Hande Taylan Sekeroglu

Ocular surface alterations in blepharospasm patients treated with botulinum toxin A injection.

Purpose To evaluate ocular surface changes secondary to periocular botulinum toxin A injection in patients with essential blepharospasm. Methods Thirteen eyes of 13 patients with essential blepharospasm who underwent periocular botulinum toxin A injection were included in this prospective study. Patients were evaluated prior to and at 2-week and 1-, 3-, and 6-month time points following injections. Ocular surface tests were carried out in the order of tear break-up time (TBUT), lissamine green (LG) staining, Schirmer I test with anesthesia, and ocular surface disease index (OSDI) questionnaire for all patients. The Friedman test with Conover post hoc method was used for statistical comparisons of values at different time points. Results The TBUT was found to be increased at 1 month after the injection (8.5 ± 2.1; p = 0.018) and decreased below baseline levels (6.4 ± 2.1) at the 6-month visit (5.7 ± 2.0; p = 0.018). None of the Schirmer test values at follow-up visits were significantly different as compared to baseline levels (11.3 ± 5.5), although the 2-week measurement (14.3 ± 5.6) was significantly higher as compared to that at the 6-month follow-up visit (9.6 ± 4.9; p = 0.034). There was also a significant decrease in LG staining scores at 2-week (0.6 ± 0.4; p = 0.012) and 1-month (0.6 ± 0.4; p = 0.012) time points compared to the baseline levels (1.1 ± 0.6). The OSDI scores improved at 2-week (5.4 ± 6.8; p<0.001), 1-month (3.2 ± 5.1; p<0.001), 3-month (2.5 ± 4.4; p<0.001), and 6-month (5.5 ± 5.4; p<0.001) time points as compared to baseline levels (11.6 ± 8.5). Conclusions Botulinum toxin A injection appears to have a positive but temporary effect on ocular surface parameters in patients with blepharospasm.

Topical anesthesia for laser treatment of retinopathy of prematurity

General anesthesia (GA) is the mostly preferred method for laser treatment of retinopathy of prematurity (ROP). In developing countries and in the absence of a specialized pediatric anesthetist, alternative anesthesia methods started to be used including sub-Tenon’s local anesthesia, intravenous (i.v.) sedation, oral sedation combined with topical anesthesia, i.v. ketamine combined with topical anesthesia, rectal chloral hydrate and paracetamol combined with topical anesthesia, and topical anesthesia alone. Herein, we present a baby girl born at 28 weeks of gestation with a birth weight of 650 g was diagnosed with a zone II stage 3 ROP plus disease on third screening examination at 10 weeks of age, and the decision was made to perform diode laser photocoagulation. Because of the chronic lung disease of the infant and anatomical difficulty for intubation (narrowed and edematous airway secondary to previous prolonged intubation), we decided to perform the procedure under topical anesthesia in order to preclude anesthetic exposure, avoid intubation of the infant with chronic lung disease and the potential for postanesthetic apnea. Procedure was performed in neonatal intensive care unit (NICU) in a temperature controlled environment in order to avoid hypothermia, and after institution of intravenous (i.v.) catheter and pulse oximeter for cardiorespiratory monitoring with a neonatologist. The child was fed and burped 45 min before treatment. Topical anesthetic proparacaine 0.5% eye drops instilled 15 min