VOLUME 82 - ISSUE 3

Purposes: This study aimed to present the characteristics of visual development from a clinical viewpoint in infants and preschool children aged 0-6 years who were born at term with no pregnancy or childbirth complications.
Methods: We conducted a bibliographic review on visual development in infants and preschool children.
Results: We described visual development in children according to age groups: 0-1 month, 1-3 months, 3-6 months, 6-10 months, 10 months-1 year and 4 months, 1 year and 4 months-2 years, 2-4 years, and 4-6 years.
Conclusion: Visual responses in infants and preschool children born at term and with normal development were observed to occur in an integrated manner with neuromotor functions in addition to cognitive and psycho-emotional sensory, behavioral, and visual capacity.

Keywords: Vision, ocular; Child; Infant; Visual acuity

Purpose: To correlate provocative test-based intraocular pressure (IOP) variation parameters (fluctuation and peak) with functional status, and to compare these IOP parameters between treated eyes with asymmetric primary open-angle glaucoma (POAG).
Methods: A prospective observational study including consecutively treated patients with primary open-angle glaucoma was performed. Subjects with ocular diseases other than glaucoma or previous incisional glaucoma surgery were excluded. The primary inclusion criteria were ≥3 visual field tests and ≥2 years of follow-up, without any changes on current medical regimen. Long-term intraocular pressure parameters were acquired via isolated intraocular pressure measurements from the patients' last 5 office visits. To evaluate provocative test-based intraocular pressure parameters, all patients were submitted to a water drinking test. Initially, the partial correlation coefficients between each intraocular pressure variation parameter and visual field mean deviation were calculated, adjusting for the baseline intraocular pressure and number of antiglaucoma medications. In addition, each intraocular pressure parameter was compared between eyes with better visual field mean deviation and fellow eyes with worse visual field mean deviation in patients with asymmetric visual field loss (defined as an inter-eye visual field mean deviation difference of at least 3 dB).
Results: A total of 87 eyes (87 patients; mean age, 61.9 ± 12.5 years; 59.8% women) with primary open-angle glaucoma were included. The patients underwent a median of 5 visual field tests, with a mean follow-up of 4.3 ± 1.4 years. Neither long-term nor water-drinking test intraocular pressure variation parameters were significantly associated with visual field mean deviation values (p≥0.117). In the subgroup with asymmetric visual field loss (64 eyes of 32 patients; mean age, 65.0 ± 11.4 years), neither long-term water-drinking test intraocular pressure variation parameters differed significantly between eyes with better and worse visual field mean deviation (p≥0.400).
Conclusion: Our results indicate that neither long-term intraocular pressure variation parameters nor stress test-derived intraocular pressure metrics, as assessed by the water-drinking test, appear to correlate with the visual field status or differ significantly between eyes with asymmetric visual field damage, suggesting that other factors may explain such functional asymmetry, and that the water-drinking test does not add significant information to these cases.

Keywords: Glaucoma, open-angle/physiopathology; Intraocular pressure/physiology; Diagnostic techniques, ophthalmological; Drinking; Water; Circadian rhythm

