Dilek Dursun

Ocular surface changes in keratoconjunctivitis sicca with silicone punctum plug occlusion

Purpose. To evaluate histopathologic and clinical response to silicone plug insertion in dry eye patients. Methods. Punctal plugs were placed in 32 eyes of 18 dry eye patients with aqueous deficiency who were on maximum medical therapy and who had Schirmer testing with topical anesthetic measuring less than 5 mm. Pre-treatment and posttreatment (6 weeks and 1 year) evaluations included temporal and inferior quadrant impression cytology examinations, Schirmer-1, BUT, corneal fluorescein and rose-bengal staining patterns and questionnaire scores. The cytology samples were graded according to the method described by Nelson. Results. There was an improvement in subjective symptoms of patients 6 weeks after punctal occlusion. Corneal fluorescein and rose-bengal staining scores decreased from a mean of 5.33 ± 1.74 to 1.37 ± 1.48 and from 5.90 ± 1.2 to 2.45 ± 1.89 (p < 0.05) respectively. BUT values increased from 2.98 ± 1.1 to 11.3 ± 3.1 seconds (p < 0.05) at 6 weeks posttreatment. Increase in goblet cell density was observed after punctal occlusion at 6 weeks (p < 0.05) and at 1 year (p < 0.05) compared to the pre-treatment values. After occlusion, 3% of temporal specimens had Grade 0 squamous metaplasia, 63% had Grade 1, 34% had Grade 2; while 25% of inferior specimens had Grade 0, 56% had Grade 1, 19% had Grade 2 squamous metaplasia. Conclusions. Punctum plug occlusion in keratoconjunctivitis sicca provides improvement of tear film stability, ocular surface staining scores, conjunctival squamous metaplasia grades and goblet cell density. Increased ocular surface exposure to essential tear components with punctal occlusion may be important for the genesis of these changes.

Impression cytology of the conjunctival epithelium in patients with chronic renal failure

AIMS To assess ocular surface changes in patients with chronic renal failure (CRF), to compare the results with the degree of corneo-conjunctival calcium deposits, and to determine whether precipitation of calcium salts predisposes ocular surface modifications. METHODS Impression cytology from 50 CRF patients on regular haemodialysis and 22 age and sex matched control subjects were studied. Specimens were obtained from the temporal bulbar conjunctiva using cellulose acetate filter paper. The samples were fixed in 95% ethanol, stained with the periodic acid Schiff (PAS) stain, and evaluated by light microscopy and were graded by a masked observer. Corneo-conjunctival calcification was graded by the Porter and Crombie classification. RESULTS In the study group, three patients (6%) disclosed grade 0, 14 patients (28%) grade 1, and 33 patients (66%) grade 2–3 cytological changes. There was a statistically significant difference between the patient and the control groups (p= 0.0007), but no correlation could be found between the impression cytology grades and the calcium deposit grades (p=0.62). CONCLUSION The ocular surfaces of CRF patients differ significantly from those of normal individuals, and it can be detected using impression cytology. These data suggest that the severity of conjunctival changes are not related to the presence or extent of calcium deposition.

Effect of wind instrument playing on intraocular pressure.

Purpose: To evaluate the effect of wind instrument playing on intraocular pressure. Methods: In a prospective, nonrandomized clinical trial, 24 eyes of 24 wind instrument players with no history of any ocular or systemic disease were evaluated. The musicians were members of Bilkent Academic Symphony Orchestra of Bilkent University in Ankara. A complete eye examination, including best‐corrected visual acuity, slit‐lamp examination, and fundus examination, was performed. The intraocular pressure was measured before and after a 90‐minute rehearsal of a piece by Wagner. All intraocular pressure measurements were carried out by the same researcher using Goldmann applanation tonometry. The difference in intraocular pressure measurements before and after the 90‐minute wind instrument‐playing performance was analyzed. Results: The mean intraocular pressure was 13.79 ± 1.93 mm Hg before and 15.12 ± 2.44 mm Hg after the performance. Wind instrument playing significantly increased the mean intraocular pressure by 9.6% (P = 0.0149). Conclusion: These results indicate that wind instrument playing may significantly increase intraocular pressure in healthy patients. The significance of this finding for patients with suspected normal‐tension or high‐tension glaucoma needs further evaluation.

Tear clearance measurement in patients with dry eye syndrome using quantitative lacrimal scintigraphy.

