VOLUME 80 - ISSUE 3

Purpose: To evaluate intraocular pressure (IOP) and extraocular orbital vessels with color Doppler ultrasound (CDU) and investigate the effects of obesity on retrobulbar blood flow. Methods: Fifty-nine patients were included in this prospective study. Patients were divided into two groups according to body mass index: Group 1 (31 obese patients) and Group 2 (28 non-obese patients). IOP was measured with a Goldmann applanation tonometer, and CDU was used to evaluate the retrobulbar vessels. Results: The mean IOP was 18 ± 6.68 mmHg in the obese group and 13.71 ± 1.60 mmHg in the control group (p<0.001). When the CDU values for the central retinal artery were compared between the groups, the pulsatility index was found to be significantly lower in the obese group than in the control group (p<0.001). When the CDU values for the ophthalmic artery (OA) were compared between the groups, the peak systolic velocity (p<0.001) and end-diastolic velocity (p=0.002) values were found to be significantly lower in the obese group than in the control group. Conclusions: Obese patients have a higher mean IOP and lower flow velocity than non-obese patients. Increased IOP together with decreased retrobulbar blood flow, particularly in obese individuals, may increase the risk of glaucoma development.

Keywords: Ultrasonography, Doppler, color; Intraocular pressure; Obesity/complications; Hemodynamics; Blood flow velocity; Blood vessels/diagnostic imaging; Ophthalmic artery/diagnostic imaging; Eye/blood supply; Ultrasonogra phy/me thods

Purpose: To compare central corneal backscatter obtained from Scheimpflug images between patients with insulin-dependent and non-insulin-dependent diabetes mellitus (IDDM and NIDDM, respectively) and healthy controls. Methods: Seven patients with IDDM (7 eyes), eleven patients with NIDDM (11 eyes), and sixteen healthy subjects (16 eyes) were included in this pilot study. Scheimpflug imaging system (Pentacam, Oculus Inc., Germany) was used to obtain optical sections of the cornea. Seven meridians were analyzed for each eye, oriented from 70° to 110°. Optical density values for the central 3-mm and 5-mm zones of the cornea were obtained by image analysis using external software. Results: Corneal backscatter was significantly higher in the diabetic patients than in the controls for the central 3-mm (p=0.016) and 5-mm (p=0.014) zones. No significant differences in corneal backscatter were found between the IDDM and NIDDM groups for either zone (both p>0.05). In the NIDDM group, significant correlations were observed for both central zones between corneal backscatter and age (3 mm: r=0.604, p=0.025; 5 mm: r=0.614, p=0.022) and central corneal thickness (3 mm: r=0.641, p=0.017; 5 mm: r=0.671, p=0.012); this was not found in the IDDM group (p>0.05). The presence of diabetes showed a significant effect on central corneal backscatter (Kruskal-Wallis test, p<0.001). Conclusions: Diabetic patients showed higher values of corneal light backscatter than healthy subjects. Corneal optical density analysis may be a useful tool for monitoring and assessing the ocular changes caused by diabetes.

Keywords: Scheimpflug imaging; Corneal topography; Diabetes mellitus; Diabetes mellitus, type 1; Diabetes mellitus, type 2; Pilot project

Purpose: To assess the efficacy of monotherapy using tacrolimus eye drops versus sodium cromoglycate for the treatment of vernal keratoconjunctivitis (VKC). Methods: Randomized double-masked controlled trial comparing the efficacy of tacrolimus 0.03% eye drops t.i.d. (Group 1) with sodium cromoglycate 4% eye drops t.i.d. (Group 2) for the symptomatic control of VKC at days 0, 15, 30, 45, and 90 of follow-up. Visual acuity, intraocular pressure, and other complications were evaluated to assess safety and side effects. Results: In total, 16 patients were included, with 8 enrolled in each group. Two patients from Group 2 were excluded from the analysis at days 45 and 90 because of corticosteroid use. Most patients were male (81.8%) and presented with limbal VKC (56.3%). There were statistically significant differences in favor of tacrolimus in the following severity scores: itching at day 90 (p=0.001); foreign body sensation at day 15 (p=0.042); photophobia at day 30 (p=0.041); keratitis at day 30 (p=0.048); and limbal activity at days 15 (p=0.011), 30 (p=0.007), and 45 (p=0.015). No relevant adverse effects were reported, except for a burning sensation with tacrolimus, though this did not compromise treatment compliance. Conclusion: Treatment with tacrolimus was superior to sodium cromoglycate when comparing severity scores for symptoms of itching, foreign body sensation, and photophobia, as well as for signs of limbal inflammatory activity and keratitis.

