Ahmet Sarici

Phacoemulsification with topical anesthesia: Resident experience

PURPOSE: To compare the intraoperative and postoperative complications and outcomes of phacoemulsification performed by residents using topical and retrobulbar anesthesia. SETTING: Two university ophthalmology departments. METHODS: One hundred fifty phacoemulsification procedures were performed by 3 residents who used retrobulbar anesthesia (retrobulbar group), and 146 phacoemulsification procedures were performed by another 3 residents who used topical anesthesia and who had no experience with retrobulbar or peribulbar anesthesia (topical group). Case notes were prospectively compared. The data analyzed included the ocular history, intraoperative and postoperative complications, and final best spectacle‐corrected visual acuity (BSCVA). RESULTS: There were no differences between the 2 groups in complication rates. Anterior capsule tears occurred in 8 eyes (5.3%) in the retrobulbar group and 7 eyes (4.7%) in topical group. Capsulorhexis was continuous but not curvilinear in 14 eyes (9.3%) and 12 eyes (8.2%), respectively. Capsulorhexis tear or posterior capsule rupture that necessitated conversion to extracapsular cataract extraction occurred in 3 eyes (2.0%) in the retrobulbar group and in 1 eye (0.6%) in the topical group. Posterior capsule rupture with vitreous loss occurred in 10 eyes (6.6%) and 9 eyes (6.1%), respectively. Loss of lens fragments in the vitreous cavity occurred in 3 eyes (2.0%) and 4 eyes (2.7%), respectively. The 63 postoperative complications (41 eyes [27.3%], retrobulbar group; 22 eyes [15.0%], topical group) included cystoid macular edema, intraocular lens decentration, endophthalmitis, bullous keratopathy, transient intraocular pressure elevation, temporary corneal edema, and vitreous hemorrhage. Some cases had more than 1 complication. The BSCVA, including in eyes with preexisting ocular pathology, was 20/40 or better in 86.7% in the retrobulbar group and 84.9% in the topical group. CONCLUSION: When supervised and in selected patients, residents who have no retrobulbar or peribulbar anesthesia experience can safely perform phacoemulsification using topical anesthesia.

Glutathione S transferase M1 and T1 genetic polymorphisms are related to the risk of primary open-angle glaucoma: a study in a Turkish population.

Background: Genetic factors and oxidative damage have been shown to have a role in the development of primary open angle glaucoma (POAG). Aim: To determine the effects of genetic polymorphisms of glutathione S transferase (GST)M1 and GSTT1 on the risk of POAG in a Turkish population. Methods: Using a multiplex polymerase chain reaction (PCR), GSTM1 and GSTT1 gene polymorphisms were analysed in 144 patients with POAG and in 121 otherwise healthy controls of similar age. Results: The GSTM1 positive genotype and the GSTT1 null genotype had an increased risk of developing POAG (p<0.001, OR 2.93, 95% CI 1.66 to 5.20 and OR 4.25, 95% CI 2.30 to 7.80, respectively). The risk of glaucoma also increased significantly in subjects with a combination of GSTM1 positive and GSTT1 null genotypes (p<0.001, OR 3.46, 95% CI 1.64 to 7.38). Conclusion: The GSTM1 positive genotype and GSTT1 null genotype or the combination of both may be associated with the increased risk of development of POAG in the Turkish population.

Bioadhesive sulfacetamide sodium microspheres: Evaluation of their effectiveness in the treatment of bacterial keratitis caused by Staphylococcus aureus and Pseudomonas aeruginosa in a rabbit model

