Altuğ Çetinkaya

Topical cyclosporine in the management of shield ulcers.

Purpose To report our experience with 0.05%–2% topical cyclosporine in the treatment of 4 cases of severe, corticosteroid-resistant, vernal keratoconjunctivitis with shield ulcers. Methods Four patients with shield ulcers not responding to medical treatment with topical steroids, antihistamines, and mast-cell stabilizers were treated with 0.05%–2% topical cyclosporine. The frequency of application was 4 times daily in all cases, and the concentration was adjusted according to the clinical status starting with 2%. Results Healing of ulcers with no epithelial defect occurred in 10 days with the 2% concentration in all cases. The patients experienced no side effects except for a burning sensation during administration. Recurrences occurred when the concentration was decreased to 0.05% in 3 cases. The recurrences were effectively treated with 1% concentration in all cases, and patients were stable with this concentration for at least 6 months. Conclusions Topical cyclosporine is an effective treatment alternative in the management of shield ulcers in patients with vernal keratoconjunctivitis. The 1% concentration seems to be the minimal effective concentration in such cases in our experience, but further controlled studies are needed to support our findings.

Comparison of additional intraocular pressure-lowering effects of latanoprost vs brimonidine in primary open-angle glaucoma patients with intraocular pressure uncontrolled by timolol-dorzolamide combination

AbstractPurposeTo compare the additive intraocular pressure (IOP)-lowering effects of latanoprost 0.005% and brimonidine 0.2% in primary open-angle glaucoma (POAG) patients uncontrolled on fixed combination of timolol 0.5% and dorzolamide 2% (TDC) alone.MethodsIn all, 80 eyes of 80 POAG patients with IOP inadequately controlled by TDC were randomly assigned to receive either latanoprost 0.005% or brimonidine 0.2%. IOP measurements were recorded at 1000 (peak effect) and 1600 (trough effect) on day 0 (baseline) and at 1 and 3 months. At each stage and time point, the mean IOP reductions from baseline were evaluated for both groups, and success rates (minimum 15% reduction) were determined.ResultsAt baseline, the mean peak/trough IOPs with TDC were 20.2/21.6 and 19.9/21.4 mmHg in latanoprost and brimonidine groups, respectively. Latanoprost+TDC reduced the mean peak/trough IOP by 4.4/3.4 and 5.2/3.5 mmHg at 1 and 3 months. The corresponding values for brimonidine+TDC were 3.9/2.9 and 4.6/2.9 mmHg. Each of these results represented a significant reduction from baseline (P<0.001 for all); however, the groups’ peak/trough reductions from baseline did not differ at any time point (P>0.05 for all). With the latanoprost+TDC combination, the peak/trough success rates at 1 and 3 months were 76.3%/42.1% and 77.1%/40%. The corresponding values with the brimonidine+TDC combination were 71.8%/41% and 77.7%/41.7%. There were no significant differences in the groups’ success rates at any time point (P>0.05 for all).ConclusionAddition of latanoprost 0.005% or brimonidine 0.2% to TDC reduces peak/trough IOPs significantly and the effects of these combinations are comparable.

Effect of topical brinzolamide 1% and brimonidine 0.2% on intraocular pressure after phacoemulsification

Purpose: To compare the effectiveness of brinzolamide 1% (Azopt®) and brimonidine 0.2% (Alphagan®) with a placebo in preventing an early increase in intraocular pressure (IOP) after phacoemulsification. Setting: Department of Ophthalmology, Baskent University, School of Medicine, Ankara, Turkey. Methods: In this prospective double‐masked study, 90 eyes of 90 patients having clear corneal phacoemulsification were randomly divided into 3 groups of 30 eyes each. One hour before surgery, 1 group received 1 drop of brinzolamide 1%, another received 1 drop of brimonidine 0.2%, and the third received 1 drop of a balanced saline solution (placebo). The IOP was measured preoperatively and 3 and 16 to 20 hours postoperatively. Results: Three hours postoperatively, the mean IOP increased by 4.2 mm Hg ± 7.0 (SD), 3.2 ± 6.4 mm Hg, and 5.3 ± 4.2 mm Hg in the brinzolamide, brimonidine, and placebo groups, respectively. The IOP increase from baseline was significant in all 3 groups (all P<.01), with no difference between the groups (P>.05). The change in IOP at 16 to 20 hours was 0.2 ± 2.8 mm Hg, 0.2 ± 2.4 mm Hg, and –0.8 ± 2.4 mm Hg, respectively. The changes were not significant compared to baseline (all P>.05). Six eyes (20%) in the brinzolamide group, 5 eyes (16.7%) in the brimonidine group, and 7 eyes (23.3%) in the placebo group had an IOP higher than 25 mm Hg 3 hours postoperatively; the difference between groups was not significant (P = .8). Conclusion: Prophylactic use of 1 drop of brinzolamide or brimonidine was not more effective than a placebo in controlling early postoperative IOP elevations after clear corneal phacoemulsification.

