Ilkay Kilic Muftuoglu

Ultrasound biomicroscopy in patients with unilateral pseudoexfoliation.

AIM To compare the anterior segment morphology evaluated using ultrasound biomicroscopy (UBM) in patients with clinical pseudoexfoliation syndrome (XFS) in one eye and no clinical XFS in the fellow eye. METHODS Thirty patients with unilateral XFS were included in the study. All patients underwent evaluation of their anterior segment using UBM with and without dilatation with 1% cyclopentolate. The anterior chamber depth (ACD), lens thickness (LT), anterior chamber angle (ACA), ciliary body thickness (CBT), scleral thickness (ST), trabeculae -ciliary processes distance (T-CPD), and iris-ciliary processes distance (I-CPD) were measured using UBM scans. All results between the eyes with clinical XFS and their fellow eyes without clinical XFS were then compared. RESULTS Before dilatation the eyes with XFS (4.350±0.531 mm) were found to have a significantly thicker lens (P=0.002) than the eyes without XFS (4.238±0.540 mm). In addition after dilatation, the eyes with XFS (4.310±0.500 mm) were found to have a significantly thicker lens than the eyes without XFS (4.160±0.480 mm) (P=0.019). The average ACD, for the group with XFS, comparing pre-dilatation (2.616±0.349 mm) and post-dilatation measurements (2.714±0.413) was found to be statistically increased (P=0.014). The average ACD, comparing pre-dilatation to post-dilatation measurements in patients without XFS (2.680±0.360), (2.720±0.500) was found to be statistically unchanged (P=0.450). DISCUSSION Crystalline lenses tended to be thicker in the eyes with clinical pseudoexfoliation than their fellow eyes without pseudoexfoliation.

VISUALIZATION OF MACULAR PUCKER BY MULTICOLOR SCANNING LASER IMAGING.

Purpose: To compare the visualization of the epiretinal membrane (ERM) using multicolor imaging (MCI) (Heidelberg Engineering, Carlsbad, CA) and conventional white light flood color fundus photography (FP) (Topcon). Methods: The paired images of patients with ERM who underwent same-day MCI and FP examinations were reviewed. Visibility of the ERM was graded using a scale (0: not visible, 1: barely visible, and 2: clearly visible) by masked readers, and surface folds were counted to quantify the membrane visibility for each method. Images from individual color channels in MCI (green, blue, and infrared) were also graded using the same method to further investigate MCI images. Results: Forty-eight eyes of 42 patients were included. The average ERM visibility score was 1.8 ± 0.37 for MCI and 1.01 ± 0.63 for FP (P < 0.001). The number of the surface folds detected per quadrant was signifi8cantly higher in MCI than that in FP (6.79 ± 3.32 vs. 2.85 ± 2.81, P < 0.001). The ERM was graded with similar scores on the two modalities in 43.8% of the eyes; in 56.2%, the ERM was better visualized on MCI than that on FP. Conventional FP failed to detect ERM in 11.4% of eyes when the mean central retinal thickness was <413 microns. Analysis of laser color reflectance revealed that green reflectance provided better detection of surface folds (5.54 ± 2.12) compared to blue reflectance (4.2 ± 2.34) and infrared reflectance (1.2 ± 0.9). Conclusion: Multicolor scanning laser imaging provides superior ERM detection and delineation of surface folds than conventional FP, primarily due to the green channel present in the combination-pseudocolor image in MCI.

INTEGRITY OF OUTER RETINAL LAYERS AFTER RESOLUTION OF CENTRAL INVOLVED DIABETIC MACULAR EDEMA.

Purpose: To evaluate the integrity of outer retina layers after resolution of central involved diabetic macular edema (DME) and to demonstrate the effect of various baseline factors for the final vision and final external limiting membrane (ELM) integrity. Methods: Fifty-nine eyes of 48 patients with resolved DME were included. Several optical coherence tomography parameters including central subfield thickness, maximum foveal thickness, foveal center point thickness, and the extent of the ellipsoidal (ISe) layer and ELM damage were assessed at the time of DME and after resolution of DME. Eyes having laser scars near the fovea were excluded. Final visual acuity was classified as good (Snellen≥20/40, logarithm of the minimum angle of resolution ⩽0.3) or impaired (Snellen <20/40, logarithm of the minimum angle of resolution >0.3) for the logistic regression analysis. Zero Inflated Poison Regression model was used to find the best predictors for post-treatment ELM damage. Results: External limiting membrane and inner segment ellipsoidal band layers were disrupted in 16 eyes (27.2%) and 21 eyes (35.5%) at the final visit, respectively. Baseline ELM damage (p=0.001), baseline impaired vision (p= 0.013), and the most recent glycosylated hemoglobin level (p=0.018) were the best set of parameters for having impaired final visual acuity. Baseline vision, severity of diabetic retinopathy, absence of intravitreal injection, central subfield thickness, and history of extrafoveal macular laser (not within 1 mm of fovea) (p<0.001, for all parameters) were independent predictors for the final ELM damage. Conclusion: Outer retinal layers may be damaged even after complete resolution of DME, where inner segment ellipsoidal band layer damage appeared to be more common than ELM damage. Poorly controlled diabetic patients with damaged ELM and worse vision at the time of DME were more likely to have ELM damage and subsequent impaired vision after complete resolution of DME.