The aim of this study was to prepare bioadhesive sulfacetamide sodium (SA) microspheres to increase their residence time on the ocular surface and to enhance their treatment efficacy on ocular keratitis. Microspheres were fabricated by spray drying method using mixture of polymers such as pectin, polycarbophil and hydroxypropylmethyl cellulose (HPMC) at different ratios. The particle size and distribution, morphological characteristics, thermal behavior, encapsulation efficiency, mucoadhesion and in vitro drug release studies on formulations have been investigated. After optimisation studies, SA-loaded polycarbophil microsphere formulation with polymer:drug ratio of 2:1 was found to be the most suitable for ocular application and used in in vivo studies. In vivo studies were carried out on New Zealand male rabbit eyes with keratitis caused by Pseudomonas aeruginosa and Staphylococcus aureus. Sterile microsphere suspension in light mineral oil was applied to infected eyes twice a day. Plain SA suspension was used as a positive control. On 3rd and 6th days of the antimicrobial therapy, the eyes were examined in respect to clinical signs of infection (blepharitis, conjunctivitis, iritis, corneal oedema and corneal infiltrates) which are the main symptoms of bacterial keratitis and then cornea samples were counted microbiologically. The rabbit eyes treated with microspheres demonstrated significantly lower clinical scores than those treated with SA alone. A significant decrease in the number of viable bacteria in eyes treated with microspheres was observed in both infection models when compared to those treated with SA alone. In conclusion, in vitro and in vivo studies showed that SA-loaded microspheres were proven to be highly effective in the treatment of ocular keratitis.

Glutathione-S-transferase M1 and T1 genetic polymorphisms and the risk of cataract development: a study in the Turkish population.

In this study, we aimed to determine the effects of genetic polymorphisms of glutathione-S-transferase M1 (GSTM1) and glutathione-S-transferase T1 (GSTT1) on risk of developing different subtypes of age-related cataract in the Turkish population. Using a multiplex polymerase chain reaction (PCR), GSTM1 and GSTT1 gene polymorphisms were analyzed in 195 patients with age-related cataract (75 patients with cortical, 53 with nuclear, 37 with posterior subcapsular, and 30 with mixed type) and in 136 patients of an otherwise healthy control group of similar age. GSTM1 null genotype had a significant association with the development of cataract in female subjects (p < 0.0029; OR, 2.98; 95% CI, 1.41–6.34). This relationship in female subjects was only in nuclear and mixed types cataract cases (p < 0.002; OR, 4.58; 95% CI, 1.67–12.78 and p < 0.03, respectively). There was also a statistically significant association between the combination of GSTM1-null and GSTT1-positive genotypes and the risk of cataract development in female subjects (p = 0.01; OR = 2.87; 95% CI = 1.25–6.69). Stratification by the subtypes revealed that this association was only in nuclear type cataract (p = 0.001; OR, 3.92; 95% CI, 1.34–11.71). GSTM1-null genotype or combination of the GSTM1-null and GSTT1-positive genotypes in females may be associated with increased risk of cataract development in the Turkish population.

Unilateral mydriasis without ophthalmoplegia-A sign of neurovascular compression?: Case report

OBJECTIVE: We aimed to demonstrate the use of neuroimaging studies in vascular compression of the oculomotor nerve. CLINICAL PRESENTATION: A 24-year-old woman was noted by her dentist to have anisocoria, with the left pupil being larger than the right. After detailed ophthalmologic and neurological examination, we proceeded to peform neuroimaging. T2-weighted images (2 mm) and constructive interference in steady-state (0.3 mm) images were utilized. INTERVENTION: Magnetic reasonance imaging showed that duplicated left superior cerebellar artery, a prominent posterior communicating artery, and a posterior cerebral artery combined to compress the superomedial portion of the left oculomotor nerve. CONCLUSION: With continued improvements in neuroimaging, we think that more cases of isolated cranial neuropathies previously labeled as “idiopathic” will be shown to result from vascular compression.

Corneal Viscoelastic Differences Between Pseudoexfoliative Glaucoma and Primary Open-angle Glaucoma