Purpose: To test the hypothesis that Chagas disease predisposes to optic nerve and retinal nerve fiber layer alterations.
Methods: We conducted a cross-sectional study including 41 patients diagnosed with Chagas disease and 41 controls, paired by sex and age. The patients underwent ophthalmologic examinations, including intraocular pressure measurements, optic nerve and retinal nerve fiber layer screening with retinography, optical coherence tomography, and standard automated perimetry.
Results: All of the patients with Chagas disease had a recent cardiologic study; 15 (36.6%) had heart failure, 14 (34.1%) had cardiac form without left ventricular dysfunction, and 12 (29.3%) had indeterminate form. Optic nerve/retinal nerve fiber layer alterations were observed in 24 patients (58.5%) in the Chagas disease group and 7 controls (17.1%) (p≤0.01). Among these, optic nerve pallor, optic nerve alterations suggestive of glaucoma, notch, peripapillary hemorrhage, and localized retinal nerve fiber layer defect were detected. Alterations were more prominent in patients with Chagas disease and heart failure (11 patients), although they also occurred in those with Chagas disease without left ventricular dysfunction (7 patients) and those with indeterminate form (6 patients). Optical coherence tomography showed that themean of the average retinal nerve fiber layer thickness measured 89 ± 9.7 µm, and the mean of retinal nerve fiber layer superior and inferior thickness measured 109 ± 17.5 and 113 ± 16.8 µm, respectively were lower in patients with Chagas disease. In controls, these values were 94 ± 10.6 (p=0.02); 117 ± 18.1 (p=0.04), and 122 ± 18.4 µm (p=0.03).
Conclusion: Changes in optic nerve/ retinal nerve fiber layer were more prevalent in patients with Chagas disease.

Keywords: Chagas disease; Eye disease; Optic nerve; Heart failure

PURPOSE: The purpose of this study was to objectively assess the optical vision quality of patients before and after Nd:YAG capsulotomy for posterior capsular opacification using a double-pass retinal imaging system.
METHODS: We retrospectively analyzed the data from 26 pseudophakic eyes with posterior capsular opacification that underwent Nd:YAG capsulotomy. The objective scatter indices, modulation transfer function cutoff frequencies, Strehl ratios, and logMAR corrected distance visual acuities were assessed before and after YAG capsulotomy with a double-pass retinal imaging system (OQAS II, Visiometrics, Spain). We also analyzed data from a subgroup of 10 patients with pre-YAG corrected distance visual acuity of 0.10 logMAR (20/25) or better.
RESULTS: Vision quality indices improved in all 26 eyes, resulting in a statistically significant improvement in the corrected distance visual acuity (p=0.007), objective scatter index (p=0.001), modulation transfer function cutoff frequency (p=0.001), and Strehl ratio (p=0.020). The overall mean improvements included 0.12 ± 0.04 logMAR for corrected distance visual acuity, 2.84 ± 0.76 for objective scatter index, 12.29 ± 2.77 for modulation transfer function cutoff frequency, and 0.06 ± 0.03 for Strehl ratio. Our sub-analysis of 10 eyes with 0.10 logMAR (20/25) corrected distance visual acuity or better also showed a statistically significant improvement in the mean objective scatter index (0.76 ± 16; p=0.001), resulting in approximately 35% decrease in intraocular light scatter.
CONCLUSIONS: The objective vision quality measurements as assessed by the double-pass retinal imaging system showed a significant improvement after YAG capsulotomy. This suggests that the objective scatter index improves after YAG capsulotomy, even in eyes with pre-YAG 0.10 logMAR (Snellen 20/25) corrected distance visual acuity or better.

Keywords: Capsule opacification; Cataract extraction; Posterior capsulotomy; Visual acuity; Lasers

PURPOSE: To investigate changes in axial length after intravitreal dexamethasone implantation in patients with macular edema.
METHODS: We performed a prospective comparative study of 46 patients with unilateral macular edema, due to diabetic retinopathy, retinal vein occlusion, and non-infectious uveitis, who underwent dexamethasone implantation. The fellow eyes of the patients were considered the control group. The central macular thickness was measured by spectral-domain optical coherence tomography, and axial length was measured by IOLMaster 700 optical coherence biometry. We compared axial length and central macular thickness values within the groups.
RESULTS: In the study group, the baseline central macular thickness was 460.19 ± 128.64 µm, significantly decreasing to 324.00 ± 79.84 µm after dexamethasone implantation (p=0.000). No significant change in central macular thickness measurements was seen in the control group (p=0.244). In the study group, the baseline axial length was 23.16 ± 0.68 mm, significantly increasing to 23.22 ± 0.65 mm after dexamethasone implantation (p=0.039). However, the control group exhibited no significant change in axial length (p=0.123).
CONCLUSIONS: In addition to significantly reducing central macular thickness measurements, intravitreal dexamethasone implantation also significantly changes optical biometry-based axial length measurements.