Aqueous humour penetration of moxifloxocin and gatifloxacin eye drops in different dosing regimens before phacoemulsification surgery

Aim To compare the aqueous humour penetration of moxifloxacin 0.5% and gatifloxacin 0.3% eye drops administered in two different dosing regimens during phacoemulsification surgery. Methods This prospective, randomised study included 97 patients. The patients were randomly divided into two treatment groups to receive either moxifloxacin or gatifloxacin. All patients received the topical antibiotics four times per day for 2 days prior to surgery. Patients in each group were further subdivided to receive additional doses of antibiotic drops as two drops 30 min apart (subgroup 1) versus four drops 10 min apart (subgroup 2) 1 h prior to the surgery. At the beginning of surgery, 0.1 ml of aqueous humour was aspirated, and the concentrations of moxifloxacin and gatifloxacin were analysed by high-performance liquid chromatography. Results The mean concentrations of moxifloxacin and gatifloxacin in the aqueous humour were 0.72±0.40 μg/ml and 0.47±0.29 μg/ml, respectively, in the first subgroup, and 1.95±1.05 μg/ml and 0.77±0.52 μg/ml, respectively, in the second subgroup. Both the inter-group (p=0.006 and p=0.000, respectively) and the intra-group (p=0.000 and p=0.035, respectively) differences between the aqueous humour concentrations of moxifloxacin and gatifloxacin subgroups were statistically significant. Conclusion Moxifloxacin, given in the same dosage, penetrated the aqueous humour better then gatifloxacin during cataract surgery. The penetration of both antibiotics increased significantly when the dosage of the agent was doubled.

The effect of topical bevacizumab as an adjunctive therapy for corneal neovascularization

Editor, A lthough recent research on human cornea showed promising results regarding the efficacy of topical bevacizumab on corneal neovascularization (NV) (Kim et al. 2008; Dastjerdi et al. 2009), many aspects such as patient selection, long-term safety and efficacy are yet to be determined. Here, we report our experience with topical bevacizumab in the treatment of corneal NV. The records of all patients who were treated with topical bevacizumab for corneal NV between July 2007 and August 2010 were reviewed. Inclusion criterion was progressive corneal NV despite aggressive systemic and local treatment including topical corticosteroids, topical cyclosporine, autologous serum eye drops and topical vitamin A (Table 1). Bevacizumab eye drops were added to the ongoing therapy at a dose of 5 mg ⁄ml qid, as the minimal effective dose was defined as 4 mg ⁄ml previously (Habot-Wilner et al. 2010). Patients were examined at weekly intervals. Treatment with bevacizumab was terminated when no further regression of corneal NV was observed for the last 4 weeks. The extent of corneal NV was evaluated by standardized digital slit-lamp photographs (16· magnification) taken before treatment and at each visit. The neovascularized area and the total corneal area were calculated in terms of pixels by an image analysis software (imagej 1.44p, Wayne Rasband, National Institutes of Health, Bethesda, MD, USA). Neovascularization regression percentage (NRP) was calculated for pretreatment and last visit images by using the formula [(neovascularized area % before therapy-neovascularized area % after therapy) ⁄neovascularized area % before therapy] · 100. The patients were separated into two groups: group 1 (good responders) involved the first eight patients showing the highest reduction in the percentage of the vascularized area with therapy and group 2 (poor responders) involved the other eight patients on the bottom of the list, when ranked according to the regression of neovascularization. The study group consisted of 16 patients (11 men, 5 women) with corneal NV because of different aetiologies. During treatment, varying degrees of regression in the vascularized corneal area were identified in all patients and no further vessel outgrowth was observed. The mean NRP was 29.6 ± 23% overall (range, 1.8– 77.4%), 49.8 ± 15.5% (range, 35.9– 77.4%) in group 1 (good responders) and 9.4 ± 5.7% (range, 1.8 ± 17.3%) in group 2 (poor responders). The mean visual acuity (logMAR) before treatment was 0.50 ± 0.39 (range, 0.0–1.3), which significantly increased to a mean of 0.34 ± 0.19 (range, 0.0–0.7) at the end of the follow-up (p = 0.018, Wilcoxon signed-ranks test) (Table 1). The mean duration of corneal NV before the initiation of topical bevacizumab therapy was 20.2 ± 23.4 weeks (range, 1–64). The patients in the good-responders group had the corneal NV for a significantly shorter duration before treatment (8.0 ± 11.6 weeks), compared to the poor-responders group (32.4 ± 26.4 weeks) (p = 0.028, Mann–Whitney U-test) (Table 1). The mean age of the patients in the goodresponders group (29.6 ± 10.9 years) was significantly lower than the poorresponders group (47.4 ± 14.4 years) (p = 0.01,5 Mann–Whitney U-test). The duration of therapy was longer in the good-responders group who had younger neovessels; however, this difference was not statistically significant (p = 0.195, Mann–Whitney Utest) (Table 1). Ocular surface side effects were neither reported by patients nor observed during the visits. Our study showed that early treatment of actively growing vessels and lower patient age at the time of therapy showed a significantly better outcome, suggesting that the short duration of corneal NV and younger age are good prognostic indicators. Previous investigations showed increased expression of VEGF and its receptors in actively growing vessels (Bock et al. 2008). It is also known that anti-VEGF agents have an inhibitory effect on mural cell recruitment and thus vascular maturation (Greenberg & Cheresh 2009), which also explains the more potent effect of topical bevacizumab on more immature vessels, as observed in our study.