Purpose:The aims of this study were to assess the biomechanical properties of corneas with pseudoexfoliative glaucoma (PEXG) and to compare them with those of patients with primary open-angle glaucoma (POAG). Methods:This prospective, comparative case series consisted of 73 eyes of 73 patients, 35 eyes with PEXG (PEXG group) and 38 eyes with POAG (POAG group). Corneal hysteresis (CH), corneal resistance factor (CRF), corneal-compensated intraocular pressure (IOPCC), and Goldmann-correlated intraocular pressure (IOPG) were determined by using ocular response analyzer (ORA). IOP using Goldmann applanation tonometer (GAT) and ultrasonic central corneal thickness (CCT) were also measured for each eye. Exclusion criteria included refractive error/astigmatism of >3.00 D, history of intraocular surgery, corneal disease, angle-closure glaucoma, and secondary glaucoma other than PEXG. In cases where both eyes were eligible, the right eye was preferred for analysis. The main outcome measures were CH, CRF, IOPCC, IOPG, and GAT. The results were statistically analyzed by using t test, general linear model, and the Pearson correlation test. Results:The mean CH was found to be significantly lower in patients with PEXG (8.8±1.4 mm Hg) than those with primary open-angle glaucoma (9.9±1.2 mm Hg; P=0.0007). The mean CRF was found to be significantly lower in patients with PEXG (9.5±1.8 mm Hg) than those with POAG (11.1±1.3 mm Hg; P<0.0001). IOPCC was not significantly different between the groups (PEXG, 16.7 ±2.5 mm Hg; POAG, 16.9±2.4 mm Hg; P=0.72). IOPG was significantly lower in PEXG group (14.7±2.7 mm Hg) compared with the POAG group (16.5±2.5 mm Hg; P=0.004). GAT was significantly lower in the PEXG group (14.6±2.7 mm Hg) compared with the POAG group (16.4±2.8 mm Hg; P=0.007). There was no significant difference between the groups regarding mean CCT (PEXG, 546.1±34.9 &mgr;; POAG, 549.1±25 &mgr;; P=0.66) and mean age (PEXG, 70.3±8.2; POAG, 67.6±8.8; P=0.17). The difference between the IOPCC and the GAT was 2.1 and 0.5 mm Hg in both PEXG and POAG groups, respectively. Conclusions:Patients with PEXG had lower CH and CRF values than those with POAG. These findings require further investigation to assess the role of differing corneal biomechanical properties between the 2 groups and its association with poor prognosis among patients with PEXG.

Treatment of the Lower Eyelid with the CO2 Laser: Transconjunctival or Transcutaneous Approach?

Purpose: To compare the effects of CO2 laser transcutaneous blepharoplasty with CO2 laser transconjunctival blepharoplasty with simultaneous resurfacing for the treatment of lower lid dermatochalasis. Methods: Thirteen men and 23 women, between 42 and 67 years of age, participated in this study. Patients were divided into two groups: (1) CO2 laser transconjunctival blepharoplasty with resurfacing or (2) CO2 laser transcutaneous blepharoplasty by the skin-muscle approach without resurfacing. The two operative techniques were compared with regard to the patients satisfaction, complications and effectiveness on lower lid bulging and wrinkles. Results: Transconjunctival blepharoplasty with simultaneous laser resurfacing yielded satisfactory results with improvement of the lower lid bulging in 92% of the 20 subjects. Persistent erythema was seen in only 5% and hiperpigmentation in 10% of this group, but 80% of the patients complained of long postoperative care. On the other hand, with the transcutaneous approach, lower lid bulging was perfect in 98% of the 16 subjects; although the rate of complications such as lateral canthal rounding (3.2%) and ectropion (6.25%) was higher, the patients had no problems with the period of postoperative care. Fourteen of 16 subjects in this group also demonstrated a better appearance of the lower lid wrinkles. Conclusion: Although transconjunctival blepharoplasty with laser resurfacing is now the most common surgical procedure for lower eyelid dermatochalasis and orbital fat herniation, postoperative care after laser resurfacing can be a problem in a certain group of patients. Transcutaneous blepharoplasty via the skin-muscle approach may be preferable in certain cases because of the short recovery period.

Upper Lid Blepharoplasty in Patients with LASIK

Purpose: To investigate the changes in tear secretion and tear film stability after upper lid blepharoplasty in patients that had previously undergone excimer laser in situ keratomileusis (LASIK). Methods: We performed carbon dioxide (CO2) laser upper lid blepharoplasty to 18 eyes of 9 patients that had undergone bilateral LASIK at least 18 months before the surgery. Six women and 3 men aged 35 to 52 were included in this group. An additional control group of 18 eyes of similar age patients with no history of LASIK, contact lens usage or dry eye symptoms were studied. We studied the Schirmer tear test values without anesthesia at 5 minutes in both groups before and after the upper lid blepharoplasty procedure. Tear break-up time values were also measured before and 4 weeks after (CO2) laser upper lid blepharoplasty. The Schirmer tear test and tear break-up time values were analyzed statistically using the independent t-test. Results: The mean Schirmer tear test value was 19.07 ± 4.03 mm in both eyes of the patients who had undergone LASIK and upper lid blepharoplasty, and it was 21.07 ± 7.03 mm in the eyes of the control group that only had (CO2) laser upper lid blepharoplasty. The mean tear break-up time value was 21.0 ± 3.55 seconds in the eyes that had LASİK treatment, and it was 21.27 ± 6.79 seconds in the eyes of the control group. There was no statistical difference between the two groups. Conclusion: Because LASIK and blepharoplasty both may cause dry eye symptoms, the possible cumulative effect of these surgeries is a serious consideration. However, dry eye symptoms after LASIK is usually temporary, and we may perform upper lid blepharoplasty to these patients after a certain time interval by closely monitoring their preoperative and postoperative tear function.