Keywords: Conjunctivitis; Allergic; Anti-allergic agents; Tacrolimus; Ophthalmic solutions; Cromolyn sodium

Purpose: To determine the vision status, ophthalmic findings, and quality of life among the very elderly. Methods: This was a cross-sectional observational study of individuals aged 80 years and above. A comprehensive ophthalmic exam was performed with mea surement of both the presenting (PVA) and best-corrected visual acuity. The Quality of Life Short Form-36 (SF-36) and the Visual Function Questionnaire (VFQ-25) were also administered. Results: A total of 150 non-institutionalized participants were assigned to three age groups: 80-89 years (n=70), 90-99 years (n=50), and 100 years and older (n=30). PVA and best-corrected visual acuity were normal (≥20/30) in 20 (13.3%) and 37 participants (24.7%), respectively. Regarding PVA, mild visual impairment (<20/30 to ≥20/60) was found in in 53 (35.4%), moderate visual impairment (<20/60 to ≥20/200) in 50 (33.3%), severe visual impairment (<20/200 to ≥20/400) in 8 (5.3%), and blindness (<20/400) in 19 (12.7%) participants. Regarding best-corrected visual acuity, mild, moderate, and severe visual impairments were present in 55 (36.7%), 38 (25.3%), and 5 (3.3%) participants, respectively, and blindness was present in 15 (10%). The main causes of visual impairment/blindness were cataract (43.8%), refractive errors (21.5%), age-related macular degeneration (17.7%), and myopic degeneration (3.8%). SF-36 scores were worse in those with low visual acuity, while VFQ-25 domain scores were poorer in those with vision impairment/blindness. Conclusion: Vision impairment and blindness was present in three-quarters of this sample, but it was notable that adequate correction with spectacles improved visual acuity. This reinforces the need for regular ophthalmic care in elderly patients to improve their quality of life by optimizing vision.

Keywords: Aging; Vision disorders/diagnosis; Geriatric assessment; Blindness; Vision, low; Quality of life; Surveys and questionnaires; Aged; Aged, 80 and over

Purpose: To evaluate the safety and efficacy of 0.05 mL intracameral injection of moxifloxacin in patients who underwent phacoemulsification and intraocular lens (IOL) implant. Methods: Retrospective study comprising patients who underwent phacoemulsification and IOL implant between January 2009 and December 2013. Patients were divided into two groups. Group A followed standard endophthalmitis prevention protocol and group B followed the same protocol plus intracameral injection of 0.05 mL of moxifloxacin hydrochloride at 5.45 mg/mL, immediately after IOL implant. Results: Medical records from 7,195 eyes of 3,751 patients (median age: 67.8 ± 8.96, range: 48-83 years, 53.8% female) were evaluated. Group A included 3,515 eyes of 1,838 patients and group B included 3,680 eyes of 1,913 patients. The incidence of endophthalmitis in group A was 0.22% (8:3,515 eyes) and in group B was 0.03% (1:3,680 eyes, p=0.0198, Fischer's exact test). No toxicity or inflammation related to the use of moxifloxacin was observed. Conclusions: There was a 7.3-fold lower ratio of endophthalmitis in the group that received moxifloxacin intracameral injection. This study provides further evidence that moxifloxacin is an effective intracameral prophylactic antibiotic.