Keywords: Axial length, eye; Dexamethasone/administration & dosage; Intravitreal injections, Drug implants; Macular edema

Purpose: Obesity is accepted as a risk factor for postoperative visual loss due to possible perioperative elevations in intraocular pressure. This study investigated whether intraocular pressure changes differed according to the body mass index of patients undergoing laparoscopic cholecystectomy.
Methods: Thirty obese and 30 non-obese patients (body mass index cutoff point, 30 kg/m²) undergoing laparoscopic cholecystectomy were enrolled. Intraocular pressure was measured at baseline (T1), after induction of anesthesia (T2), 5 min after initiation of mechanical ventilation (T3), 5 min after pneumoperitoneum inflation (T4), 5 min after the patient was placed in the head-up position (T5), 5 min after deflation with the patient in the supine position (T6), and 5 min after extubation with the patient in the 30 degrees upright position (T7).
Results: The mean intraocular pressure values of the obese and non-obese groups were similar at T1 (16.60 ± 2.93 and 16.87 ± 2.85 mmHg respectively). In both groups, intraocular pressure decreased following initiation of anesthesia (T2) (p<0.001, T2 vs T1). Intraocular pressure values at T7 were significantly higher than those at T1 in the obese (20.38 ± 4.11 mmHg, p<0.001) and non-obese (20.93 ± 4.37 mmHg, p<0.01) groups. There were no significant differences between intraocular pressure values of obese and non-obese patients at any time point.
Conclusions: Obesity is not correlated with intraocular pressure during short laparoscopic surgeries with the patient in the head-up position.

Keywords: Laparoscopy; Intraocular pressure/etiology; Obesity/complications; Visual loss

PURPOSE: To measure changes in the anterior ciliary muscle during accommodation at the nasal, superior, temporal, and inferior sectors by means of an anterior chamber optical coherence tomographer, and correlate them with vergence changes.
METHODS: Twenty-four subjects with healthy, phakic eyes, whose mean age was 27.1 ± 8.9 years, underwent measurement with an anterior chamber optical coherence tomographer. The anterior ciliary muscle was measured at the nasal, temporal, superior, and inferior sectors for 0, -1, -2, and -3 D of vergence. A linear model was used to assess the correlation of each eye parameter with the accommodative demand.
RESULTS: The anterior ciliary muscle area significantly increased with accommodation for each sector, with a maximum increase of about 30% for the nasal-temporal sectors and about 25% for the inferior-temporal sectors. The linear model showed a tendency toward a positive relationship between change in the ciliary muscle area of each sector and vergence.
CONCLUSION: The anterior ciliary muscle area tends to increase with accommodation, although the increase has been shown to be symmetric between the pair sectors superior-nasal and inferior-temporal. These results may help to increase understanding of accommodation biometry and biomechanics.

Keywords: Accommodation, ocular; Biometry; Ciliary muscle; Tomography; Optical coherence; Presbyopia

Purpose: To evaluate the effects of suturing 23-gauge pars plana vitrectomies on ocular discomfort and tear film dynamics.
Methods: This retrospective chart review involved data from 50 procedures in 50 patients who underwent 23-gauge pars plana vitrectomy from January to November 2016. We divided the eyes into two groups according to the presence or absence of sutures; 35 eyes underwent sutureless vitrectomies (Group 1), and 15 eyes underwent vitrectomy with at least one sclerotomy suture site (Group 2). In each group, we assessed objective variables including tear film break-up time, Schirmer test I, corneal surface grading with Oxford system, and a quantitative method evaluating subjective dry eye symptoms using ocular surface disease index questionnaires preoperatively 1 week, and 1 and 3 months after surgery.
Results: The tear film break-up time showed a significant difference at the 3-months follow-up (p=0.026). The Schirmer test I and corneal surface staining score showed no statistically significant differences between two groups at any time after the operations. The ocular surface disease index score was significantly lower in Group 1 than in Group 2 at 1 week (p=0.032), 1 month (p=0.026), and 3 months (p=0.041) after the operation.
Conclusion: Sclerotomy suturing caused ocular discomfort and had a negative effect on tear film dynamics during the late postoperative period. Sclerotomies without suturing seem to reduce the ocular surface changes.