before and just before the procedure at time of lid speculum insertion, and in each 15 min during the procedure. An assistant hold the head to prevent unwanted movements while the surgeon stabilized the chin. 810 nm diode laser (Iridex Corporation, Iris, CA, USA) was applied to both eyes under topical anesthesia. Heart rate, oxygen saturation, blood pressure, and electrocardiography records were all stable during and after the procedure. Both eyes were examined the next morning to detect the signs of regression. No side effects were present. Although laser treatment may not necessarily be painful, the light stimulus from the indirect ophthalmoscope, insertion of a lid speculum, and manipulation of the globe may induce stress and may be associated with systemic instability of the neonate during screening examination (1). Many studies found a decreased ‘Premature Infant Pain Profile’ (PIPP) scores after instillation of topical anesthetic proparacaine 0.5% eye drops and supported its use during eye examinations of premature babies (2). In a survey of ophthalmologists who were performing laser treatment for ROP in the United Kingdom (3), 15 of them were using GA; eleven were using i.v. sedation combined with topical anesthesia; one was using oral sedation combined with topical anesthesia; one was using rectal chloral hydrate and paracetamol combined with topical anesthesia; one was using i.v. ketamine combined with topical anesthesia; and one was using sub-Tenon’s local anesthesia. Jalali et al. (4) reported that they had started to perform laser under topical anesthesia as a preferred modality especially due to logistics and risks of GA for preterm infants. Haigh et al. (5) reported severe cardiorespiratory complications and life-threatening events in prematures undergoing cryotherapy for ROP who were treated using topical anesthesia alone because of the more painful nature of the cryotherapy when compared to laser ablation. Cryotherapy requires the direct contact of a cryoprobe to the globe, which may be related to more extensive damage to surrounding tissues contrary to laser ablation. Intubation during GA provides safer conditions both for neonatologists and ophthalmologists. Retinal ablation is easier, quicker, and more accurate when the baby is still. Unwanted ocular movements increase the risk of visual damage due to accidental ablation. Because the risk of ROP development is increased in extremely small infants, topical anesthesia alone seems to be enough to maintain immobility during laser procedure. Treatment of ROP under topical anesthesia can be performed in NICU without mechanical ventilation contrary to treatment under GA. This prevents prolonged intubation and transportation of infant from NICU to the theater. Because the infant is not intubated, there is freedom for surgeon during application of laser burns. Another advantage seems to be the shorter fasting period before and after the procedure. Jalali et al. (4) reported that the child can be fed 30–60 min before surgery if topical anesthesia is used, while 4–5 h of fasting is needed if the treatment is under GA. In conclusion, the treatment for ROP should be initiated as soon as possible. In view of our limited experiences, the incidence of conversion to general anesthesia seemed to be low if appropriate patients are selected. Since topical anesthesia is a simple approach, laser photocoagulation under topical anesthesia seems to be a

