The effects of adjuvant hormonotherapy on tear functions in patients with breast cancer.

PURPOSE: Aromatase inhibitors (anastrozole, letrozole) and selective estrogen receptor modulators (tamoxifen) are widely used as adjuvant hormonal therapy in women with hormone receptor-positive breast cancer. We aimed to evaluate the effects of oral adjuvant hormonotherapy on tear functions in patients with breast cancer. METHODS: In this case-control study, we enrolled eligible patients with breast cancer who were receiving regular medical selective estrogen receptor modulator (tamoxifen, n:50), aromatase inhibitors (anastrozole, letrozole, n:50) and gender-matched healthy controls (n:50). Tear functions were measured and compared by the Schirmer test, fluorescein breakup time, corneal staining evaluated by Oxford grading scale and Ocular Surface Disease Index scores. RESULTS: Mean age was 49.95 (± 9.2), 51.52 (± 7.2) and 51.91 (± 10.3) in tamoxifen, aromatase inhibitors groups and controls (p = 0.426). Mean duration of BC diagnosis (p = 0.536) and drug use (p = 0.417) was not significant between two groups. Ocular Surface Disease Index scores were lower (p < 0.001), and fluorescein breakup time measurements were higher (p < 0.001) in controls. Schirmer test scores were higher in controls than aromatase inhibitors group (p < 0.001). According to the scores of all measurements, the differences between aromatase inhibitors and tamoxifen groups were statistically significant (p < 0.001). CONCLUSIONS: Our results demonstrated a high difference in all parameters in patients receiving aromatase inhibitors compared to tamoxifen group and controls. Aromatase inhibitors, which reduce estrogen levels in the blood, might affect the tear functions more than tamoxifen, which affects as antiestrogenic on estrogen receptors.

Interexaminer Reliability of Meibography: Upper or Lower Eyelid?

OBJECTIVES: To investigate the interexaminer reliability of meibography evaluation and the impact of eyelid selection for the procedure. METHODS: Meibography images of 30 subjects' right eye, including both lids, were evaluated by three clinicians. Meibomian gland (MG) dropout was noted with respect to both percentage and grading (0-4). The examiners' (E1, E2, and E3) consistency was assessed by the intraclass correlation coefficient for MG loss percent and weighted kappa for grading. Correlations between the meibography findings and the fluorescein tear break-up time (FBUT), ocular surface disease index (OSDI) questionnaire, and noninvasive tear break-up time (NIBUT) data were also analyzed. RESULTS: The patients' mean age was 49.2±13.4 years, and the male/female ratio distribution was 15/15. Mean FBUT was 9.6±3.1 sec. OSDI and NIBUT were not correlated with meibography findings. FBUT measurements were correlated with the MG loss assessments of all examiners for the upper lid (Spearman correlation test, E1: r=-0.617, P<0.001; E2: r=-0.428, P<0.018; E3: r=-0.429, P=0.018) but not for the lower lid. Weighted kappa statistics based on MG dropout grading revealed moderate-to-good agreement for the upper lid (E1-E2: κ=0.516, P<0.001; E1-E3: κ=0.621, P<0.001; E2-E3: κ=0.650, P<0.001) and fair-to-moderate agreement for the lower lid (E1-E2: κ=0.212; E1-E3: κ=0.272; E2-E3: κ=0.530). CONCLUSIONS: Meibography is an objective tool for the detection of MG loss. Because of the correlation with FBUT and better interexaminer agreement on dropout by grading, the upper lid might be the preferred lid to make an evaluation.

Alterations in corneal epithelial thickness in patients with congenital myogenic eyelid ptosis.

PURPOSE: To evaluate whether the corneal epithelial thickness (CET) maps obtained by optical coherence tomography (OCT) of the congenital myogenic eyelid ptosis differ from controls. METHODS: CET maps of 13 patients with congenital myogenic eyelid ptosis (m/f = 9/4; mean age 20.5 ± 7.5) and randomly selected one eye of 13 controls (m/f = 7/6; mean age 21.5 ± 6.5) were investigated. Three pachymetry scans of each eye were performed by OCT (RTVue-XR, Optovue Inc., USA), and the scan with the highest signal strength index was selected for the analysis. RESULTS: In ptosis group: Minimum corneal epithelial thickness was thinner (p = 0.029), standard deviation of thickness was higher (p = 0.039), the negative of min-max values were higher (p = 0.007). This difference was originating from the significant thinness of the superior sectors (S, SN, ST) of the corneal epithelium than the inferior counterparts (I, IT, IN) (p = 0.001, p = 0.017, p = 0.002), respectively. There was no difference regarding total corneal thickness measurements. CONCLUSIONS: The mechanic effects of ptotic eyelid to the ocular surface may reshape the corneal epithelium, which can be objectively detected by OCT.