Keywords: Endophthalmitis; Cataract; Phacoemulsification; Anti-bacterial agents; Injections; Antibiotic prophylaxis

Purpose: The purpose of this study was to determine the indications and frequency of evisceration after penetrating keratoplasty (PK). Methods: The medical records of all patients who underwent evisceration after PK between January 1, 1995 and December 31, 2015 at Ankara Training and Research Hospital were reviewed. Patient demographics and the surgical indications for PK, diagnosis for evisceration, frequency of evisceration, and the length of time between PK and evisceration were recorded. Results: The frequency of evisceration was 0.95% (16 of 1684), and the mean age of the patients who underwent evisceration was 56.31 ± 14.82 years. The most common indication for PK that resulted in evisceration was keratoconus (37.5%), and the most common underlying cause leading to evisceration was endophthalmitis (56.25%). The interval between PK and evisceration ranged from 9 to 78 months. Conclusions: Although keratoplasty is one of the most successful types of surgery among tissue transplantations, our findings show that it is associated with a possible risk of evisceration.

Keywords: Eye evisceration/etiology; Keratoplasty, penetrating/adverse effects; Endophthalmitis; Keratoconus

Purpose: To compared the ultrasound findings of the lacrimal sac between subjects with normal lacrimal systems those with chronic dacryocystitis. Methods: A retrospective study of 10 subjects with a normal lacrimal system (Group 1) and 10 with chronic dacryocystitis (Group 2) diagnosed according to B-mode ultrasound with a 10-MHz transducer and the direct-contact technique (AVISO, Quantel Medical) for lacrimal sac assessment. We analyzed the dimensions, features, and content of the sacs. Characteristics of the population: female: 6, Group 1; 8, Group 2; mean age 48.4 years (SD=19.9; range, 22-80 years), Group 1; 50.5 years (SD=15.5; range, 25-75 years), Group 2. Results: The dimensions of the lacrimal sac were as follows: anteroposterior 1.86 and 10.99 mm in Groups 1 and 2, respectively, p<0.0001; vertical 9.79 and 14.13 mm in Groups 1 and 2, respectively, p=0.049. Qualitative evaluation of the lacrimal sac contents showed hypoechogenic content in Group 1 (10, 100%) and hyperechogenic punctiform content in Group 2 (10, 100%) with partial filling in seven cases (70%). Conclusions: Ultrasonography can differentiate normal lacrimal sacs from sacs compromised by chronic dacryocystitis, thus being useful as an adjunct to clinical examination and surgical planning.

Keywords: Lacrimal apparatus, ultrasonography; Lacrimal duct obstruction; Dacryocystitis

Purpose: To evaluate the effects of hemodialysis (HD) on corneal and anterior chamber morphometry, as well as intraocular pressure (IOP) in patients with end-stage renal disease. Methods: Fifty right eyes were examined 30 minutes before and after HD. IOP was measured with a Goldmann applanation tonometer, and Ehlers' formula was used to calculate the corrected IOP values. The central corneal thickness (CCT), corneal volume (CV), keratometric values, anterior chamber depth (ACD), aqueous depth (AQD), anterior chamber volume (ACV), and anterior chamber angle (ACA) in the nasal and temporal quadrants were measured with a Sirius anterior segment analysis system. Blood urea nitrogen levels, body mass, and systolic and diastolic arterial pressure were also measured before and after HD. Results: The mean age was 60.80 ± 13.38 (range: 35-80) years. The mean uncorrected and corrected IOP values decreased from 18.06 ± 3.91 and 18.31 ± 4.83 mmHg to 16.94 ± 3.87 and 16.95 ± 4.74 mmHg after HD, respectively (p=0.011 and p=0.003, respectively). The mean CCT decreased from 536.38 ± 24.73 to 533.18 ± 27.25 µm (p=0.002), and the mean CV decreased from 57.52 ± 3.15 to 55.68 ± 3.55 mm³ (p<0.001) after HD. There were no significant changes in ACD, AQD, ACV, ACA, or the keratometric values (p>0.05 for all values). There were no significant correlations between the ocular and systemic parameters (p>0.05 for all correlations). Conclusions: Uncorrected IOP, corrected IOP, CCT, and CV values decreased after HD, whereas the anterior chamber morphometry values remained similar between the measurements performed before and after HD.