Inferior Oblique Muscle Weakening: Is It Possible to Quantify Its Effects on Horizontal Deviations?

Objective. To evaluate and quantify the effect of inferior oblique muscle weakening on horizontal deviations. Methods. The medical files of patients who had undergone an inferior oblique weakening as a single procedure were all reviewed. The main measures were the type of inferior oblique overaction (IOOA), pre- and postoperative amount of IOOA, and horizontal deviations in primary position. Results. The study was conducted with 66 patients (30 males, 36 females). The median age was 11 years (1–49). Of the 66 patients, 30 (45.5%) had primary and 36 (54.5%) had secondary IOOA. The most common procedure was inferior oblique anteriorization in 32 patients (48.5%). The mean postoperative horizontal and vertical deviations and the amount of IOOA were decreased postoperatively (p = 0.001 for all). The median amount of correction of horizontal near and distance deviations was 4Δ (0–20). The preoperative amount of IOOA, the presence of fourth nerve palsy, and the type of the weakening procedure had no significant effect on the amount of correction of horizontal deviations. Conclusion. The inferior oblique weakening procedures have secondary effects and warrant reduction of horizontal deviations in varying degrees. This should be borne in mind in planning a simultaneous horizontal muscle surgery and setting the surgical amount.

Strabismus Surgery in Congenital Fibrosis of the Extraocular Muscles: A Paradigm

Abstract Background: Congenital fibrosis of extraocular muscles (CFEOM) is a rare group of disorders with variable phenotypes that result from aberrant innervation to the EOMs leading to synergistic vertical and/or horizontal deviations. We report our experience with the surgical management of patients with CFEOM. Materials and Methods: We reviewed the clinical findings, the surgical management, and outcomes of 52 consecutive CFEOM patients operated by one surgeon at a university hospital setting between 1993 and 2014. Patients were divided into CFEOM1, 2, or 3 based on clinical and/or molecular genetic findings. Results: Thirty-seven (71.2%) cases were bilateral and 15 (28.8%) were unilateral. Six of the bilateral cases had CFEOM2, and the rest of the patients had either CFEOM1 or CFEOM3. The median age at the first surgery was 10 (1–43) years. Twenty-five were females and 27 were males. Nineteen patients had previous strabismus and/or ptosis surgeries elsewhere. The mean number of operations at our center was 1.6 ± 0.7 (1–4). A temporary stay suture was used in eight patients and permanently in seven. Of the 40 patients with abnormal head position, 18 achieved excellent, 15 good, and seven poor outcomes and ocular alignment in primary position following the latest surgery was excellent in 19, good in 18, and poor in 14 of the patients, as defined in the “Methods” section of the paper. Conclusions: Although patients with CFEOM present significant strabismus surgical challenges because of EOM dysinnervation, fibrosis, and/or heterotopia, satisfactory alignment and improvement of the head posture can be attained in a significant proportion of patients using an individually tailored surgical approach.

The frequency and causes of abnormal head position based on an ophthalmology clinic’s findings: is it overlooked?

Purpose To determine the frequency of abnormal head position (AHP) and identify the underlying causes in patients who presented to an ophthalmology clinic due to any ophthalmologic complaint. Methods The medical records of patients who presented with any ophthalmologic symptoms during a 6-month period were prospectively evaluated. In all, 2,710 patients (1,492 female and 1,218 male) aged 6 months-91 years were included in the study. Each patient underwent complete ophthalmologic evaluation. Results Among the 2,710 patients, 30 (1.1%) (7 female and 23 male) with a mean age of 14.62 ± 17.45 years (range 6 months-60 years) had AHP. In total, 24 (80%) of the patients with AHP were aged ≤16 years. The initial complaint in the patients with AHP was ocular misalignment in 18 (60%) patients, AHP in 4 (13.3%), abnormal ocular movements in 4 (13.3%), double vision in 3 (10%), and droopy eyelid in 1 (3.3%). Comitant strabismus, nystagmus, and Duane syndrome were the most common causes of AHP. Other diagnoses included fourth nerve palsy, sixth nerve palsy, Brown syndrome, congenital muscular torticollis, ptosis, and blowout orbital fracture. Conclusions The leading underlying causes of AHP in patients who presented to an ophthalmology clinic were ocular and treatable. Of note, in only a minority of these patients AHP was the initial presenting complaint. Clinicians must be aware that observation of any head position that is not normal should prompt additional investigation, as the underlying pathology can cause treatable morbidity or in rare instances mortality, such as in cases of acute cranial nerve palsy.

Ocular surface changes following botulinum toxin injection for strabismus

Abstract Context: Botulinum toxin injection is widely used for many purposes, including neuromuscular diseases, movement disorders and strabismus. Objective: To evaluate and report the impact of botulinum toxin injection on ocular surface parameters in patients with strabismus. Participants: Twenty-six consecutive patients who underwent botulinum toxin A injection for ocular misalignment were recruited for this prospective study. Materials and methods: Testing of ocular surface parameters including tear break-up time (BUT), lissamine green (LG) staining and Schirmer test (under topical anesthesia) was performed, and Ocular Surface Disease Index (OSDI) questionnaire scores were recorded before and at certain time points after injection (one week, two weeks, one month, three months and six months after botulinum toxin A injection). Two-way analysis of variance (ANOVA) with repeated measures, Friedman’s test and Wilcoxon test were used for statistical analysis. Results: Twenty six patients (15 eso- and 11 exo-deviations) with a mean age of 32.46 ± 14.41 (17–65) years were recruited for the study. All injections were performed in one eye. The mean amount of deviation at near and distance reduced after injection. The change of BUT, LG staining and OSDI scores was found to be significant during follow-up in treated eyes (p = 0.001, p = 0.007 and p = 0.009, respectively) whereas the change was insignificant for the Schirmer test results (p = 0.266). Conclusions: The ocular surface parameters appear to be altered by botulinum toxin injection in strabismic patients. Even though these effects seemed to be temporary, the findings of the present study support the notion of botulinum toxin effects on ocular surface parameters.