The Effect of Demodex Infestation on Blepharitis and the Ocular Symptoms.

OBJECTIVE: This study aimed to determine the frequency of Demodex infestation of eyelashes in patients with and without blepharitis and to determine the effects of Demodex infestation on blepharitis and the ocular symptoms. METHODS: The study included patients with chronic mixed (anterior + posterior) blepharitis who presented to our clinic. Patients with refractive error and no ocular disease were enrolled as the control group. From each participant, a total of 4 eyelashes were removed and were then examined under a light microscope for Demodex infestation. Symptoms, fluorescein tear breakup time, and ocular surface staining pattern were recorded. RESULTS: The prevalence of Demodex infection in the blepharitis group was 67.2%, versus 54.9% in the control group (P=0.18). The incidence of itching in the blepharitis group was significantly higher in the Demodex (+) patients than in the Demodex (-) patients (P<0.001). Fluorescein tear breakup time in the Demodex (+) patients was significantly shorter than in the Demodex (-) patients (P<0.001). There was not a significant difference in the fluorescein staining pattern between the 2 groups (P=0.57). The incidence of advanced stage blepharitis was significantly higher among the Demodex (+) patients (P=0.007). The incidence of cylindrical eyelash dandruff in the blepharitis group was significantly higher in the Demodex (+) patients (P<0.001). There was a significant difference in meibomian gland dysfunction between the 2 groups (P=0.039). CONCLUSION: Demodex infestation must be investigated in patients with advanced stage blepharitis, itching, and shorter than normal fluorescein tear breakup time.

Serum insulin-like growth factor-1 levels in patients with pseudoexfoliation syndrome and glaucoma.

Insulin-like growth factor-1 (IGF-1) is altered in several neurodegenerative diseases, the association between serum IGF-1 levels and glaucoma has not been evaluated. This study was designed to evaluate whether serum IGF-1 levels are different in patients with Pseudoexfoliation (PEX) with or without glaucoma. The study was conducted with 110 participants aged 65 years or older who were divided into three groups: group 1, patients with PEX syndrome; group 2, patients with PEX glaucoma; and group 3, participants without PEX or glaucoma. All participants underwent full ophthalmological examination and a detailed medical history was recorded. Patients with known neurodegenerative diseases other than PEX glaucoma were excluded. Serum IGF-1 levels were measured by automated chemiluminescent assay. Groups 1, 2, and 3 included 35, 34, and 41 patients, respectively; there were no differences regarding age, gender, or systemic disease status. There were also no statistically significant differences between the groups in terms of IGF-1 levels, which were 91.7 ± 39.1, 101.1 ± 40.2, and 107.2 ± 43.8 ng/ml for groups 1, 2, and 3, respectively (p = 0.276). Serum IGF-1 levels were similar by gender, the presence of systemic disease, status of diabetes mellitus, and laterality of the PEX material. There was no correlation between the cup-to-disk ratios and IGF-1 levels (r = -0.214, p = 0.223). IGF-1 levels in the circulation did not differ in the presence of PEX syndrome with or without glaucoma. This may indicate that the neurodegenerative process is local rather than systemic.

Claudin-1 expressions decrease in pterygium with respect to normal conjunctiva.

