants. The incidence of choroidal melanoma was 0.49 per 100,000 inhabitants, which is somewhere in the middle of the incidence between south and north Europe. Choroidal melanoma most commonly appeared in the 7th decade of life. The average dimensions of choroidal melanoma (basis x height) were 13.4 x 8.0 mm. Histopathologic findings according to Callender classification showed the following types of melanoma: epithelioid cell type 8%, spindle cell type 40%, and mixed type 52%. The most common forms of therapy were enucleation 47.8% and brachytherapy 28.3%, which means that patients presented relatively late when choroidal melanoma advanced in size. The Split-Dalmatia County has 1/10 of the Croatian population, so it could be supposed that approximately 25 new cases of malignant melanoma of the choroid are discovered annually in Croatia. For early detection of the disease, regular and complete checkups are necessary, especially in presbyopic population. Study results enabled better evaluation of the disease and better planning of ophthalmologic service in the treatment of this serious eye disease.

[Bilateral choroidal metastases of kidney carcinoma]. / Metastaze zilnice oba oka kod karcinoma bubrega.

Metastatic tumors are among the most common intraocular malignancies, and are exclusively localized in the uvea, 88% in the choroids. A 54-year-old male patient was admitted to Urology Department for macrohematuria. A tumor of the left kidney was found. Upon nephrectomy, histopathology indicated papillary carcinoma of the kidney with some focal sarcomatous differentiation. The left suprarenal gland was normal, but one of the regional lymph nodes was invaded. Three years later, the patient was hospitalized again for tumor of the right suprarenal gland and para-aortic tumor. At the same time, the patient complained of visual acuity worsening on the left eye. Fundus examination and fundus photography revealed yellowish subretinal lesions with serous retinal detachment. Metastatic eye lesions may anticipate or follow the diagnosis of kidney carcinoma. All tumors with a tendency of hematogenous metastasizing have a high affinity of metastasizing into the uvea because of its abundant blood flow. Posterior pole is the most common localization; over 40% of lesions are found in macular region, which is attributed to the higher posterior choroidal blood flow and easy macular symptom detection. That is why kidney carcinoma has to be ruled out in all patients with such yellowish subretinal lesions.

Afect of botulinum toxin-A injection on intraocular pressure and proptosis in thyroid associated orbitopathy.

The aim of this study was to evaluate the effects of extraocular muscle injection of botulinum toxin-A (BTX-A) on intraocular pressure (IOP) and proptosis in patients with ocular motility disturbances in thyroid associated orbitopathy (TAO). In 17 patients (20 eyes) with restrictive strabismus and diplopia, BTX-A injections were applied. Intraocular pressure was measured with a Goldmann applanation tonometer in primary gaze position before and 2-4 weeks after BTX-A injection. Extraorbital prominention of the eyeball was measured before and after BTX-A injection using a Hertel instrument. Before the injection, the mean IOP in primary position of gaze was 18.6 +/- 2.8 mmHg and 2-4 weeks after BTX-A injection was 16.9 +/- 3.3 mmH; (p = 0.001). There was no statistically significant difference in Hertel egzophthalmometer readings before and after BTX-A injection, 21.5 +/- 2.7 mm vs. 22.0 +/- 2.6 mm; (p = 0.678). In conclusion, BTX-A injection has a secondary lowering effect on IOP in TAO due to relaxation of extraocular muscles, but with no influence on proptosis.

Epidemiological characteristics of orbital cellulitis among adult population in the Split region, Croatia.

BACKGROUND: There are few diseases in ophthalmology which could have a fatal outcome, one of them is orbital cellulitis. The aim of this article is to give epidemiological analysis of orbital cellulitis in adult patients in the Split region, Croatia. METHODS: The study was based on a retrospective review of medical records of 53 adult patients with orbital cellulitis treated during the period of 26 years from 1991 to 2016 at the Department of Ophthalmology in the University Hospital of Split. RESULTS: The incidence of orbital cellulitis in adults in the Split region was 0.57. The mean age of the patients was 53.5 ± 19.0 years. Patients were male in 47.2% of the cases and female in 52.8%. The distribution of orbital cellulitis according to seasons shows that it was most common during winter with 20 (37.7%) and in autumn with 16 (30.2%) cases and less frequent in summer with 6 (11.3%) and in spring 11 (20.8%) cases. The most common cause of orbital cellulitis was sinusitis in 33 (62.2%) patients. In total, there were 16 (30.2%) surgical interventions. CONCLUSIONS: Orbital cellulitis in adult patients is a relatively rare disease but with a possible fatal ending and damage to vision. It should be diagnosed quickly and treated adequately, very often in cooperation of an ophthalmologist with an otorhinolaryngologist and a maxillofacial surgeon. Orbital cellulitis appears to be more common in colder months, because sinusitis occurred more often then. It is treated with adequate antibiotic application but in almost one third of cases a surgical intervention was necessary.

