Fazıl Cüneyt Erdurman

Imaging late capsular block syndrome: Ultrasound biomicroscopy versus Scheimpflug camera

UNLABELLED We describe 2 patients with late capsular block syndrome whose anterior chamber morphology was evaluated with ultrasound biomicroscopy and Scheimpflug imaging before and after neodymium:YAG laser capsulotomy. Pretreatment ultrasound biomicroscopy examination showed significant capsular bag distension in both patients. Scheimpflug imaging failed to capture the posterior capsule displaced far behind the intraocular lens. Automatic anterior chamber depth measurements were incorrect with Scheimpflug imaging in 1 patient. Ultrasound biomicroscopy seems to be superior to Scheimpflug imaging in eyes with extremely distended capsular bags. FINANCIAL DISCLOSURE No author has a financial or proprietary interest in any material or method mentioned.

Intravitreal triamcinolone acetonide compared with bevacizumab for the treatment of patients with macular edema secondary to central retinal vein occlusion.

Abstract Purpose: To compare 12-month outcomes achieved using intravitreal triamcinolone acetonide (IVTA) injections with those achieved using intravitreal bevacizumab (IVB) injections for the treatment of patients with macular edema (ME) secondary to central retinal vein occlusion (CRVO). Materials and Methods: Between 2007 and 2011, 17 patient eyes were administered IVTA(4 mg/0.1 mL) and 30 patient eyes were administered IVB (1.25 mg/0.05 mL) injections for the treatment of ME secondary to CRVO. Patients were retrospectively evaluated within and between treatment groups. Results: Patients in both groups (IVTA and IVB) were similar in terms of demographic characteristics. Improvements in log of the minimum angle of resolution-visual acuity (logMAR-VA) at 3-month follow-up (P = 0.02), and in the logarithmic transformation of optical coherence tomography (OCT)-determined central subfoveal thickness (logOCT) at all visits, were significantly greater in the IVTA-treated group than in the group treated with IVB (P < 0.05). In patient eyes with nonischemic CRVO (n = 21), while no significant difference in improvement in logMAR-VA was seen between the groups, significantly greater improvements in logOCT were observed in the IVTA-treated group for all visits (P < 0.05). Inpatient eyes with ischemic CRVO (n = 26) treated with IVTA (n = 9), improvement in logMAR-VA was significantly greater at months 1 and 3 (P = 0.01), and was significantly greater for logOCT at months 6 and 12 (P < 0.05). A significantly higher percentage (29.4%) of eyes treated with IVTA had an intraocular pressure ≥ 30 mmHg (P = 0.004), 2 eyes (11%) developed glaucoma, and 23.5% of eyes developed cataracts at the 12-month follow-up examination (P = 0.05). Conclusion: Treatment with IVTA injections seems to be more effective in improving best-corrected visual acuity during the early postinjection period in patients with ischemic CRVO, and in decreasing central subfoveal thickness in patients with nonischemic CRVO. However, higher intraocular pressure and development of glaucoma and cataracts must be considered seriously in patients with CRVO who receive IVTA injections. Change in logOCT may be used to monitor patient response to treatments for CRVO-related ME.

The comparison of intravitreal triamcinolone and bevacizumab in patients with macular edema secondary to branch retinal vein occlusion

Purpose This study was conducted to compare the efficacy and safety of intravitreal triamcinolone acetonide (IVTA) and intravitreal bevacizumab (IVB) in the treatment of macular edema related to branch retinal vein occlusion (BRVO), using the new optical coherence tomography parameters. Material and methods The medical records of 62 patients (IVTA n=26; IVB n=36) with macular edema secondary to BRVO and at least 12 months follow-up between 2007 and 2011 were evaluated by within-group and inter-group comparisons. Results Both groups were similar in terms of demographic characteristics (P>0.05). Best corrected visual acuity (BCVA) improvement and central subfoveal thickness (CST) reduction were significantly higher in the IVTA group at only the third month (P<0.05). In nonischemic BRVO, while BCVA improvement was significantly higher in the IVTA group at the third and sixth months (P<0.05), no significant difference was found in CST reduction at all visits (P>0.05). In ischemic BRVO, no significant difference was found in BCVA improvement at all visits, but CST reduction was significantly higher in the IVTA group at the first and third months. Logarithmic optical coherence tomography change (LogOCTc) and relative change in retinal thickness (RCRT) showed the same levels of significance in the comparisons. Relative change in retinal thickening (RCRTing) was more valuable compared to the other parameters in the subgroup analyses. Conclusion There was no difference between groups at the 12th month. IVTA was more efficient than IVB in regard to BCVA improvement in nonischemic BRVO in the early follow-up. IVTA made significant retinal thinning compared to IVB in ischemic BRVO in the early period. RCRTing and LogOCTc are important parameters used to monitor the response to treatment in BRVO. Because of the similar levels of significance, RCRT and LogOCTc can be used interchangeably.