CONTEXT: Pterygium is the fibrovascular growth of the limbal conjunctiva over cornea. This proliferative nature might have a pathogenesis associated with tight junction proteins. OBJECTIVE: To investigate the tight junction protein claudin-1 expressions in pterygium with respect to normal conjunctiva. MATERIALS AND METHODS: This retrospective study included 28 patients who underwent pterygium surgery with autograft. Claudin-1 expressions were immunohistochemically evaluated in normal and lesional conjunctiva of the same eye. Immunohistochemical evaluation was done with regard of both the intensity and the extent of staining. The distribution of the immunohistochemical scores in pterygium and normal conjunctiva has been compared with using McNemar test. RESULTS: The mean age of the patients was 52.2 ± 11.2 years and male/female ratio was 8/20. Among 28 samples of normal conjunctiva 25 (89.2%) demonstrated a strong immunohistochemical expression with claudin-1 whereas this rate was 10.8% for pterygium samples. Statistical analysis revealed a significant decrease in claudin-1 expressions in pterygium with respect to normal conjunctiva (p < 0.001). DISCUSSION AND CONCLUSIONS: The loss of claudin-1 appears to be involved in the pathogenesis of pterygium and the future studies will elucidate the exact role of tight junction proteins in the invasive and recurrent nature of pterygium.

Evaluation of dry eye findings in patients with vitiligo.

OBJECTIVE: To evaluate the association of dry eye and vitiligo diseases with objective parameters and a questionnaire. METHODS: The study was conducted in 30 vitiligo patients and 31 patients with non-complicated refractory complaints. All the patients underwent complete ophthalmologic examinations including fluorescein break-up time (FBU), corneal fluorescein staining (CFS) and Schirmer test-I. The dry eye status was evaluated by means of Ocular Surface Disease Index (OSDI). RESULTS: The groups were similar regarding the age and gender distribution. The vitiligo group had higher OSDI scores (26.1±15.9 vs 14.7±5.4, t-test, p<0.001), shorter FBU (7.8±2.9 vs 9.8±2.2, Mann Whitney U test, p=0.005) and higher CFS positivity (18/30 vs 3/31, chi-square test, p<0.001) than control group. The groups were similar regarding the Meibomian Gland Dysfunction (MGD) and Schirmer test results. Fourteen (46.7%) of vitiligo patients had periocular involvement. The analysis within vitiligo patients revealed that FBU and Schirmer test were shorter in patients with periocular involvement, the OSDI scores and MGD status were similar. CONCLUSION: Our study suggest a possible association of dry eye and vitiligo diseases. The diagnostic tools for dry eye disease are in good correlation with each other. The OSDI questionnaire seems practical for both diagnostic purposes and follow-up.

The Effect of Photochromic Contact Lenses on Pupil Size.

Objectives: Photochromic contact lenses (PCL) are designed to increase the comfort of patients, in bright light conditions. The aim of the study was to evaluate the effect of PCL on pupil size. Methods: The study was conducted with 30 patients who were admitted to the contact lens department. Automated pupilography images of the right eyes of patients were obtained without contact lenses (group 1) in scotopic (S: 0.4 lux), mesopic (M: 4.0 lux), and photopic (p=40 lux) conditions. The procedures were repeated with silicone hydrogel contact lenses (Group 2) and with silicon hydrogel PCL (group 3). Results: Mean age was 23.87±3.27 (17-30) years and male/female ratio was 10/20. The mean spheric equivalent of their right eyes was -3.60±1.73 (-0.50--7.50). Pupil diameters of Group 3, under scotopic conditions, were larger than Group 1 and 2 (p=0.001, p=0.044). There was no difference between groups under mesotopic and photopic conditions. Pupil diameters at the different illumination levels were similar regarding gender. Conclusion: Similarity in mesotopic and photopic pupil sizes compared to all groups may be a result of insignificant pupil changes of photochromic lenses in indoor conditions or insufficient time for lens activation.

Association between age-related macular degeneration and 25(OH) vitamin D levels in the Turkish population.