Refraction paradox in diabetics: An extreme case of transient hyperopia (糖尿病患者的屈光颠倒：一个暂时远视的极端病例)

Various ocular conditions that lead to vision loss to different degrees, such as cataract, ischemic optic neuropathy, and retinopathy, are closely related to diabetes mellitus. In addition, diabetic patients may suffer from transient or permanent changes in refraction. Herein we describe an extreme case of transient hyperopia in a newly diagnosed diabetic patient following intense blood glucose control.

Retinopathy of Prematurity: A Nationwide Survey to Evaluate Current Practices and Preferences of Ophthalmologists:

Purpose To emphasize the demographic and occupational characteristics of ophthalmologists primarily involved in retinopathy of prematurity (ROP) care and to ascertain their practices and preferences. Methods A questionnaire was sent to all Turkish ophthalmologists known to be primarily involved in ROP. They were asked about personal and occupational characteristics, practices and preferences related to ROP care, and for their proposals related to ROP training. Results Seventy questionnaires were sent, of which 63 (90%) were returned. A total of 44 respondents reported performing laser and 13 vitreoretinal surgery. Preferred treatment was transpupillary laser photocoagulation (54.5%), mostly performed in the operating theater (84.1%) under general anesthesia (72.7%). Only 19 (30.2%) reported intravitreal injection of vascular endothelial growth factor inhibitors (anti-VEGF). Ophthalmologists from university hospitals, trained in retina during fellowship, and performing treatment for ROP more commonly performed anti-VEGF injection. Most of them studied ROP after residency and 76.2% think that ROP training during residency is inadequate for clinical practice. Conclusions This survey reveals considerable variation among Turkish ROP specialists regarding ROP care. The survey data are critical in order to develop quality improvement and help in planning more effective future programs for ROP care in terms of training.

Is macular pigment optical density really involved in fixation preference

Purpose: To evaluate macular pigment optical density in healthy children and to compare the values with those of strabismic children with respect to fixation preference. Methods: The study recruited 54 healthy and 41 strabismic children. Two groups were matched in terms of gestational age, birth weight, and body mass index. All participants underwent complete ophthalmological evaluation and macular pigment optical density measurement and filled a self-reported food frequency questionnaire. Strabismic children were categorized according to fixation preference. Results: The mean age was 9.87 ± 2.39 years in healthy children and 9.07 ± 2.07 years in children with strabismus (p = 0.091). Mean macular pigment optical density was 0.23 ± 0.25 in healthy eyes and 0.25 ± 0.27 in non-preferred eyes of strabismic children (p = 0.964). Macular pigment optical density was significantly higher in preferred eyes of strabismic children (0.43 ± 0.34) compared to non-preferred eyes (p = 0.004) and healthy eyes (p = 0.001). There was a difference of macular pigment optical density between both eyes in patients with grades 1, 2, and 3 fixation preference, whereas patients with grade 4 preference had similar macular pigment optical density in both eyes (p = 0.008). There was a statistically significant positive correlation between macular pigment optical density in preferred eyes and body mass index (r = 0.354, p = 0.023). Conclusion: Preferred eyes of children with strabismus seem to have higher macular pigment optical density readings. This difference may emerge from the higher tendency of recognizing the flicker stimulus while preferred eye is under testing. Similar macular pigment optical density in healthy and non-preferred eyes and the fact that both lower than preferred eyes remain unexplained. It should be kept in mind that macular pigment optical density results should be carefully interpreted and macular pigment optical density in cases with strabismus should be further investigated.

Ocular Inflammation And Depression: Ophthalmologists’ Perspective

Inflammation may act throughout all the systems in the body including the brain and contribute to many pathological processes. This mini-review starts with a brief overview of the literature in respect with the relation between ocular inflammation and depression. In addition, the discussion is mainly condensed on relevant studies about two ocular diseases: uveitis and dry eye. With this review, we aim to summarize the current evidence, potential mechanisms and to provide a clinical point of view to patients with ocular inflammatory diseases who may also be prone to concurrent depression and depressive symptoms.