Ismet Durak

The role of needle revision and 5-fluorouracil application over the filtration site in the management of bleb failure after trabeculectomy: a prospective study.

Fifty-three eyes of 49 consecutive patients with an intraocular pressure (IOP) over 21 mmHg; without bleb or with a thick, flat bleb after the second postoperative week following trabeculectomy were included in the study. Needle revision was performed with a 26-gauge tuberculin syringe containing 5 mg (0.2 ml) 5-FU in a period of 2 weeks to 10 months postoperatively after unsuccessful digital massage and/or laser suture-lysis. 5-FU injection was not performed when a bleb formation was observed during needling. In case of no bleb formation, 5-FU was injected subconjunctivally over the scleral flap area and repeated a maximum of six times until a functioning bleb was maintained. Needle revision was successful in 14 of 53 eyes (26.4%) as an initial procedure and nine (16.9%) eyes maintained success. Forty-four eyes (83.1%) had 5-FU injection since needle revision did not provide bleb formation (39 eyes) or did not maintain initial success (five eyes). Mean IOP was 27.8±4.7 mmHg (range, 22–41) before any intervention and decreased to 20.5±4.8 mmHg (range, 8–35) after a mean follow-up of 25.1 months and the difference was statistically significant (p<0.001). Mean IOP after needle revision in 14 patients was 18.9±4.9 mmHg (range, 8–29) and 16.3±3.7 mmHg in nine out of 14 patients that maintaned success. Mean IOP after the last 5-FU injection was 21.4±4.6 mmHg (range, 13∼35 mmHg). The mean number of 5-FU injections was 2.4 (range, 1 – 6). During a mean follow-up of 25.1 months (range, 1–48 months), three eyes (5.7%) had diffuse corneal punctate epitheliopathy lasting for 3–4 weeks and subconjunctival hemorrhage was seen in nine eyes (17%). Needle revision and/or subconjunctival injection of 5-FU over the bleb area is a safe, relatively efficient approach with a low rate of complications to overcome the early and mid term bleb failure after trabeculectomy.

Pars plana vitrectomy with pars plana tube implantation in eyes with intractable glaucoma

AIMS Intractable glaucoma is glaucoma resistant to medical therapy and conventional surgical procedures. In this study, a planned surgical technique is discussed for controlling the increased intraocular pressure in selected cases with intractable glaucoma. METHODS Total pars plana vitrectomy with pars plana tube implantation was performed in 17 eyes of 17 cases with intractable glaucoma. Patients with neovascular glaucoma were not included in this study. The mean age of these patients (seven men, 10 women) was 44.6 (SD 22.1) years and mean follow up period was 30.3 (15.5) months (range 4–71). Drainage implants with a disc were used in 16 cases, whereas, a tube with scleral buckle (Schocket surgery) was preferred in one case. An intraocular pressure below or equal to 20 mm Hg without any adjunctive medication or with only one type of antiglaucomatous drop was considered as an adequate operative outcome. RESULTS 16 out of 17 eyes maintained adequate pressure control. Only three out of these 16 eyes required prophylactic antiglaucomatous medications. One patient underwent reoperation for pressure control. The most severe complications observed postoperatively were intravitreal haemorrhage (one case), choroidal detachment (one case), implant failure (one case), total retinal detachment (two cases), and corneal endothelial decompensation (five cases). CONCLUSION Pars plana placement of drainage tube following pars plana vitrectomy should be considered as an alternative method for controlling increased intraocular pressures in selected patients with intractable glaucoma.

Unilateral retinal vasculitis, branch retinal artery occlusion and subsequent retinal neovascularization in Crohn's disease

Purpose: To report on a case of Crohns disease and unilateral retinal vasculitis, branch retinal artery occlusion and subsequent retinal neovascularization. Methods: We examined a 38-year-old woman with severe left visual loss and biopsy-proven Crohns disease diagnosed four years prior to the ocular involvement. A Heidelberg scanning laser ophthalmoscope was used for fundus fluorescein angiography and indocyanine green angiography. Retinal neovascularization was detected during the follow-up. Results: Successful regression of retinal neovascularization was achieved after argon green laserpanretinal photocoagulation in addition to oral steroid and salazopyrine. Conclusion: Retinal vascular involvement is a rare ocular feature of Crohns disease and may result in retinal neovascularization that may necessitate prompt laser photocoagulation.