PURPOSE: Age-related macular degeneration is the most common cause of blindness in developed countries, and several factors have been attributed for its etiology. This study was conducted to explore the relationship between serum vitamin D levels and age-related macular degeneration. METHODS: We retrospectively analyzed the data of 114 patients with age-related macular degeneration. A total of 102 patients who did not have any other diseases than refractive error were allocated to the control group. The best-corrected visual acuity, fundus findings, and spectral domain optical coherence tomography findings were analyzed. Patients were allocated to groups based on the Age-related Eye Disease Study classification. Serum 25(OH) vitamin D levels were measured. The central foveal thickness and the subfoveal choroidal thickness were measured by optical coherence tomography. RESULTS: The 25(OH) vitamin D levels in age- and gender-matched patients with age-related macular degeneration and in healthy subjects were 14.6 ± 9.8 and 29.14 ± 15.1 ng/ml, respectively. The age-related macular degeneration group had significantly lower vitamin D levels than the control group (p>0.001). The subfoveal choroidal thickness was lower in patients with age-related macular degeneration (p>0.001). The 25(OH) vitamin D level showed a weak positive correlation with choroidal thickness (r=0.357, p=0.01). When the level of 25(OH) vitamin D was evaluated according to the stages of age-related macular degeneration, it was found to be lower in the advanced-stage disease (p=0.01). The risk for the development of choroid neovascular membrane and subretinal fibrosis was found to increase with decreased vitamin D levels. CONCLUSIONS: Significantly decreased levels of 25(OH) vitamin D in advanced-stage age-related macular degeneration suggest a significant correlation existing between vitamin D deficiency and age-related macular degeneration development. Further studies are required to examine whether vitamin D supplementation has an effect on the development and progression of age-related macular degeneration.

Acute Corneal Hydrops in Keratoconus Patients with Graves' Orbitopathy.

Presented are 2 cases of acute corneal hydrops in keratoconus with Graves' orbitopathy (GO). Two patients (Case 1: female, 54 years old; Case 2: male, 33 years old) with coexisting keratoconus and GO demonstrated typical findings of acute corneal hydrops (ACH) in 1 eye during the active stage of orbitopathy. There was no history of trauma. The ACH healed with scarring after management with a therapeutic contact lens and medical treatment in each patient within 3 months and 5 months, respectively. The development of ACH in keratoconus patients has previously been reported to be associated with male gender, ethnicity, age, eye rubbing, trauma, rapidly progressive disease, atopy, and vernal conjunctivitis. GO involves ocular surface inflammation and fluctuation of intraocular pressure. Active GO can be a risk factor for ACH in keratoconus patients.

Validation and reliability of the Turkish version of Contact Lens Dry Eye Questionnaire-8 (CLDEQ-8).

PURPOSE: Contact lens dry eye questionnaire-8 (CLDEQ-8) quantifies the disturbing symptoms with the aim of assessing the satisfaction and overall opinion of contact lens wearers. The aim of this study was to develop Turkish version and to evaluate the validity and reliability of the questionnaire. METHODS: CLDEQ-8 was translated into Turkish language, using the back translation methods. In a sample of 10 individuals, validation of translation was checked as pre-test evaluation. Turkish version of CLDEQ-8 questionnaire was conducted in 100 soft contact lens wearers. Validity was investigated using Rasch analysis and reliability by Cronbach's alpha (α) and person separation index (PSI). RESULTS: The participants were healthy other than refractive errors. Their mean age was 25.19 ± 7.03 years and male to female ratio was 14/86. All of them were silicone-hydrogel soft contact lens wearers. Their contact lens history was 3.13 ± 3.77 years and mean refraction error was -2.69 ± 1.64 diopters. The whole 8 items were consistent with the Rasch model (p > 0.05) and unidimensional (paired t test, p = 0.1). Both Cronbach's alpha and PSI values were higher than 0.7 (α = 0.873, PSI = 0.867). There were not functional differences in questionnaire items regarding overall age groups (Andersen LR test, p = 0.518). CONCLUSION: Turkish version of the CLDEQ-8 conforms to the Rasch model and provides the one dimensional assumption. The questionnaire has internal consistency, is valid and reliable in Turkish contact lens wearers.

Unilateral Painful Red Eye with Corneal Cysts Assessed with Corneal Confocal Microscopy: A Case Mimicking Acanthamoeba Keratitis.

A 28-year-old woman with a history of trauma to her right eye 2 months prior reported experiencing a stinging sensation and tearing in the morning since the injury occurred and the need to occasionally use an eye patch. Three days before presentation she had been prescribed a therapeutic contact lens (CL) with the diagnosis of a corneal epithelial defect. She described significant pain despite the CL. There was a corneal lesion with haze at the base surrounded by corneal edema. Corneal confocal images revealed hyperreflective cystic lesions that suggested Acanthamoeba keratitis (AK). However, the lesion healed within 10 days and the results of cultures taken before the initiation of treatment proved to be negative. The history of trauma and CL wear, the presence of severe pain, corneal findings, and the confocal microscopy detection of cysts led to a suspicion of AK in a differential diagnosis, but the final diagnosis was recurrent epithelial erosion based on the negative culture results, quick response to treatment, and the possibility of similar confocal findings in a healing epithelium. Since AK may cause loss of vision, suspicion should require that samples be obtained for microbiological study and close follow-up of the clinical course until a final diagnosis can be achieved.

