Erkin Kir

Pituitary apoplexy: an overview of 186 cases published during the last century

BackgroundPituitary apoplexy is a rare and life-threatening complication occurring in 0.6–10.5% of all cases of pituitary adenomas. Although the association between pituitary apoplexy and visual dysfunction has been recognized for a long time, the optimal management of this problem still remains controversial. The purpose of this overview was to present the surgical experience by analyzing the literature on the management of pituitary apoplexy for better treatment of these cases.Materials and methodTo establish a new guideline for the surgical treatment of this entity, publications reported during the last century and databases containing medical literature were analyzed. In addition, an illustrative case with pituitary apoplexy presenting with complaints of sudden onset severe headache associated with nausea, vomiting, and a sudden loss of vision was described. In fact, the experience in our complicated patient prompted us to review the available literature on the management of pituitary apoplexy to date.ConclusionsBased on an overview of 186 cases of apoplectic pituitary adenoma presenting with monocular or binocular blindness, we highlight the importance of correct diagnosis and an early, but not necessarily emergency, surgery within the first week of admission to optimize visual outcome of such patients. The illustrative case further exemplifies the value of close interaction between members of the management team for optimal outcome.

Anesthesia with EMLA® Cream for Botulinum A Toxin Injection into Eyelids

We investigated the efficacy of an eutectic mixture of local anesthetics (EMLA®) in reducing the pain of a botulinum toxin injection into eyelids. 17 patients with facial dyskinesia (9 blepharospasm and 8 hemifacial spasm) who had been treated regularly with botulinum toxin injections received EMLA cream and placebo. The pain was assessed by the ophthalmologist and the patient. Injection with EMLA cream showed lower pain scores (mean 1.82 ± 2.13, median 1) than injection with placebo (8.76 ± 2.17; p = 0.0001). Percutaneous anesthesia induced by EMLA cream is an effective and safe method which improves the comfort in patients who need repeated botulinum toxin injections for their facial dyskinesia.

Treatment of two postoperative endophthalmitis cases due to Aspergillus flavus and Scopulariopsis spp. with local and systemic antifungal therapy

AbstractBackgroundEndophthalmitis is the inflammatory response to invasion of the eye with bacteria or fungi. The incidence of endophthalmitis after cataract surgery varies between 0.072–0.13 percent. Treatment of endophthalmitis with fungal etiology is difficult.Case PresentationCase 1: A 71-year old male diabetic patient developed postoperative endophthalmitis due to Aspergillus flavus. The patient was treated with topical amphotericin B ophthalmic solution, intravenous (IV) liposomal amphotericin-B and caspofungin following vitrectomy. Case 2: A 72-year old male cachectic patient developed postoperative endophthalmitis due to Scopulariopsis spp. The patient was treated with topical and IV voriconazole and caspofungin.ConclusionAspergillus spp. are responsible of postoperative fungal endophthalmitis. Endophthalmitis caused by Scopulariopsis spp. is a very rare condition. The two cases were successfully treated with local and systemic antifungal therapy.

Patient-controlled analgesia and sedation with fentanyl in phacoemulsification under topical anesthesia

Purpose: To investigate the effects of intravenous (IV) patient‐controlled sedation/analgesia with fentanyl during phacoemulsification surgery under topical anesthesia. Setting: Adnan Menderes University Medical School, Departments of Ophthalmology and Anesthesiology and Reanimation, Aydin, Turkey. Methods: In this double‐blind randomized study, 68 patients were randomly allocated to 2 groups. In the fentanyl group comprising 34 patients, fentanyl was administered by patient‐controlled analgesia (PCA) equipment in 5 &mgr;g bolus doses with a lockout period of 5 minutes after an IV loading dose of 0.7 &mgr;g/kg in 2 mL balanced salt solution. In the control group comprising 34 patients, a balanced salt solution was given without an analgesic drug by PCA equipment. Verbal pain scale (VPS) and sedation scores were recorded preoperatively and 5, 10, 15, 20, and 30 minutes after the start of surgery. Patient comfort and surgeon satisfaction were assessed postoperatively. Results: The sedation score was higher in the fentanyl group than in the control group at 5 and 10 minutes (P = .006 and P = .012, respectively). The VPS scores were higher in the control group than in the fentanyl group at 15 and 20 minutes (P = .02 and P = .016, respectively). Patients pressed the button for additional analgesia 2.6 times ± 3.9 (SD) in the control group and 0.9 ± 1.6 times in the fentanyl group (P = .025). Patient and surgeon satisfaction were higher in the fentanyl group than the control group (P = .023 and P = .018, respectively). Conclusion: The results of this study suggest that IV PCA with fentanyl has supplemental effects on analgesia and sedation during cataract surgery under topical anesthesia and increases patient comfort and surgeon satisfaction.