Photic retinopathy after cataract surgery in diabetic patients.

Purpose: To report and emphasize photic retinopathy (PR) after cataract surgery in diabetic patients. Methods: The charts of 2,573 patients who underwent cataract surgery at Baskent University Hospital (Ankara, Turkey) between January 2001 and December 2003 were retrospectively analyzed for PR and diabetes mellitus (DM). All surgeries were performed using the same coaxial illuminated microscope. The diagnosis of PR was confirmed by fluorescein angiography, showing typical mottled fluorescein transmission in a well circumscribed area in each case. Statistical analyses were performed with &khgr;2 and Mann–Whitney U tests. Results: Diagnoses of PR and DM were established in 16 cases (0.62%) and 382 cases (14.85%), respectively. DM was present in 7 (43.75%) of the PR cases. PR occurred more frequently in DM patients than in non-DM patients (7/382 vs. 9/2,191, respectively; P = 0.001; &khgr;2 = 10.64). All 16 patients with PR had received retrobulbar anesthesia (RA). RA was used in 61.21% of all surgeries and in 78.01% of the surgeries for DM patients. Occurrence of PR during RA was higher for DM patients than for non-DM patients (7/298 vs. 9/1,277, respectively; P = 0.011; &khgr;2 = 6.50). Mean operation times ± SD for PR cases were 29.9 ± 9.9 minutes and 38.2 ± 5.3 minutes in DM and non-DM cases, respectively (P = 0.091). None of the photic lesions were sight threatening. Conclusions: Diabetic patients may be more vulnerable to photic injury. Surgeons should take precautions to prevent PR when performing cataract surgery on diabetic patients.

Relationship between optokinetic nystagmus response and recognition visual acuity

PurposeThe aim of this study was to investigate the relation between recognition visual acuity (RVA) and optokinetic nystagmus (OKN) response exhibited to different bar sizes with varying contrast.MethodsOKN testing was performed in 52 children aged between 3 and 11 years. The children were evaluated in two groups according to their RVA. Group I consisted of 22 eyes with RVA equal to or better than 0.1 logMAR units. Group II consisted of 30 eyes with RVA 0.2–1 logMAR units. Each subject was seated 60 cm from the screen of Ophthimus® device, and was exposed to consecutive black and white stripes of seven different spatial frequencies (0.08–1.6 cycle/degree). The narrowest bar that elicited OKN was identified, and then the OKN contrast threshold at this bar size was established.ResultsTwenty-one of the 22 eyes in Group I, and 26 of the 30 eyes in Group II exhibited 1.6 cycle/degree spatial frequency (P=0.287). In Group II, 88.9% of the 18 eyes with RVA 0.2–0.5 logMAR responded at this maximum spatial frequency, whereas the corresponding figure for the 12 eyes with RVA 0.6–1 logMAR was 83.3% (P=0.531). Contrast sensitivity (CS) significantly changed with age in Group I (P=0.006). When the eyes that responded at maximum spatial frequency in the two groups were compared, the mean CS in Group II was significantly lower than that in Group I (P=0.005).ConclusionsThe results indicate no relation between spatial frequency threshold for OKN response and RVA in children. However, the children with RVA deficits had significantly lower CS.