Late postoperative opacification of hydrophilic acrylic intraocular lenses.

BACKGROUND AND OBJECTIVE To evaluate the incidence of postoperative opacification of hydrophilic acrylic intraocular lenses (IOLs) and discuss the surgical management. PATIENTS AND METHODS Seventy-two eyes of 72 consecutive patients who received the same type of hydrophilic acrylic IOL (Intraocular Optical International, I.O.I., California, USA) after uneventful phacoemulsification were evaluated retrospectively. Systemic status, follow-up time, recognition time of IOL opacification, time lapse between implantation and explantation, and surgical technique during explantation were reported. RESULTS IOL opacification was noted in 3 patients (4.1%). Time lapse between implantation and first recognition of opacification was 6.3+/-1.5 months (range: 5-8 months). Two of the patients had insulin-dependent diabetes mellitus and both were on renal dialysis for diabetic nephropathy, whereas one had no systemic disease. Opacified hydrophilic acrylic IOLs were exchanged with Acrysof IOL, and no further opacification occurred after lens exchange. CONCLUSION Use caution on implantation of hydrophilic IOLs because late opacification is a serious complication requiring further surgery.

Identification of three novel plasminogen (PLG) gene mutations in a series of 23 patients with low PLG activity

Inherited severe hypoplasminogenaemia is a multisystemic disorder leading to deficient extravascular fibrinolysis. As a clinical consequence wound healing capacity of mucous membranes is markedly impaired leading to ligneous conjunctivitis and several other manifestations. Here we report the molecular genetic and clinical findings on 23 new cases with severe hypoplasminogenaemia. Homozygous or compound-heterozygous mutations in the plasminogen (PLG) gene were found in 16 of 23 patients (70%), three of which were novel mutations reported here for the first time (C166Y, Y264S, IVS10-7T/G). Compared to 79 previously published cases, clinical manifestations of the current group of patients showed higher percentages of ligneous periodontitis, congenital hydrocephalus, and involvement of the female genital tract. In contrast, involvement of the gastrointestinal or urogenital tract was not observed in any of the cases. Patients originated to a large extent (61%) from Turkey and the Middle East, and showed a comparably frequent occurrence of consanguinity of affected families and a greater female to male ratio than was derived from previous reports in the literature. Individual treatment of ligneous conjunctivitis included topical plasminogen or heparin eye drops, topical or systemic fresh frozen plasma, and surgical removal of ligneous pseudomembranes, mostly with modest or transient efficacy. In conclusion, the present study underscores the broad range of clinical manifestations in PLG-deficient patients with a trend to regional differences. Transmission of genetic and clinical data to the recently established Plasminogen Deficiency Registry should help to determine the prevalence of the disease and to develop more efficient treatment strategies.

Long-Term Results of Various Anterior Capsulotomies and Radial Tears on Intraocular Lens Centration

BACKGROUND AND OBJECTIVE To evaluate the long-term effects of various anterior capsulotomies and radial tears on intraocular lens (IOL) centration. MATERIALS AND METHODS Ninety-five eyes of 87 senile cataract patients operated with extracapsular technique were evaluated in IOL tilt and decentration with a new method of measurement. According to the type of anterior capsulotomy and number of radial tears, five groups were constituted as, can opener, envelope, continous curvilinear capsulorrhexis (CCC), CCC with one radial tear (relaxing incision at quadrant 12), and CCC with two relaxing incisions (relaxing incisions at quadrants 6 and 12), respectively. RESULTS Early decentration and tilt in groups CCC and CCC with one radial tear were significantly lower than the other groups (P < 0.05). Late decentration and tilt in the CCC group were significantly lower than the other groups (P < 0.01). Highest values of tilt and decentration were determined in envelope capsulotomy. Additional symmetric relaxing incision at quadrant 6 revealed no effect on the prevention of decentration and tilt compared to one relaxing incision. CONCLUSION CCC with one radial tear is not ideal but sufficient for IOL centration. All other anterior capsulotomy techniques, other than intact CCC, do not guarantee the IOL centration.