Effect of Fasting on Corneal Biomechanical and Structural Parameters.

ABSTRACT Purpose: To evaluate the effects of hunger and thirst on corneal biomechanical and structural parameters during Ramadan fasting. Materials and Methods: Corneal biomechanical properties and intraocular pressures of 29 eyes of 29 healthy subjects were evaluated by Reichert ocular response analyzer; and structural and anatomical properties of cornea and anterior eye chamber of same eyes were scanned with Oculus Pentacam anterior segment analyzer. Each eye has been evaluated at 8 am and 4 pm both during and 1 month after Ramadan. Changes of subjects’ weight were calculated and their relationship with corneal biomechanical and structural parameters was assessed. Results: Intraday changes in horizontal corneal astigmatism (p = 0.02), anterior chamber volume (p = 0.01), intraocular pressure associated with the Goldmann IOPg (p = 0.02) and corneal resistance factor (CRF) (p = 0.04) were significantly different when measured during the fasting period in Ramadan and 1 month thereafter. Moreover, when we compared 8 am measurements taken during and after Ramadan, we observed significant differences for anterior chamber volume (p = 0.04) and anterior chamber angle values (p = 0.03). Similarly, for 4 pm measurements, there were significant differences for IOPg (p = 0.01) and CRF values (p = 0.00). Conclusions: Fasting lasting for more than 12 h during Ramadan creates an important window of opportunity to investigate the response of anterior chamber of eye to hunger and thirst. The current study contributes to the existing literature on the effects of dietary habits and water intake on corneal and anterior chamber properties.

Diode laser photocoagulation posterior to the ridge in severe stage 3+ threshold retinopathy of prematurity

Abstract Purpose: To evaluate the results of diode laser photocoagulation (DLP) of the retina posterior to the ridge in eyes with severe Zone II, Stage 3+ threshold retinopathy of prematurity (ROP). Method: DLP was applied posterior to the fibrovascular ridge for advanced Zone II, Stage 3+ threshold ROP patients, either as the primary treatment combined with DLP of the avascular retina (group 1), or as a secondary treatment in eyes that had previously undergone DLP of the avascular retina (group 2). Statistical analysis was performed using SPSS software trail version 16.0. Values are presented as mean ± SD. Results: A total of 50 eyes of 29 premature infants were treated (14 [48%] male, 15 [52%] female). The mean gestational age was 29.5 ± 2.2 weeks (range: 26–34 weeks). The mean birth weight was 1259 0.72 ± 409.15 g (range: 500–2050 g). The mean gestational age for DLP of the avascular region anterior to the ridge and DLP posterior to the ridge was 37 ± 3 weeks and 38 ± 3 weeks, respectively. The mean follow-up was 26 ± 5 weeks (18–38 weeks). In 48 eyes, the tractional fibrovascular ridge had regressed. Transient retinal hemorrhage was the most common complication. Three eyes exhibited optic-disc dragging; two eyes progressed to Stage 4a ROP; two eyes presented with macular traction, without any detachment; and one eye developed a vitreous hemorrhage, which resolved spontaneously. There were no statistically significant differences between complicated and uncomplicated eyes regarding gestational age, birth weight and applied laser spot numbers (p > 0.05 for all, Mann–Whitney U test). Conclusion: DLP, posterior to the ridge as an additive treatment in the management of severe Zone II, Stage 3+ threshold ROP patients, is safe and effective; this approach could be used as either the primary treatment, or as the follow-up to failed laser treatment of the avascular retina to halt the progression of the disease.