ObjectiveThe aim of this study was to evaluate the tear clearance in patients with dry eye syndrome using quantitative lacrimal scintigraphy.aterials and MethodsWe investigated 21 patients (42 eyes; 18 women, 3 men; mean age, 63.19 ± 13.33 years) with dry eye syndrome. Additionally, for the sake of comparison, 12 normal subjects of the same age group (24 eyes; 10 women, 2 men; mean age, 68.25 ± 2.63 years) were included. Lacrimal scintigraphy, Schirmer-1 test, BUT, and rose bengal ocular surface vital staining were performed in these cases.Resultsccording to the results of lacrimal scintigraphy, the mean value of Tl/2 was 4.16 ± 1.22 minutes and the mean value of RI was 14.15% ± 2.30% in normal subjects. However, in patients with dry eye syndrome, these values were 20.59 ± 1.97 minutes and 55.64% ± 6.90%, respectively. Consistent with the results of Ophthalmologic tests, the mean Schirmer-1 value was 12.46 ± 2.10 mm, the mean value of BUT was 14.36 ± 3.40 seconds, and the mean staining value of the rose bengal was 1.98 ± 0.80 in normal subjects, whereas these values were 1.36 ± 0.49 mm, 5.46 ± 1.33 seconds, 6.62 ± 0.86, respectively, in patients with dry eye syndrome. When we compared the results of lacrimal scintigraphy and the results of Ophthalmologic tests, an inverse correlation was noted between both the Tl/2 and RI values and both the Schirmer-1 and BUT values in all subjects (p < 0.001). However, there was a greater positive correlation between the rose bengal ocular surface staining value and both the Tl/2 and RI values in all cases (p < 0.001).ConclusionIn the current study, it was concluded that although the lacrimal drainage system was normal, tear clearance was significantly delayed in dry eye patients. With this study, we have shown that quantitative lacrimal scintigraphy, which is an objective, practical, and noninvasive method, appears to be useful for the assessment of the tear clearance in patients with dry eye syndrome.

Myositis and scleritis associated with Behçet's disease: an atypical presentation

We report a case of an 18-year-old female, who was diagnosed as having systemic Behçets disease with chief complaints of vision loss in the right eye and redness and pain in both eyes. In addition to an anterior necrotizing scleritis, she had several attacks of retrobulbar neuritis and lateral rectus myositis. She responded well to i.v. and topical prednisolone and her subsequent attacks were treated with i.v. cyclophosphamide (500 mg on presentation and on Days 7, 10, 12, 15, and 20; the cycle was repeated every 20 days). She benefited on this treatment and her vision improved dramatically. Her final acuity of 20/50 was thought to be due to presumed previous attacks of optic neuritis and anterior segment inflammation. During the five-month follow-up period, she had no other attacks. Ischemia and inflammation are common in Behçets disease and sometimes thrombosis and vasculitic changes may cause a decrease in vision. In this case, the immunosuppressive therapy helped attenuate the inflammatory vasculitic episodes during the disease course.

Management of Hypotony Maculopathy and a Large Filtering Bleb After Trabeculectomy With Mitomycin C: Success With Argon Laser Therapy

We report a patient with postkeratoplasty glaucoma that developed a large, filtering bleb following trabeculectomy with intraoperative antimetabolite treatment. The hypotony and the bleb were managed using argon laser photocoagulation. A 26-year-old female patient underwent penetrating keratoplasty in the left eye for keratoconus. Postoperatively, her elevated intraocular pressure could not be controlled medically, and the patient underwent a trabeculectomy with intraoperative antimetabolite application. Two months later, hypotony maculopathy, optic disc edema, and choroidal folds developed, and her vision dropped. Steroid treatment and soft contact lenses did not help. Photocoagulation was applied twice to the surface of the bleb and the surrounding area. After the photocoagulation therapy, the patients vision improved, intraocular pressure increased, and the optic disc edema and macular folds had resolved. Argon laser photocoagulation applied to a large filtering bleb associated with hypotony maculopathy is a useful treatment for bleb remodeling and elevating intraocular pressure.