Ciliary Body Toxicity of Subconjunctival Suramin Compared with Mitomycin-C in the Rabbit Eye: Determining the Toxic Concentration

Background/Aims: To evaluate the safety of suramin compared with mitomycin-C (MMC) as an adjunctive agent in trabeculectomy by determining its ciliary body toxicity at predetermined effective dosages in rabbit eyes. Methods: Thirty-two New Zealand albino rabbits received either suramin (200, 300, 400, or 800 mg/ml) or MMC (0.2, 0.3, 0.4, or 0.8 mg/ml) injections subconjunctivally in the right eye. Enucleations were performed on the 1st, 3rd, 7th and 28th day. Untreated left eyes were injected with balanced salt solution and served as controls. The injection-exposed ciliary body specimens were processed to be investigated under the light microscope and transmission electron microscope. Results: There was no pathologic abnormality in specimens under light microscopy. The morphologic evaluation with transmission electron microscopy showed severe changes in structure, except for eyes treated with 200 mg/ml suramin and 0.2 mg/ml of MMC. These changes were more prominent in eyes exposed to MMC, and appeared earlier compared to suramin-treated eyes. Conclusions: Suramin 200 mg/ml and MMC 0.2 mg/ml seem to be comparatively nontoxic to the ciliary body of the rabbit eye. Concentrations higher than these values caused severe damage.

Decision-making in second-eye cataract surgery: can presence of Pulfrich phenomenon help?

PurposeTo determine whether testing for the Pulfrich phenomenon (PP) can be used as a tool to assess the need for and optimal timing of second-eye cataract surgery.MethodsA total of 61 patients with logMAR 0 visual acuity (VA) after cataract surgery in one eye and logMAR 0.2–0.7 VA in the other eye were tested for PP using a computer-generated oscillating target at Baskent University Hospital. Only patients who had no ophthalmologic or systemic problem that could cause PP were included. In all, 15 normal patients with logMAR 0 VA in both eyes served as controls. The main outcome measures were presence and magnitude (measured by neutral density filters) of PP and presence of complaints related to binocular vision.ResultsOf the 61 patients, 36 (59%) and none of the controls were PP (+) (P<0.001). A total of 27 (75%) of the PP (+) patients had logMAR 0.7–0.4 VA, and nine (25%) had logMAR 0.3–0.2 VA (P=0.01). In all, 16 patients (all PP (+)) had developed binocular vision-related complaints since cataract surgery. The mean PP magnitude in these cases was significantly greater than the mean for the 20 patients without complaints (1.2±0.5 vs0.6±0.4 log units, respectively; P<0.001). There was no significant difference between the mean VA in the complaint (+) and complaint (−) subgroups (P=0.213).ConclusionPP testing may detect binocular visual dysfunction after first-eye cataract surgery; thus, it could help assess the need for second-eye cataract surgery on this basis.

Results of cataract surgery in renal transplantation patients

AbstractPurpose To evaluate the results of conventional extracapsular cataract extraction and phacoemulsification cataract surgery, in renal transplant patients.Methods A total of 11 eyes of eight renal transplant recipients who underwent cataract surgery in Ankara between 1995 and January 2001 were evaluated. Each individual underwent routine ophthalmologic examination including visual acuity with Snellen chart testing, slit-lamp examination, intraocular pressure measurement, and fundus examination. Of these, seven patients had posterior subcapsular cataracts and four had nuclear cataracts. Conventional extracapsular cataract extraction (cECCE) was performed in four eyes with single-piece all-polymethylmethacrylate posterior chamber intraocular lens implantation. The other seven eyes were treated with small-incision phacoemulsification and implantation of a foldable hydrophilic acrylic lens.Results We observed intraoperative posterior capsule rupture and vitreous loss in one patient, postoperative intraocular tension elevation in one patient, and sterile suture infiltration in one patient in our series. Average of the visual acuities 6 months after the operation was 20/30 (range, 20/60–20/20).Conclusions In this, the first published report to describe outcomes of cataract surgery in renal transplant patients, most complications were associated with high of steroids use and immunosuppressives, and were independent of the type of cataract surgery used, either ECCE or phacoemulsification surgery. The study suggests the need for additional care before, during, and after operation.