Outcomes of Intravitreal Dexamethasone Implant in the Treatment of Recalcitrant Diabetic Macular Edema

Objectives: To investigate the efficacy and safety of intravitreal dexamethasone (OZURDEX®) implantation in patients with recalcitrant diabetic macular edema. Materials and Methods: This is a retrospective non-randomized study of patients who underwent intravitreal dexamethasone implantation for recalcitrant diabetic macular edema. Main outcome measures included changes in best corrected visual acuity (BCVA), central macular thickness (CMT), and incidence of ocular side effects. Results: Fifty-seven eyes of thirty-eight patients (20 females, 18 males; mean age 65±7 years) were included in the study. The mean hemoglobin A1c level was 7.9±1.7%. Before entering the study, patients had undergone 5.71±3.40 anti-vascular endothelial growth factor (anti-VEGF) and 3.44±2.46 intravitreal triamcinolone acetonide injections. The mean duration of diabetes and diabetic macular edema was 17.2±6.4 years and 60.2±17.6 months, respectively. At baseline, mean CMT was 506.76±166.74 µm, and the mean BCVA was 0.68±0.38 LogMAR. Mean CMT significantly decreased to 341.36±146.26 µm (p<0.001), 324.41±114.58 µm (p<0.001), and 384.82±151 µm (p<0.001) at 1, 3, and 4 months of follow-up and increased again to 462.29±152.87 µm at 5 months. Sixteen eyes (28%) received second injections after mean of 7.4±2.3 months and mean CMT was again significantly decreased at 7, 8, and 9 months. Significant improvement in mean BCVA (0.54±0.41 LogMAR; p<0.001) occurred only at 1 month after implantation. However, subgroup analysis revealed significant BCVA improvement in the pseudophakic group at 1, 3, and 4 months. Among phakic patients, 50% showed cataract progression and 28% had elevated intraocular pressure increase which was managed medically. Conclusion: Intravitreal dexamethasone implantation was effective for the first 4 months in eyes with recalcitrant diabetic macular edema. However, it is hard to displace anti-VEGF agents as first-line therapy due to steroid-related complications.

Soccer Ball Related Posterior Segment Closed-Globe Injuries in Outdoor Amateur Players

BACKGROUND The aim of this study is to report the characteristics, treatment, and anatomical and functional outcomes of outdoor amateur soccer players with soccer ball-related posterior segment ocular trauma. METHODS We conducted a retrospective chart review of 22 patients with diagnoses of closed-globe ocular trauma caused by soccer play activity from 2004 through 2008. Injuries were classified according to Ocular Trauma Classification. RESULTS All patients (n=22) were male, and all injuries were caused by contact with the soccer ball itself. Sixteen (72%) patients did not require any treatment. Surgery was performed on 5 (22%) patients. Twenty (91%) patients had 5/200 or better visual acuity (VA) at presentation and 2 (9%) had hand movements or worse VA. At the final visit, all patients had 5/200 or better VA (p<0.01). CONCLUSION A soccer ball can cause significant posterior segment trauma, and using eye protection equipment might be an appropriate solution.