Keywords: Vitrectomy/methods; Dry eye syndrome; Tears/physiology; Sclera/surgery

PURPOSE: Beta-thalassemia minor, a common hereditary blood disorder in Mediterranean countries such as Turkey, is associated with insulin resistance. Insulin resistance, in turn, can be associated with excessively high intraocular pressure and, therefore, intraocular pressure-induced blindness. This study aimed to investigate the intraocular pressure in subjects with beta-thalassemia minor.
METHODS: We conducted a cross-sectional study comprising of 203 subjects divided into two groups: beta-thalassemia minor (103) and healthy (100).Hemoglobin electrophoresis was performed and complete blood count, blood pressures, serum fasting glucose and insulin levels were measured. All subjects underwent ophthalmological examinations including intraocular pressure measurements.
RESULTS: Intraocular pressure in the subjects with beta-thalassemia minor was significantly lower than that in healthy subjects (p=0.007). Additionally, intraocular pressure was inversely correlated with hemoglobin A₂ levels (p=0.001, r=-0.320). Serum insulin and systolic blood pressure were significantly higher in subjects with beta-thalassemia minor (p=0.03, p=0.009, respectively).
CONCLUSION: Subjects with beta-thalassemia minor had lower intraocular pressure than healthy controls, suggesting beta-thalassemia minor may actually protect against high intraocular pressure.

Keywords: Beta-Thalassemia; Blood pressure; Glaucoma; Hemoglobin A₂; Intraocular pressure

PURPOSE: To study the efficacy and safety of treatments with ranibizumab and bevacizumab for exudative age-related macular degeneration.
METHODS: A parallel randomized clinical trial was conducted to compare the efficacy and safety of three regimens (bevacizumab every month, bevacizumab every 2 weeks, and ranibizumab every month), followed by as-needed retreatments, for 1 year, in previously untreated individuals with age-related macular degeneration. The primary outcome was change in visual acuity and in central macular thickness after 1 year of follow-up. Subjects were assigned randomly to one of the three groups in a 1:1:1 ratio, and investigators and examiners were blinded to the randomization results.
RESULTS: We included 15 patients in each group. After 1 year of follow-up, we found statistically significant improvements in visual acuity and central macular thickness reduction in all groups. However, we found no statistically significant differences between the three groups.
CONCLUSIONS: The bi-weekly follow-up was effective and we found no significant differences in efficacy or safety between the treatments with ranibizumab and bevacizumab.

Keywords: Macular degeneration; Retina; Bevacizumab; Ranibizumab; Clinical trial

A 21-year-old man presented with visual acuity of 20/200 in both eyes. The fundus picture, fluorescein angiography, and optical coherence tomography revealed severe bilateral acute posterior multifocal placoid pigment epitheliopathy and serous macular detachments. We treated the patient with triamcinolone acetonide, an intravitreal injection (4 mg/0.1 mL) in one eye and a posterior subtenon injection (40 mg/1 mL) in the other eye. Within 2 weeks the visual acuity was 20/80 in both eyes. At the 8-week follow-up visit his vision was 20/63 bilaterally. One year later the vision remained 20/63 in both eyes. In this patient, the triamcinolone acetonide injections, whether administered intravitreally or via the posterior subtenon route, achieved similar anatomic and functional recovery results.