Keywords: Renal dialysis; Cornea; Anterior chamber; Intraocular pressure; Kidney failure, chronic; Vision disorders

Purpose: To examine differences between fluorescein angiography (FA) and indocyanine green angiography (ICG) findings in patients with chronic central serous chorioretinopathy (CSC), comparing these with optical coherence tomography (OCT) findings. Methods: Ten consecutive patients with chronic CSC (19 eyes; 7 men; mean age, 50.7 ± 8.4 years) underwent multimodal evaluation that included FA, ICG, and OCT (Spectralis HRA-OCT, Heidelberg Engineering, Heidelberg, Germany). Changes such as hyperfluorescence (caused by increased transmission of the normal choroidal fluorescence, staining, or "pooling") and hypofluorescence (caused by a blockage or vascular filling defect) were evaluated in the early (4 min), middle (4-8 min) and late (>8 min) angiography phases and compared to OCT findings. Results: Bilateral disease was present in nine of the 10 patients. Areas of discontinuation or attenuation of the hyporeflective layer of the retinal pigment epithelium (RPE) on OCT were observed at the same locations as hyperfluorescent angiography window defects on FA and ICG within examination phases. In areas of serous or RPE detachment, the hyperfluorescence pattern was similar on FA and ICG. However, ICG demonstrated areas of hyperfluorescence secondary to choriocapillaris hyperpermeability, with no corresponding change on FA in 12 (70%) of the 19 eyes. This finding was more evident in the middle and late phases of the examinations and there was no evident change in retinal architecture on OCT in these hyperpermeable choroidal regions. Conclusion: In patients with chronic CSC, ICG may reveal choroidal abnormalities that are not evident on FA. This finding may help optimize the monitoring and treatment of CSC.

Keywords: Central serous chorioretinopathy; Fluorescein angiography; Indocyanine green; Tomography, optical coherence

Purpose: To evaluate the use of supratarsal injection of triamcinolone acetonide in severe vernal keratoconjunctivitis (VKC) in children. Methods: Patients included in this open clinical trial were those with severe VKC-associated with keratitis, gelatinous limbal infiltrates, and/or giant papillae, with a history of recurrence and resistance to conventional topical antiallergic agents. Patients were treated with a supratarsal injection of 20 mg triamcinolone acetonide. Results: Analysis included 27 injections in 23 eyes of 17 patients with severe allergic keratoconjunctivitis. Mean age was 12.3 (range: 7-19) years. Mean follow-up time was 39.3 months (SD=19.21). In the 17 patients, the disease was successfully controlled for an average of 3.6 months (range: 1-16), during which allergy symptoms and signs were significantly improved, with complete resolution of lid edema and conjunctival chemosis, significant decline of pannus and keratitis, and reduction of giant papillae size. Conclusion: Treatment of severe, acute VKC in children with supratarsal injection of 20 mg triamcinolone acetonide showed satisfactory results and was well tolerated by patients; it may therefore constitute a safe option for severe and challenging cases. While full disease remission was not achieved, a significant improvement was found in ocular allergy symptoms and signs, with a reduction in the frequency of acute recurrences.

Keywords: Eyelids/drug effects; Keratoconjunctivitis/drug therapy; Conjunctivitis, allergic/drug therapy; Injections; Triamcinolone acetonide/administration & dosage

Solitary fibrous tumor (SFT) is a rare mesenchymal spindle-cell neoplasm commonly found in the pleura; it is rare in the orbit and extremely rare in the lacrimal gland. We herein report a case of SFT of the lacrimal gland that mimicked a pleo morphic adenoma. We discuss the clinical, radiological, histopathological, and immunohistochemical findings that provided insight and rationale to accurately diagnose this case.