Ocular injuries caused by metal caps of carbonated mineral water bottles

BACKGROUND Bottles containing carbonated drinks are potentially hazardous to the eye. In this study, we aimed to document the clinical characteristics and visual outcomes in a series of patients with ocular injury from flying metal caps of carbonated mineral water bottles. METHODS Retrospective review of ocular injuries due to metal caps of carbonated mineral water bottles. RESULTS Sixteen eyes of sixteen patients were included in the study. All of the patients were male, with a mean age of 24 years. Ten of the patients had a history of using improper tools for bottle cap removal. The left eye was involved in twelve cases and the right eye in four cases. All patients had contusion-type closed-globe injury. Varying degrees of hyphema were observed in all patients, and vitreous hemorrhage was present in four. The visual acuity at the last follow-up was 20/20 in 15 of the patients. CONCLUSION The use of a bottle cap opener is essential for preventing ocular damage from pressed metal caps of carbonated drinks. In addition to popularising the use of screw cap bottles, warning labels that alert consumers about the possibility of eye injury should be placed on carbonated drinks with pressed metal caps.

Surgical Outcomes of Idiopathic Epiretinal Membrane: the Gülhane Experience

Objectives: We aimed to report our experiences and outcomes of vitreoretinal surgery in idiopathic epiretinal membrane. Materials and Methods: We retrospectively reviewed patients who underwent vitreoretinal surgery for idiopathic epiretinal membrane between January 2012 and 2014. The patients’ pre- and postoperative visual acuity, slit-lamp examination findings, and optical coherence tomography (OCT) images were evaluated. Results: Forty-five eyes of 45 patients (36% male, 64% female) were included (mean age, 69±8.2 years). Mean postoperative follow-up time was 7±4 (1-12) months. The mean preoperative logMAR best corrected visual acuity was 0.58±0.32 and postoperatively 0.40±0.31, 0.33±0.33, 0.28±0.34 respectively at 3, 6, and 12 months. All OCT parameters showed statistically significant anatomical improvement at 1, 3, 6, and 12 months. Correlation analysis showed that central macular thickness (r=0.69, p<0.05) and central macular volume (r=0.69, p<0.05) were the only parameters that had strong positive correlations with visual improvement. Conclusion: Epiretinal membrane causes heterogeneous anatomical changes in the macula for every patient. Therefore, a correlation between visual gain and changes in central macular thickness could not yet be demonstrated. We believe that central macular volume may be a better parameter for following these patients.

Association of retinal vein occlusion, homocysteine, and the thrombophilic mutations in a Turkish population: A case-control study

ABSTRACT Purpose: To compare homocysteine and thrombophilic mutations for the methylenetetrahydrofolate reductase (MTHFR) C677T, factor V Leiden, and prothrombin G20210A between retinal vein occlusion (RVO) and healthy controls in a Turkish population. Materials and methods: Forty-nine subjects with RVO were compared for homocysteine status and the MTHFR C677T, prothrombin G20210A, and factor V Leiden mutations with those of 68 healthy controls. Then, the groups were subdivided into two subgroups according to age (less than 50 years old, equal to or more than 50 years old) and were further compared. Results: Mean plasma level of homocysteine was similar, but the frequency of hyperhomocysteinemia was significantly higher in the RVO group when compared with the control group (22.5% and 8.8%, respectively, p = 0.037). The frequency of all thrombophilic mutations was similar between the groups (p > 0.05). The frequency of all thrombophilic mutations and homocysteine levels was also similar between age subgroups (p > 0.05). Only hyperhomocysteinemia was significantly different between subgroups (p = 0.037); the frequency of hyperhomocysteinemia was significantly different in RVO patients less than 50 years old (22.7%) from that in healthy controls less than 50 years old (11.1%). Two RVO patients (4.1%) with bilateral involvement had MTHFR C677T mutation. Conclusions: Screening for thrombophilic mutations such as MTHFR C677T, factor V Leiden, and prothrombin G20210A in RVO patients at all ages seems to be unnecessary and not cost-effective. However, thrombophilic disorders should be screened selectively, focusing on young individuals, especially with bilateral involvement, without additional cardiovascular risk factors, or a family history of thrombosis.

Letter to the Editor: Appropriate Evaluation of the Effect of Ranibizumab Injections on Retinal Nerve Fiber Layer Thickness.