Effects of Topical Ozone Application on Outcomes after Accelerated Corneal Collagen Cross-linking: An Experimental Study.

PURPOSE: Ozone is a trioxygen molecule that spontaneously degrades into oxygen and oxygen free radicals. This study was designed to assess the effects of topical ozone application on outcomes after corneal collagen cross-linking (CXL). METHODS: Enucleated fresh cadaver yearling sheep eyes (n = 28) were divided into five groups: control (C, n = 6), sham (S, n = 6), ozone only (Z, n = 6), CXL only (X, n = 5), and Ozone + CXL (ZX, n = 5). In all groups, except C, the epithelial layer was removed. In group Z, 20 µg/mL liquid ozone was topically applied. In group X, CXL was performed in the accelerated pulse mode. In group ZX, both CXL and ozone were applied. Post-interventional oxygen levels were determined and corneal confocal microscopy and optical coherence tomography were performed. Corneas were evaluated using light and electron microscopy. RESULTS: Pre-interventional central corneal thickness (CCT) was highest in the control group and considerably similar in the remaining groups (P = 0.006). Pre- and post-interventional CCT were significantly different in the ozonated groups (Z and ZX) (P = 0.028; P = 0.043). Demarcation line depths were similar in groups Z, X, and ZX (P = 0.343). Increased stromal tissue reflectivity was observed in groups Z, X, and ZX. Oxygen levels were higher in the ozonated groups (Z and ZX) (P = 0.006), and caspase activity was higher in the CXL groups (X and ZX) (P = 0.028) as compared to the other groups. Group ZX showed tighter, more regular, and parallel fibrils. CONCLUSION: Ozone increases corneal stromal oxygenation which can probably augment the effect of CXL. Future studies should investigate the safety and feasibility of ozone application during CXL.

Corneal confocal microscopy and dry eye findings in contact lens discomfort patients.

OBJECTIVES: To evaluate the corneal confocal microscopy and dry eye findings in patients with contact lens discomfort. METHODS: The study included 3 groups of participants: Contact lens wearers using silicone hydrogel soft contact lenses who are symptomatic (CLD, n=15) or asymptomatic (ACL, n=11) and non-wearers as controls (n=14). Duration of contact lens wear, Ocular Surface Disease Index (OSDI) questionnaire responses, fluorescein tear break-uptime (FBUT), and corneal confocal microscopy findings were recorded. RESULTS: Mean age was 25.7±8.2 years and male/female ratio was 7/33. Demographic findings were similar regarding the groups. CLD patients had a longer lens use history than ACL (median 5 vs 2 years, p<0.001). OSDI scores were higher in CLD group than ACL or controls (p<0.001, p=0.002). FBUT was significantly lowest in CLD group, compared to controls and ACL (p<0.001, p=0.039). FBUT was also lower in ACL patients compared to controls (p=0.036). There was no difference between basal epithelium cell counts between all 3 groups. Anterior stromal activated keratocyte numbers were similar between contact lens using groups but was lower in controls (p=0.005). However, dendritiform cells in the sub-basal nerve layer were higher in CLD group compared to controls but similar to ACL (p<0.001, p=0.058). Graded sub-basal nerve tortuosity was more prominent in CLD group than the ACL (p=0.014). CONCLUSION: Patients with CLD had been wearing contact lenses for longer than those without symptoms. OSDI and FBUT scores were worse in CLD patients. In contact lens discomfort patients, there were increased dendritiform cells, indicating intensified inflammatory status of the cornea.

Does Dry Eye Affect Repeatability of Corneal Topography Measurements?