Morphologic changes in the anterior segment using ultrasound biomicroscopy after cataract surgery and intraocular lens implantation

Purpose To evaluate morphologic changes in the anterior segment using ultrasound biomicroscopic imaging (UBM) after phacoemulsification and foldable intraocular lens implantation (IOL). Methods Thirty-six patients with a mean age of 68.68 ± 8.44 years (range 51-89) who had phacoemulsification and foldable IOL implantation were included in this prospective study. Several anterior segment parameters including aqueous depth (AQD), trabecular meshwork-iris angle (TIA), ciliary body thickness (CBT), sclera thickness (ST), trabecular meshwork-ciliary process distance (T-CPD), iris-ciliary processes distance (I-CPD), and iris thickness (IT) were measured using UBM preoperatively and at postoperative month 2. Results There was a significant increase in AQD (p<0.001) and TIA (p<0.001) at postoperative month 2. However, CBT, ST, T-CPD, I-CPD, and IT did not significantly change (p>0.05) during the study period. Conclusions Removal of the crystalline lens results in change in the anterior segment parameters. Our results confirmed that UBM is a helpful option for the analysis of anterior segment structures both qualitatively and quantitatively.

LONG-TERM REMISSION OF NEOVASCULAR AGE-RELATED MACULAR DEGENERATION WITH AS-NEEDED ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY.

Purpose: To determine the presenting characteristics of patients with neovascular age-related macular degeneration with long-term remission (LTR), which was defined as the absence of intraretinal/subretinal fluid, or hemorrhage, and absence of leakage on fluorescein angiography for longer than 6 months while on as-needed antivascular endothelial growth factor treatment. Methods: The presenting characteristics of patients with LTR were compared with a control group including 32 eyes of 28 age-, gender-, and ethnicity-matched patients who did not achieve LTR. Results: Seventy-four percent of patients in the LTR group had Type 1 choroidal neovascular membrane and 18.5% had retinal angiomatous proliferation. In the control group, 28 eyes had Type 1 choroidal neovascular membrane (87.5%), and none of the patients had retinal angiomatous proliferation; overall, there was a significant difference in lesion types between the 2 groups (P = 0.036). Eyes with LTR at presentation had significantly thinner subfoveal choroidal thickness (147 vs. 178 &mgr;m, P = 0.04). There was more intraretinal fluid and less subretinal fluid at the presentation in the remission group (59.3% intraretinal fluid and 11.1% subretinal fluid) compared with the control group (28.1% intraretinal fluid and 34.4% subretinal fluid, P = 0.03). Conclusion: The presence of retinal angiomatous proliferation, thinner choroidal thickness, more intraretinal fluid, and less subretinal fluid at presentation were associated with LTR in patients receiving as-needed treatment for age-related macular degeneration.

Restoration of photoreceptors in eyes with diabetic macular edema

Purpose To show the prognostic value of foveal microstructures using optical coherence tomography (OCT) for the restoration of inner segment/outer segment (IS/OS) junction layer following resolution of diabetic macular edema (DME). Methods Forty-one eyes of 39 patients with IS/OS damage at the time of DME that showed complete resolution of DME were included. Eyes were divided into 2 groups based on the IS/OS integrity at final visit, when edema was completely resolved: always damage group (damage at baseline and at final visit) and initial damage group (damage only at baseline). The OCT characteristics including the extent of the IS/OS damage, central subfield thickness (CST), maximum retinal thickness (MRT), presence or absence of subretinal fluid, duration of diabetic retinopathy, and duration of DME were studied. The integrity of IS/OS was evaluated at baseline and at last follow-up as percentage (0%-100%). Results Forty-four percent of eyes (18 eyes) achieved complete restoration of IS/OS after resolution of DME. There was no significant difference in CST or MRT during DME between the 2 groups. The always damage group had more IS/OS damage at baseline visit (23.6% ± 6.4% vs 10.7% ± 3.4%, p = 0.043) with a longer duration of DME (p = 0.025). Despite a borderline significance in visual acuity between the 2 groups at baseline (p = 0.05), the always damage group ended up with worse vision at last follow-up (p<0.001). Conclusions Patients with shorter duration of DME and less baseline IS/OS damage were more likely to have intact (restored) IS/OS after resolution of DME.