Keywords: Lacrimal apparatus/pathology; Lacrimal apparatus diseases/pathology; Neoplasms/diagnosis; Solitary fibrous tumors; Adenoma; pleomorphic; Diagnosis; differential

We present a case of a patient with resolved central serous chorioretinopathy (CSC) in the left eye with persistent mild visual alterations 4 years after the resolution of the disease. Left eye exam revealed a best corrected visual acuity of 20/25 and a slight change of macular pigmentation. Optical coherence tomography revealed only minor irregularities in the topography of retinal pigment epithelium and Bruch's membrane. Adaptive optics (AO) optics demonstrated lower density, spacing, and changes in the photoreceptor mosaic pattern in the left eye than in the right eye, suggesting that CSC may cause damage to cones after clinical recovery. We conclude that AO can provide additional information to assist in the treatment and follow-up of patients with CSC or other macular pathologies.

Keywords: Central serous chorioretinopathy; Optical imaging/methods tomography; Optical coherence; Retina

Fungal endophthalmitis is a rare condition often associated with poor prognosis. We present a case of postoperative acute fungal endophthalmitis caused by the yeast-like fungus Stephanoascus ciferrii (Candida ciferrii). The fungus was resistant to fluconazole, voriconazole, and amphotericin B but susceptible to caspofungin. Because the degree of vitreal penetration of caspofungin after its intravenous administration is unclear, we performed multiple intravitreal injections, first with 50 µg/0.1 ml and then with 250 µg/0.1 ml caspofungin. Despite the recurrence of symptoms, intravitreal injection of caspofungin finally abolished the inflammation and achieved ambulatory vision that persisted until 1 year of follow-up. To our knowledge, this is the first report of S. ciferrii endophthalmitis and its successful treatment with intravitreal caspofungin.

Keywords: Endophthalmitis; Phacoemulsification/adverse effects; Candida; Intravitreal injections; Lipopeptides

We describe a unique complication during primary posterior continuous curvilinear capsulorhexis (PCCC) in a patient with megalocornea scheduled for phacoemulsification with toric multifocal intraocular lens (IOL) implantation. After nucleus emulsification and cortex removal, the capsular bag was filled with cohesive viscoelastic in preparation for PCCC to achieve reverse optic capture of the IOL, thus ensuring stability. However, as soon as the initial puncture was made using a 27-gauge needle to start the capsulotomy, the posterior capsule opening extended peripherally from 0º-180º. This capsule extension was similar to the Argentinean-flag sign in hypermature cataracts, and both are caused by excessive intracapsular pressure. Careful bimanual manipulation was performed to implant the IOL on the desired axis, which occurred uneventfully. At a postoperative visit, the patient exhibited excellent uncorrected visual acuity with a well-aligned IOL.

Keywords: Cornea/abnormalities; Cataract; Phacoemulsification; Capsulorhexis; Humans; Case reports

Purpose: Studies have suggested that corneal biomechanical properties influence intraocular pressure (IOP) measurements, namely central corneal thickness (CCT) and corneal hysteresis (CH). The present study aimed to investigate the associations of CH and CCT with glaucoma development. Methods: We performed a review of the literature and meta-analysis of observational studies (2006-2016) that included both adult glaucoma patients and controls and reported CCT and CH as outcomes. Nineteen studies were conside red eligible, and the mean difference (MD) between groups (patient and control) for both variables was used for statistical analyses. Results: A total of 1,213 glaucoma and 1,055 healthy eyes were studied. Quan titative analysis suggested that CH was significantly lower in the glaucoma group than in the control group (MD=-1.54 mmHg, 95% CI [-1.68, -1.41], P<0.0001). Additionally, CCT was significantly lower in the glaucoma group than in the control group (MD=-8.49 µm, 95% CI [-11.36, -5.62], P<0.001). Conclusion: Corneal properties appear to differ between glaucoma patients and healthy controls. Our results emphasize the importance of corneal biomechanical properties in IOP interpretation and should support further studies on the influence of CH and CCT in glaucoma screening and diagnosis.

Keywords: Glaucoma; Corneal pachymetry; Cornea/physiopathology; Meta-analysis as topic