Recovery of orbital fat pad prolapsus and deepening of the lid sulcus from topical bimatoprost therapy: 2 case reports and review of the literature

Objectives: To report 2 cases of resolution of orbital fat pad prolapsus and deepening of the lid sulcus caused by topical bimatoprost therapy, and to review the literature. Methods: This was a retrospective, observational chart review. Results: A 54-year-old man with normotensive glaucoma presented with recovery of left lower lid orbital fat pad prolapsus, deepening of the lid sulcus, and iris color and eyelash changes 8 months after initiation of bimatoprost therapy in his left eye (OS). After stopping bimatoprost, his eyelashes and the lower lid orbital fat pad partially regained their natural appearance at 2 months and 4 months, respectively. However, there was no improvement of the left upper eyelid deepening and the iris hyperpigmentation, even after 30 months. A 75-year-old man with unilateral pseudoexfoliative glaucoma had been treated with bimatoprost OS. Three months after initiation of the therapy, his examination showed recovery of the inferior and superomedial orbital fat pad prolapsus, a deep and prominent upper lid sulcus with eyelash changes, and iris hyperpigmentation OS. Five months after discontinuation of bimatoprost, the eyelashes and superomedial orbital fat pad improved. Twenty-four months later, the inferior orbital fat pad partially got its natural appearance back, but the upper lid sulcus was slightly more deep and prominent than the fellow right eye. There was no alteration in iris hyperpigmentation. Conclusion: Clinicians and patients should be aware of these possible effects of topical bimatoprost therapy. These adverse effects may not be completely reversible after discontinuation of the medication.

Medical control of intraocular pressure after phacoemulsification

Purpose: To compare the effectiveness of oral acetazolamide, topical brinzolamide 1%, and no ocular hypotensive medication after phacoemulsification. Setting: Adnan Menderes University Department of Ophthalmology, Aydin, Turkey. Methods: This prospective randomized double‐blind study comprised 60 eyes of 52 patients having phacoemulsification under topical anesthesia. There were no intraoperative complications. Eyes were randomized to receive oral acetazolamide 500 mg 1 hour preoperatively followed by 250 mg acetazolamide every 6 hours, 1 drop of brinzolamide 1% every 12 hours starting immediately after speculum removal, or no ocular hypotensive medication. Intraocular pressure (IOP) was measured using a Perkins tonometer preoperatively and 4 to 6 hours and 18 to 24 hours postoperatively. Results: The preoperative IOP was not significantly different between the 3 groups. Four to 6 hours postoperatively, the acetazolamide group (P = .002) and brinzolamide group (P = .001) had significantly lower IOP than the control group. The same trend was observed at 18 to 24 hours in the brinzolamide group (P = .001) but not the acetazolamide group (P = .018). The IOP levels were not significantly different between the acetazolamide group and brinzolamide group at any postoperative time point. No eye receiving medication and 2 eyes (10%) in the control group had an IOP of 30 mm Hg or higher 4 to 6 hours postoperatively. Compared with preoperatively, an IOP increase of more than 5 mm Hg was seen at 4 to 6 hours in 3 eyes (15%), 2 eyes (10%), and 14 eyes (70%) in the acetazolamide, brinzolamide, and control group, respectively. Conclusion: Brinzolamide was as effective as acetazolamide in preventing IOP elevation 4 to 6 hours after phacoemulsification and more effective than acetazolamide at 18 to 24 hours.

Botulinum Toxin A in the Treatment of Adherence Syndrome

The effect of botulinum toxin A is investigated in the treatment of adherence syndrome related to strabismus surgery. An 18-year-old boy with decompensated right congenital fourth nerve palsy underwent ipsilateral superior rectus muscle recession and inferior oblique muscle disinsertion. During the early postoperative period, a right hypotropia with limitation of elevation developed and the result of the forced duction test was positive for passive elevation of the right eye. Botulinum toxin A was injected into the right inferior rectus muscle on the 15th postoperative day and orthophoria was achieved 1 week later. A repeat injection of botulinum toxin A was performed 6 months later. On follow-up 2 1/2 years later, his eyes remained orthophoric with limitation of elevation in the right eye and the patient was satisfied with the result. This case demonstrated that adherence syndrome can be treated successfully by botulinum toxin A injection if it is administered during the acute phase, before the development of fibrous scar tissue.

Prevention of suture exposure in transscleral intraocular lens fixation: an original technique.