Flow Changes in Orbital Vessels Detected with Color Doppler Ultrasound in Patients with Early Dysthyroid Optic Neuropathy.

Thyroid-associated orbitopathy (TAO) is a common manifestation of Graves' disease. The aim of the study was to assess the six percent of patients with TAO that develop dysthyroid optic neuropathy (DON), which is the most serious complication of TAO. As DON can cause perma-nent damage, it is essential to detect DON early when visual loss is still reversible. Color Doppler ultrasound is a noninvasive diagnostic method, which may be useful in early detection of DON. Thirty-six patients with confirmed Graves' disease and active TAO were included, 21 (58%) of them with early DON (eDON) and 15 (42%) free from any signs of eDON. All study patients underwent Doppler ultrasound examination to determine the blood flow rates in the internal carotid artery, ophthalmic artery, and central retinal artery. Study results showed color Doppler ultrasound examination to have a potential to detect orbital blood flow changes in patients with eDON. Early detection of DON may result in earlier treatment and prevention of permanent optic nerve damage.

Cauterisation versus fibrin glue for conjunctival autografting in primary pterygium surgery (CAGE CUP): study protocol of a randomised controlled trial.

INTRODUCTION: Pterygium is a non-cancerous growth of the conjunctival tissue over the cornea that may lead to visual impairment in advanced stages, restriction of ocular motility, chronic inflammation and cosmetic concerns. Surgical removal is the treatment of choice, but recurrence of pterygium is a frequent problem. It has been previously shown that fibrin glue may result in less recurrence and may take less time than sutures for fixing the conjunctival graft in place during pterygium surgery. However, fibrin glue is a biological material and it carries the risk of transmitting infectious agents from pooled and single-donor blood donors and anaphylaxis in susceptible individuals. Cauterisation is another surgical option, and it would be advantageous to know whether cauterisation may be superior surgical option compared with fibrin glue. This protocol describes the rationale and design of the randomised controlled trial (RCT) in which we will compare cauterisation versus fibrin glue for conjunctival autografting in primary pterygium surgery. METHODS AND ANALYSES: This will be a parallel group RCT comparing cauterisation versus fibrin glue for conjunctival autografting in primary pterygium surgery. Computer-generated randomisation will be used, and allocation concealment will be conducted using sequentially numbered opaque sealed envelopes. Surgeons will not be blinded to the procedures, but participants, other investigators and outcome assessors will be blinded. Adult participants with primary pterygium operated in a tertiary hospital in Split, Croatia, will be included. Primary outcome will be recurrence of pterygium, defined as any regrowth of tissue from the area of excision across the limbus onto the cornea after 180 days. ETHICS AND DISSEMINATION: The trial was approved by the ethics review board of the University Hospital Split (500-03/17-01/68). Results will be disseminated at conferences and through peer-reviewed publications. TRIAL REGISTRATION NUMBER: NCT03321201; Pre-results.

[Traumatic carotid-cavernous fistula]. / Traumatska karotidno-kavernozna fistula.

Carotid-cavernous fistula is uncommon consequence of craniocerebral trauma. Earlier recognition of the patients with carotid-cavernous fistula and shorter time of delay in treatment could save patients from complications and vision loss. A 27-year-old man presented with severe craniocerebral injury after an car accident. He required emergent craniotomy for an open depressed cranial fractures, haemostasis and epidural hematoma. Three months later, the patient began to exhibit progressive chemosis and proptosis of left eye. Computed tomography and cerebral angiography revealed findings consistent with a carotid-cavernous fistula. Angiography revealed a fistula between carotid artery and the cavernous sinus. The patient was treated by transarterial embolization resulting in immediate and permanent occlusion of the fistula and improved visual acuity after six months follow-up. Posttraumatic carotid-cavernous fistula may be treated successfully with the use of transarterial coil embolization.

Risk factors associated with postoperative pain after ophthalmic surgery: a prospective study.