Anterior segment indocyanine green angiography in pterygium surgery with conjunctival autograft transplantation

PURPOSE To assess indocyanine green angiography (ICGA) as a method for monitoring autograft perfusion after pterygium excision with limbal-conjunctival autograft transplantation (LCAT) and to compare ICGA with anterior segment fluorescein angiography (ASFA). DESIGN Nonrandomized prospective interventional case series. METHODS Twelve eyes of 11 patients with primary pterygium treated by excision and limbal-conjunctival autograft transplantation were studied in a clinical practice. Anterior segment fluorescein angiography and ICGA findings for autograft vascularization after pterygium surgery were compared in 12 eyes of the 11 patients. Graft perfusion was monitored for 1 month with ASFA and ICGA, on days 1,7, and 30 post-surgery. RESULTS With ASFA no graft perfusion was observed by postoperative day 30; only five grafts were isofluorescent with some vascularization, while the remaining seven grafts were hypofluorescent without any vascularization. In contrast, ICGA showed that, on postoperative day 1, all 12 grafts were hypofluorescent with multiple hyperfluorescent foci at the graft margin in the late phase and that, by postoperative day 7, 10 grafts were hypofluorescent and appeared to be perfused, originating from the episcleral vascular bed. On day 30, ICGA demonstrated isofluorescent grafts in 10 eyes with some conjunctival and episcleral vascular patterns on the graft itself, including the conjunctiva adjacent to the graft. By this stage, perfusion of the graft was complete. CONCLUSION Indocyanine green angiography is useful for monitoring graft perfusion after LCAT in pterygium surgery. Further studies are needed to identify the implications of graft perfusion for therapy following LCAT in patients with pterygium.

Is tear calcium an indicator of ocular calcification in patients with chronic renal failure

Background. In patients with chronic renal failure (CRF) on regular dialysis treatment, limboconjunctival degeneration and calcifications are common. The mechanisms of ectopic conjunctival and corneal calcification remain largely speculative. The aim of the present work was to study tear calcium levels in patients with chronic renal failure, which could alter calcium excretion patterns, and to examine whether the calcium level in tear fluid is of more diagnostic importance than static calcium levels in blood. Methods. Tear calcium levels were measured in 25 patients with chronic renal failure, compared with 14 normal subjects. Conjunctival and corneal calcium deposits were graded by the Porter and Crombie classification. Results. While 11 of the 25 patients had no clinically apparent calcium deposits, six had Grade 1 or 2, and eight had Grade 3 and over limboconjunctival calcification. Mean tear calcium levels were 1.436±0.165 mg/dl in the patients and 1.307±0.155 mg/dl in the normal group. The difference was not significant (P=0.572). No correlation was found between the grade of the calcium deposits and tear calcium levels. Conclusions. Tear calcium level has no diagnostic importance for the development of ocular calcification in chronic renal failure.

Scleritis associated with sarcoidosis

Purpose: To review scleritis cases associated with sarcoidosis and to evaluate clinical features, medical treatment, and clinical course. Methods: Two cases of diffuse anterior scleritis and a nodular scleritis case associated with systemic sarcoidosis were evaluated. Scleritis was the first manifestation of sarcoidosis in two of the patients and the diagnosis of sarcoidosis was confirmed with a conjunctival biopsy. The third patient had the diagnosis of systemic sarcoidosis when she developed scleritis. Results: Based on the clinical and histological appearance, two patients presented with bilateral diffuse anterior scleritis and the third patient with an anterior nodular scleritis. One patient already had the diagnosis of systemic sarcoidosis at presentation, while ocular findings led to the diagnosis in the other two cases. Conjunctiva or skin biopsies revealed features compatible with the diagnosis of sarcoidosis. Scleritis attacks recurred in two patients. All patients responded well to systemic corticosteroid (prednisone) therapy. Conclusions: Scleritis associated with sarcoidosis has rarely been described and it may be the presenting sign of systemic sarcoidosis.

Slime production by coagulase-negative staphylococci isolated in chronic blepharitis.

Background The purpose of the study was to determine the impact of slime-producing strains of coagulase-negative staphylococci (CNS) on non-ulcerative blepharitis. Formerly considered harmless organisms, CNS are now recognised as opportunistic pathogens. Although these microorganisms are a component of normal conjunctival flora, they often produce the typical signs and symptoms of chronic staphylococcal blepharoconjunctivitis. Certain strains produce a polysaccharide extracellular material called “slime”. Slime production is considered to be associated with the virulence of the organism. Methods Swabs were taken from the lids of 38 eyes of 19 patients with chronic non-ulcerative blepharitis and cultured for CNS. A group of 42 normal control eyes were similarly sampled. The strains of CNS isolated from 26 eyes (68.4%) of the patients with blepharitis and 25 eyes (59.5%) of the normal subjects were studied for slime layer production. Results No significant difference was found between normal subjects and patients in the incidence of slime producing CNS strains from the conjunctiva. The antibiotic sensitivity profiles of the slime-producing strains were no different from the slime-negative isolates in the blepharitis (p=0.85) and normal group (p=0.25). Conclusions Our data suggest that slime production by CNS does not play a significant role in the pathogenesis of staphylococcal blepharitis.