Objectives: The purpose of this study was to assess the repeatability of corneal topography measurements in dry eye patients and healthy controls. Materials and Methods: Participants underwent consecutive corneal topography measurements (Sirius; Costruzione Strumenti Oftalmici, Florence, Italy). Two images with acquisition quality higher than 90% were accepted. The following parameters were evaluated: minimum and central corneal thickness, aqueous depth, apex curvature, anterior chamber volume, horizontal anterior chamber diameter, iridocorneal angle, cornea volume, and average simulated keratometry. Repeatability was assessed by calculating intra-class correlation coefficient. Results: Thirty-three patients with dry eye syndrome and 40 healthy controls were enrolled to the study. The groups were similar in terms of age (39 [18-65] vs. 30.5 [18-65] years, p=0.198) and gender (M/F: 4/29 vs. 8/32, p=0.366). Intra-class correlation coefficients among all topography parameters within both groups showed excellent repeatability (>0.90). Conclusion: The anterior segment measurements provided by the Sirius corneal topography system were highly repeatable for dry eye patients and are sufficiently reliable for clinical practice and research.

Blepharoptosis and hypertrophic osteoarthropathy: A case report.

A 52-year-old male patient presented to our hospital with a history of secondary hypertrophic osteoarthropathy (HOA) associated with an abdominal neoplasia and blepharoptosis. He had finger clubbing, hyperhidrosis, and hypertrichosis. He also had a recent history of extensive abdominal surgery with a pathology report of myelolipoma. Routine blood work was unremarkable. Upper eyelid reconstruction with blepharoplasty, upper eyelid wedge resection, and brow suspension was performed to address his eyelid concerns. By this case report, we would like to attract notice that the eyelid involvement may be a part of HOA and to emphasize the importance of systemic and pathologic evaluation in failed blepharoptosis surgery.

Association Between Keratoconus and Familial Mediterranean Fever in Turkey.

PURPOSE: To evaluate the association between familial Mediterranean fever (FMF) and keratoconus (KC). METHODS: This retrospective case-control study was performed to compare the prevalence of KC in patients with FMF with the corresponding prevalence in control patients without FMF referred to Genetic Diagnostic Center at Diskapi Yildirim Beyazit Training and Research Hospital from June 2012 to June 2015. We included all 100 patients with FMF. Each FMF-affected patient was matched to 3 controls. RESULTS: None of the patients in the control group (0%, 0/300) had KC, whereas 4 of 100 patients with FMF (4%) had KC (P < 0.004). Three of 33 patients with a homozygous mutation (9.1%) (M694V/M694V in 2 cases and M680I/M680I in 1 case) and 1 of the 46 patients with a compound heterozygous mutation (2.2%) (M694V/M680I) had KC, whereas none of the 21 patients with a heterozygous mutation (0%) had KC. All patients with KC were women, and mean age was 40.8 years (range, 30-51). Although 1 of the 4 patients with KC had hypertension and type 2 diabetes mellitus, the other 3 patients did not have any systemic illness except FMF. When we compared the prevalence of KC in patients with FMF (4%) with the highest prevalence of KC reported in the literature (0.2%), FMF was a predisposing factor to develop KC [odds ratio: 18.1 (95% CI: 11.9-27.5)] especially in patients with a homozygous mutation [odds ratio: 43.4 (95% CI: 28.6-65.7)]. CONCLUSIONS: Mediterranean fever (MEFV) gene mutations, particularly in homozygous mutations of the MEFV gene, may be a predisposing factor in the development of KC.

Effects of topical antiglaucoma drugs on apoptosis rates of conjunctival epithelial cells in glaucoma patients.

BACKGROUND: To investigate the effects of topical antiglaucoma drugs on apoptosis rates of conjunctival epithelial cells in vivo. METHODS: Specimens were obtained from the bulbar conjunctiva of 30 patients who underwent either cataract or glaucoma surgery. Of these 30 patients, 14 had glaucoma and received topical antiglaucoma drugs. The 16 patients in the control group had neither systemic nor ocular disease except cataract and they did not receive any medications. TUNEL (terminal deoxynucleotidyl transferase-mediated dUTP nick-end labelling) method was used to show the apoptosis of the conjunctival epithelial cells. RESULTS: Increased apoptosis rates were detected in specimens of patients who were on topical antiglaucoma therapy (mean +/- SD 0.208 +/- 0.154) when compared with the healthy subjects (mean +/- SD 0.083 +/- 0.102; P = 0.013). The apoptosis rates did not differ according to type, number or duration of drugs. CONCLUSIONS: The apoptosis observed in the conjunctival epithelial cells might be due to the preservative benzalkonium chloride in the antiglaucoma medications because the apoptosis rates did not differ in patients using different types of medications.