BACKGROUND: Risk factors associated with postoperative pain intensity and duration, as well as consumption of analgesics after ophthalmic surgery are poorly understood. METHODS: A prospective study was conducted among adults (N=226) who underwent eye surgery at the University Hospital Split, Croatia. A day before the surgery, the patients filled out questionnaires assessing personality, anxiety, pain catastrophizing, sociodemographics and were given details about the procedure, anesthesia, and analgesia for each postoperative day. All scales were previously used for the Croatian population. The intensity of pain was measured using a numerical rating scale from 0 to 10, where 0 was no pain and 10 was the worst imaginable pain. The intensity of pain was measured before the surgery and then 1 hour, 3 hours, 6 hours, and 24 hours after surgery, and then once a day until discharge from the hospital. Univariate and multivariate analyses were performed. RESULTS: A multivariate analysis indicated that independent predictors of average pain intensity after the surgery were: absence of premedication before surgery, surgery in general anesthesia, higher pain intensity before surgery and pain catastrophizing level. Independent predictors of postoperative pain duration were intensity of pain before surgery, type of anesthesia, and self-assessment of health. Independent predictors of pain intensity ≥5 during the first 6 hours after the procedure were the type of procedure, self-assessment of health, premedication, and the level of pain catastrophizing. CONCLUSION: Awareness about independent predictors associated with average postoperative pain intensity, postoperative pain duration, and occurrence of intensive pain after surgery may help health workers to improve postoperative pain management in ophthalmic surgery.

Treatment of ocular motility disturbances in Graves' disease with botulinum toxin A.

The aim of this study was to evaluate the efficacy of botulinum toxin-A injections on motility disturbance in patients with dysthyroid eye disease. In 36 patients (52 orbits) with active phase of Grave's ophthalmopathy with motility disturbance, botulinum toxin-A injections were applied. Ocular motility was measured before and after treatment in four main directions (elevation, depression, abduction and adduction) with Förster perimeter. In all patients 20 units of botulinum toxin-A in one single injection was applied in the projection of the inferior rectus muscle. Statistically, the degree of upgaze increased notably in all three groups, but mostly in the first group where it amounted up to 5.8-6.0 (z = 10.0;p = 0.68). We could not prove notable increase of the motility grade in the adduction in none of the groups of the tested patients. Due to the fact that eyeball motility can be objectively measured, effect of the applied therapy can be clearly evaluated.

Factors associated with postoperative pain and analgesic consumption in ophthalmic surgery: a systematic review.

Pain in ophthalmic surgery is a neglected area. We systematically reviewed the factors associated with postoperative pain and analgesic consumption in ophthalmic surgery and found 12 studies with 1,515 participants. The median number of patients in the included studies was 59. Female sex, longer duration of surgical procedure, second eye surgery as a consecutive procedure, type of surgery, general anesthesia, lower satisfaction with anesthesia, and postoperative nausea may contribute to increased postoperative pain intensity. Type of surgery, type of anesthesia, and patient satisfaction with anesthesia were associated with increased analgesic consumption. The studies reviewed were heterogeneous in terms of surgical procedures, patient populations, tools for pain assessment, and timing of postoperative pain measurement. Multiple factors may be associated with increased postoperative pain and analgesic consumption and warrant further research.

The incidence of optic neuritis in Split-Dalmatia county, Croatia.

The aim of the study was to determine the incidence of monosymptomatic optic neuritis (MON) in residents of Split-Dalmatia County, Croatia. The 127 cases (83 female, aged 26.2+/-9.9 and 44 male aged 26.9+/-11.2) with MON presented between January 1985 and December 2001 were analyzed from hospital data. The annual incidence was 1.6 per 100,000 (95% CI, 0-3). The incidence among females was 2.2 (95% CI, 0-4.6) cases / 100,000 per year and 1.1 (95% CI, 0-3) among males. The difference in incidence rates for women vs. men was not significant (chi2=0.41; p=0.52), although it is more likely that a true difference exists. The peak incidence in both sexes observed in the group 20-29 years of age was 4.2 (95% CI, 0-10). The highest incidence of MON was found in spring (46 cases). In summary, the incidence of MON in Split-Dalmatia County during the 17 years period is relatively low.

[Disorders of color vision]. / Poremecaji kolornog vida.

This review gives a summary of all colour vision disorders (dyschromatopsias) and diagnostic methods and tests. Colour vision is inadequately treated in current literature with regard to the choice of diagnostic methods and the interpretation of results for a single disorder, which contributes to wrong dyschromatopsia diagnosing seen every day in specialist practice. Examination for colour disorders is usually outpatient and is carried out by ophthalmology or neurology departments or occupational health services under the supervision of an ophthalmologist to prevent misinterpretation of results and wrong occupational choices. The problem is very serious, and proper education should be able to provide guidelines for correct and early diagnosis of dyschromatopsia. As the examination is not well defined, it is very important to set unique criteria in diagnosing any single colour vision disorder.