BACKGROUND In this retrospective study, we evaluated our surgical outcomes of transscleral intraocular lens (IOL) fixation and introduced a simple, quick, and effective method to fixate and bury the sutures in the sclera to avoid suture exposure. METHODS Eyes were divided into 3 groups according to surgical technique. Half-thickness scleral flaps were prepared, and polypropylene suture ends were cut short in group 1 (12 eyes). Suture ends were left long without flaps in group 2 (47 eyes) and were buried into the scleral tunnel in group 3 (21 eyes). RESULTS The suture exposure rate was significantly lower in group 3 (0%) compared with group 2 (p = 0.006) and group 1 (p = 0.040). There was no significant difference in group 1 (25%) compared with group 2 (27.6%) (p = 1.000). INTERPRETATION Burying the suture ends into the scleral tunnel is a simple, safe, and effective technique for avoiding suture exposure in scleral-fixated IOL implantation.

The evaluation of chronic progressive external ophthalmoplegia with computerized tomography

Introduction: Chronic progressiveexternal ophthalmoplegia is characterisedby limitation of ocular motility in alldirections of gaze and ptosis.Innervational or myogenic factors wereclaimed to be responsible for thismotility disorder. The aim of thisstudy was toinvestigate the extraocular muscles inCPEO with computerized tomography in an attemptto distinguish extraocular musclemorphology caused by this disorderfrom that occurring in normal individuals.Methods: Eighteen orbits from 9patients diagnosed with CPEOwere included in the study. Axialand coronal scans were obtained for CTevaluation of extraocular muscles and thedimensions of extraocular muscles were measured.The control group consisted of40 orbits belonging to 20 individuals and,the results were compared with a studentst test.Results: The thickness (the verticaldimension of vertical recti and thehorizontal dimension of horizontal recti)of all rectus muscles wassignificantly decreased in comparison with the controlgroup, whereas the width (the horizontal dimensionof vertical recti and the verticaldimension of horizontal recti) was similar inboth the diseased and normal orbits.In all the rectus musclesof the diseased orbits,the normal fusiform shape was lost and the muscles appeared asthin bands.Discussion: The differentiation ofCPEO from other myogenic and neurogenicdisorders may present difficulty,and a cluster of criteria are required fora final diagnosis. CT has provento be a valuable tool in assessing extraocularmuscles [1, 2]. In this study, an extremeatrophy of all rectus muscles wasdemonstrated by means of CT. This diagnostic method mayconsequently contribute to a properdiagnosis of CPEO.

Medical control of intraocular pressure with brinzolamide 1% after phacoemulsification

BACKGROUND To compare the effectiveness of only 1 drop of topical brinzolamide 1% with dosing every 12 hours and with no ocular hypotensive medication following clear corneal phacoemulsification surgery. METHODS This prospective, randomized, double-blind study was composed of 60 eyes of 60 patients who underwent uneventful clear corneal phacoemulsification surgery under topical anesthesia. There were no intraoperative complications. Eyes were randomized to receive only 1 drop of topical brinzolamide 1% immediately after surgery, 1 drop of brinzolamide 1% every 12 (q12h) hours starting immediately after speculum removal, or no ocular hypotensive medication (control group). Intraocular pressure (IOP) was measured preoperatively and at 4 to 6 hours and 18 to 24 hours postoperatively by a Perkins tonometer. RESULTS Preoperative IOP was not significantly different among the 3 groups. IOPs of both the brinzolamide 1 drop group (p = 0.000) and the brinzolamide q12h group (p = 0.001) were significantly lower than those of the control group at 4 to 6 hours postoperatively. The same result was observed at 18 to 24 hours postoperatively in the brinzolamide q12h group (p = 0.001) but not the brinzolamide 1 drop group (p = 0.489). The brinzolamide q12h group had significantly lower IOP compared with the brinzolamide 1 drop group (p = 0.000) at 18 to 24 hours postoperatively. None of the eyes in the medication groups, but 1 eye (5%) in the control group, had postoperative IOP elevation > or =30 mm Hg at 4 to 6 hours; such an elevation was not encountered at postoperative 18 to 24 hours. Preoperative to postoperative IOP increase of >5 mm Hg at 4 to 6 hours postoperatively was seen in 4 (20%), 4 (20%), and 14 (70%) eyes in the brinzolamide 1 drop group, the brinzolamide q12h group, and the control group, respectively. INTERPRETATION The current study reveals that 1 drop of brinzolamide 1% is sufficient to control IOP within the first 4 to 6 hours following uneventful phacoemulsification, whereas 12-hour dosing is necessary for prolonged control of IOP.