Laser Pointers Revisited.

Laser Pointers Revisited Retina specialists increased number of cases with handheld lasers–induced retinal damages, in particular, outside the United States, where these dangerous devices are sold as toys for children. The low price of these lasers has also led to their widespread use by the public, and there are increasing complaints by airline pilots about lasers directed at their planes as well. Although there has been only one report about an alleged laser-induced injury in a pilot during landing operation, there have been many case reports with vision disturbances or vision loss (up to counting finger level) in children or in the adult population when such lasers are directed into the eye. In the United States, the Food and Drug Administration has imposed strict guidelines for the sale of laser pointers, which consider an output power of less than 5 mW to be safe. Devices with higher power are considered handheld lasers. However, a quick survey of the laser pointers used in lectures at our own institution revealed output powers of over 5 mW in 3 of the 4 devices (range from 20 to 160 mW). Recent technological advances have made high-power green lasers available with a wavelength of 540 nm, very close to the peak of photopic sensitivity (555 nm) with power outputs in excess of 2,000 mW (http://www.wickedlasers.com), 400 times the maximum power of Class 3R lasers (5 mW maximum power between 400 and 700 nm) which are considered to be safe if handled carefully, that is without direct eye exposure. Some blue laser diodes (445 nm) have output powers of 6,000 mW (https://goo.gl/ dDV1cU). These high-power laser diodes have been developed for the digital projection devices. However, a quick review of popular websites finds over 20,000 videos describing high-power laser uses including videos where 8 laser diodes with 5 W each were assembled into a 40 W laser diode array used to set various items on fire (https://goo.gl/ZzwPzJ). Although federal regulations prohibit the sale of these high-power lasers, these lasers are readily available from overseas vendors who ship them to the United States without any apparently effective regulation. Many highpowered lasers are available as handheld, batteryoperated devices which look like “laser pointers.” Most lasers are classified as Class 1, Class 2, or Class 3R devices, according to their laser power and wavelength. The American National Standard Institute (ANSI) publishes the ANSI standard on the safe use of lasers. They present a complex guideline for determining safety limits, establishing safety rules and conditions, and other aspects of laser use. The previous classifications of Classes 1, 2, 3a, 3b, and 4 have been replaced by a system with Classes 1, 1M, 2, 2M, 3R, 3B, and 4. Class 1 lasers are safe under all conditions and include CD players, DVD players, laser printers, and ophthalmic scanning laser ophthalmoscopes. Class 2 lasers are visible wavelength (400–700 nm) products that are safe because of the blink reflex that limits exposure to no more than 0.25 seconds. These lasers have an output power of 1 mW or less for continuous wave (cw). Class 2M lasers are similar to Class 2 lasers with the addition that they are not be viewed through optical instruments. Typically, these lasers have either a large diameter or a large divergence and would be unsafe if used with lenses that can refocus the energy. Class 3R laser pointers or devices are considered safe if handled carefully with restricted beam viewing. In the visible spectrum, cw lasers are limited to 5 mW at wavelengths between 400 nm and 700 nm. Class 3B lasers are hazardous if directly exposed to the eye, but diffusion reflections are not harmful. Class 3B cw lasers in the visible spectrum are limited to 500 mW. Class 4 lasers are the highest and most dangerous types of lasers. ANSI guidelines recommend that the use of Class 3R lasers in situations involving the general public should be supervised by a trained operator or used in such a fashion that direct or specularly reflected exposure is impossible. The ANSI guidelines recommend that safety and training programs should be required for Class 3R lasers. Clearly, these conditions are not met in the present situation where laser pointers are sold to the general public without any training or supervision. Safety warnings on the laser warn the user to avoid direct eye exposure but fail to offer a threshold for eye injury or damage. In addition, some lasers have warning labels with a letter size of 3/100th of an inch (0.75-mm font size). Researchers have presented studies that document eye injury due to the misuse of lasers. Robertson None of the authors have any financial/conflicting interests to disclose.