Keywords: Pigment epithelium of eye; Choroid diseases; Chorioretinopathy; Tomography, optical coherence; Triamcinolone acetonide

This report was written to describe a case of unilateral brimonidine-induced conjunctival lichen planus. Because the ophthalmic examination indicated chronic conjunctivitis or drug-induced pseudopemphigoid, the patient underwent thorough ophthalmic and systemic examinations, as well as conjunctival biopsy and direct immunofluorescence studies. A 71-year-old woman with unilateral left eye findings of chronic conjunctivitis was referred to our Ophthalmology Department. The patient reported that chronic conjunctivitis began shortly after she initiated use of topical brimonidine. Ophthalmic examination revealed foreshortening of the inferior fornix and symblepharon. Conjunctival biopsy revealed submucous lymphocytes and shaggy distribution of fibrinogen on direct immunofluorescence; this was suggestive of ocular lichen planus. No other systemic lesions were found that were consistent with the presentation of lichen planus. A good response was observed to topical cyclosporine treatment. To our knowledge, this may be the first report of unilateral ocular lichen planus without systemic findings. The correlation with the initiation of topical brimonidine suggests that this might be the first case of biopsy-confirmed brimonidine-induced ocular lichen planus.

Keywords: Brimonidine tartrate; Conjunctiva; Lichen planus; Cyclosporine

Fibroepithelial polyps are benign non-epithelial tumors arising from mesodermal tissue and are commonly found on the skin. They can develop on the eyelid and surrounding area and rarely appear at other sites. While most cutaneous cases are diagnosed incidentally, the lesions may be symptomatic based on their location. The etiology of fibroepithelial polyps is not fully understood but may involve trauma, chronic irritation, allergic factors, and developmental or congenital causes. Although fibroepithelial polyps are benign lesions, they can be malignant in extremely rare cases. Herein we discuss 2 cases of fibroepithelial polyp with an atypical presentation and their treatment.

Keywords: Neoplasms, fibroepithelial; Polyps; Eyelids; Dermoid cyst; Case report

A 12-year-old girl presented with recurrent crusty debris and dandruff at the base of both eyelashes despite having completed different medical treatments. She had had a hoarse voice since her early childhood. Upon anterior segment examination of the eyes, we found yellow-white, bead-like papules on the margins of the eyelids. An otolaryngologist detected multiple nodules on the vocal cords and buccal mucosa. Ultrasonography revealed salivary stones in the main parotid ducts. And a dermatological examination revealed thickened skin lesions on the elbows and knees with a biopsy showing histopathological findings of lipoid proteinosis. We diagnosed the patients as having Urbach-Wiethe syndrome or lipoid proteinosis, a rare autosomal recessive multisystem disorder with variable manifestations vary that difficult the diagnosis. The ocular manifestations are not well known among ophthalmologists, but the typical lid lesions are pathognomonic and ophthalmologists should be aware of this presentation to identify patients with Urbach-Wiethe syndrome.

Keywords: Blepharitis; Eyelid; Lipoid proteinosis of Urbach-Wiethe; Case reports

Glaucoma is the leading cause of irreversible blindness worldwide and can affect a broad array of daily activities, including driving. Recently, studies investigating the relationship between driving performance and glaucoma have received a great deal of interest. Assessment of driving behavior is not straightforward because driving is a complex skill involving significant multi-tasking ability. In this review, we summarize recent work from clinical studies investigating how glaucoma can affect driving performance. Patients with glaucoma are more likely to be involved in motor vehicle collisions when compared to healthy subjects. Here we describe how conventional functional tests performed in glaucoma patients, such as visual field measurements via standard automatic perimetry, are associated with driving performance. However, the risk of motor vehicle collisions is not entirely attributable to visual field impairment in glaucoma, suggesting that other factors also account for both driving safety and performance. Finally, we show different studies suggesting that parameters from driving simulators can be helpful because they can identify the impact of visual loss on complex situations.

Keywords: Glaucoma; Automobile driving; Quality of life; Visual field; Motor vehicle; Accidents, traffic