We read with great interest the recently published article ‘‘The effect of multiple injections of ranibizumab on retinal nerve fiber layer thickness in patients with age-related macular degeneration’’ by Demirel et al. In this study, researchers aimed to test whether patients with age-related macular degeneration (AMD) who underwent multiple ranibizumab therapies had peripapillary retinal nerve fiber layer thickness (RNFL) thinning in a series with longer follow-up and a high number of injections. It was reported that there were no statistically significant differences between the mean total and nasal RNFL thicknesses of the eyes with injections and the fellow eyes with no injections, or between those with injections and the healthy control group. In conclusion, the authors stated that long-term treatment with anti-vascular endothelial growth factor (VEGF) agents did not lead to significant changes in RNFL thickness in a patient population with wet AMD. While this is a straightforward and well-designed study, there are some points that we would like to address. As is known, some confounding factors, such as cataract and refractive errors may affect the measurements of RNFL. In a previous study, the authors stated that lens opacities may affect the image quality of optical coherence tomography scans and cataract extraction results in an apparent increase of the RNFL thickness. Moreover, a study by Lee et al. reported that RNFL thickness was underestimated in eyes with increasing negative refraction power and overestimated with increasing positive refraction power. In the study by Demirel et al., there is no information about the lens and the refractive status of the subjects included in the study. So, these confounding factors should be considered while performing RNFL measurements to avoid the patient selection bias. Based on this information, it cannot be accepted that anti-VEGF therapy showed no effect on RNFL thickness of the patients with AMD in the possible presence of these confounding factors, although there was no statistically significant difference between the three groups of eyes in terms of RNFL thickness in the original study.

Proper Evaluation of Factors Affecting Oxidative Status

We read with great interest the recently published article by Kilic et al., in which authors aimed to analyze the serum prolidase activity, total antioxidant capacity (TAC), and total oxidant status (TOS) in patients with keratoconus. In conclusion, it was found that serum prolidase enzyme activity was lower in the keratoconus group than in the control group while there was no statistically significant difference between the two groups in terms of TAC and TOS. In addition, there was a positive correlation between TAC and TOS in keratoconus group but not in the control group. Although this is a straightforward and well-designed study, there are some points that we would like to address. As indicated in the original study, oxidative stress plays an important role in the development and progression of keratoconus, presumably as a result of a decrease in antioxidants levels (superoxide dismutase (SOD), paraoxonase 1, aldehyde dehydrogenase) and increase in catalase levels. Also, as is known, oxidative stress is associated with local and systemic inflammation. However, here was no statistically significant difference between two groups in terms of TAC and TOS, in the original study. We think that this may be due to poor exclusion criteria preferred in the study. Although it was stated that some ophthalmic diseases and systemic diseases that affect the serum prolidase activity were excluded, there is no information about use of medications/nutrients (e.g., vitamin C, E, selenium. . .etc) and clinical conditions (e.g., Gilbert’s syndrome, hyperuricemia, etc.) known to affect oxidative/inflammation status of these patients. Gilbert’s syndrome, characterized by unconjugated hyperbilirubinemia, is a relatively common condition in the general population (3–17%) depending on the ethnicity studied. Recent studies have revealed potent antioxidant and immunomodulatory activities of unconjugated bilirubin in many clinical conditions. In addition, uric acid is a powerful chemical antioxidant, which is present in human plasma/serum and it is widely accepted that high blood levels of uric acid in humans carry an evolutionary advantage and that uric acid is a major antioxidant that protects cells from oxidative injury. However, neither the use of medications nor the presence of these clinical conditions, which may affect the oxidative status of the current patient group, was not excluded and/or indicated in the original study. These confounding factors may affect TAC and TOS results and leads to patient selection bias. Therefore, the presence of the above-mentioned issues should be detailed about the subjects included in the original study. In addition, as is known, oxidative stress index (OSI), the ratio of the total plasma TOS level to TAC, is another indicator of oxidative stress, reflecting the redox balance between oxidation and antioxidation. Evaluation of OSI, in addition to TAC and TOS, would provide additional information about the oxidative status of these patients. In conclusion, we think that exclusion criteria needed to be established more comprehensive in the original study.