Comparison of astigmatism correction using either peripheral corneal relaxing incisions or toric intraocular lenses.

Purpose To compare the efficacy and short-term stability of toric intraocular lenses (tIOL) and peripheral cornea relaxing incisions (PCRI) during phacoemulsification. Methods Patients with preexisting corneal astigmatism had cataract surgery either with tIOL (AcrySof Toric) (39 eyes of 35 patients) or standard intraocular lens (AcrySof) + PCRIs (38 eyes of 33 patients). Patients were retrospectively evaluated for manifest refraction, corneal topography, and uncorrected and corrected visual acuities preoperatively and at postoperative 1 and 6 months. The Alpins vectorial method was used to analyze the target induced astigmatism (TIA) and surgically induced astigmatism (SIA), magnitude of error (the difference between the magnitude of SIA and TIA) (ME), and correction index. Results Mean preoperative corneal astigmatism was 2.21 ± 1.32 D in the tIOL group and 2.24 ± 0.96 D in the PCRI group; the difference was not significant. The decrease in astigmatism was significant in both groups at last follow-up (64% tIOL group, 32% PCRI group, p<0.01, Wilcoxon signed rank test). The mean remaining refractive astigmatism was significantly higher in the PCRI group than in the tIOL group at 1-month (1.42 ± 1.22, 0.89 ± 0.68, respectively) and 6-month follow-ups (1.75 ± 1.37 D, 0.92 ± 0.72, respectively) (p<0.01). The mean ME was significantly lower (−0.35 versus −0.88) with a higher correction index (0.96 versus 0.56) in the tIOL group at 6 months postoperatively. Conclusions Both tIOL implantation and using PCRI were effective methods to reduce preoperative astigmatism at the time of the cataract surgery. However, tIOLs provided better remaining astigmatism with a more stable refraction than PCRI.

Correlates of Good Vision in Eyes With Subfoveal Scars From Neovascular Age-Related Macular Degeneration

BACKGROUND AND OBJECTIVE To compare subfoveal disciform scars with good and poor vision in patients with neovascular age-related macular degeneration (nAMD). PATIENTS AND METHODS A retrospective case-control study. Twenty-two eyes of 21 consecutively treated patients with nAMD with subfoveal disciform scar and best-corrected visual acuity (BCVA) of 20/63 or better at the final visit were included. Twenty-one eyes of 21 matched patients with disciform scar and final BCVA less than 20/63 served as controls. RESULTS Subretinal pigment epithelium scar location was more common in the good vision group than in the poor vision group (P < .001). The mean percent disruption of the ellipsoid and the external limiting membrane layers was significantly greater in poor vision eyes than in good vision eyes from scar formation and throughout follow-up (all P < .01). CONCLUSION Preserved photoreceptor layer correlated with good vision in patients with nAMD and subfoveal disciform scar. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:765-774.].

Tear film evaluation by scanning laser ophthalmoscopy during retinal imaging

Purpose: Herein, we describe a novel finding which appears as a reticular pattern on multicolor confocal scanning laser ophthalmoscopy image during routine imaging of retina and we aim to show whether there is an association between this pattern and dry eye findings. Materials and methods: A total of 162 eyes of 81 patients that were scheduled for a routine retinal imaging by scanning laser ophthalmoscopy at a vitreoretinal practice underwent dry eye evaluation including corneal and conjunctival lissamine green staining, fluorescein staining, tear break-up time, and tear meniscus height measurement before acquiring any images. Then, multicolor images were taken and graded for the severity of reticular pattern. Results: Among 150 eyes of 81 patients with gradable multicolor imaging, 45 eyes (30%) had some reticular pattern on multicolor image. Severity of reticular pattern on multicolor imaging was significantly correlated with total lissamine score (rho = 0.378, p = 0.007) and tear meniscus height (rho = −0.408, p = 0.011). Furthermore, they were found to be the best set of predictors for the severity pattern on multicolor imaging (odds ratio = 1.30, 95% confidence interval = 1.01–1.37, p = 0.027 and odds ratio = 0.25, 95% confidence interval = 0.128–0.342, p < 0.001, respectively). Conclusion: Reticular pattern seen on multicolor image while acquiring retinal images using scanning laser ophthalmoscopy may be related to tear film instability. Further modulations of the scanning laser ophthalmoscopy instrument will likely improve this indicator of dry eye syndrome.