Identification of Acanthamoeba genotype T4 and Paravahlkampfia sp. from two clinical samples

In this study, two free-living amoebae strains, Acanthamoeba genotype T4 and Paravahlkampfia sp., which were isolated from keratitis cases are presented. While the Acanthamoeba strain was isolated as a single agent, the Paravahlkampfia strain was found together with herpes simplex virus. Neither of the patients were contact lens wearers, but they did have a history of minor corneal trauma. Amoebae were detected on non-nutrient agar covered with Escherichia coli. Based on PCR-amplified 18S rRNA-gene analysis the first isolate was identified as Acanthamoeba genotype T4 and the second as Paravahlkampfia sp. In thermotolerance tests, the maximum temperature at which trophozoites continued to divide was determined as 37 degrees C for this Acanthamoeba strain and 35 degrees C for the Paravahlkampfia strain. To the best of our knowledge, the Acanthamoeba strain described herein is the second molecularly identified Acanthamoeba strain in an Acanthamoeba keratitis patient in Turkey. However, the Paravahlkampfia isolate is believed to be the first strain that has been isolated from a keratitis patient and has been molecularly differentiated from Vahlkampfia.

Magnetic resonance imaging characteristics of posterior scleritis mimicking choroidal mass.

We present imaging findings in a case of posterior scleritis, which may mimic tumoral mass lesion resulting in unnecessary enucleation. Magnetic resonance imaging was remarkable for a subretinal mass hypointense on T2 and hyperintense on T1 weighted images. A peripheral rim of hypointensity was noteworthy, suggestive of sclerouveal thickening. There was an ill-defined area of increased T2 signal intensity adjacent to globe at the site of nodular lesion implying an inflammatory process. A linear contrast enhancement was seen within the bulbus oculi which may represent detached retina by exudation or displaced retina due to thickened sclera and choroidal layers. The CSF space around the optic nerve was enlarged.

Colour Doppler Assessment of Blood Flow in Eyes with Central Retinal Vein Occlusion

Purpose: To assess the blood flow changes in eyes with central retinal vein occlusion (CRVO) and compare these values with values of fellow eyes and eyes of normal subjects. Methods: 25 eyes of 25 consecutive newly diagnosed patients with CRVO comprised the study group. Their fellow eyes and those of 25 healthy subjects were the control group. All patients underwent a complete ophthalmological examination. Eyes with CRVO were classified into two groups as non-ischaemic and ischaemic by fundus fluorescein angiography. Colour Doppler imaging was performed with a Toshiba Sonolayer SSH-140A and 7.5-MHz linear array probe. Maximum systolic velocity (Vmax), end-diastolic velocity (Vmin) and resistive index (Ri) values were noted for each of the central retinal artery (CRA), central retinal vein (CRV) and ophthalmic artery (OA). These parameters were compared with those of the fellow eyes and both eyes of the control group. Results: Mean ages were 63.55 and 61.45 years in the CRVO and control groups, respectively. Age and sex distributions were statistically identical in both groups. When we compared the eyes with CRVO to the control group, no statistically significant difference existed between the two groups with regard to the Vmin and Ri values of the CRA and CRV. However, Vmax values of the CRA and CRV were significantly lower in CRVO eyes when compared to the control group. The CRVO group and control group had similar Vmax, Vmin and Ri values for the OA. Only the Vmax was significantly lower in the CRV in eyes with CRVO when compared to the unaffected fellow eyes. No statistically significant difference could be detected between any of the parameters of CRA, CRV and OA of the ischaemic and non-ischaemic CRVO groups. Conlusions: More data on broader series need to be obtained in order to decide on the practical use of colour Doppler imaging in the differentiation of ischaemic eyes from non-ischaemic eyes in CRVO.

Interaction of Intraocular Lenses with Various Concentrations of Silicone Oil: An Experimental Study

The aim of this study was to evaluate the interaction between various widely used intraocular lenses (IOLs) and silicone oils of different viscosities. Four groups of IOLs, including monoblock foldable hydrophilic acrylic IOLs (Morcher, type 92s); monoblock hydrophobic acrylic IOLs (Acrysof®-SA60AT, Alcon); single-piece rigid polymethylmethacrylate (PMMA) IOLs (Intraocular Optical International-IOI-65130) and a three-piece foldable silicone optic IOL (CeeOn® Edge 911A, Pharmacia UpJohn) were analyzed in vitro to determine the percentage adherence 1,000-centistoke, 1,300-centistoke or 5,000-centistokes silicone oil on the IOL optic. For each IOL type, there was no statistically significant difference in the mean silicone oil coverage (MSC) of the IOL optics for the different viscosities of silicone oil. Silicone IOLs had the highest MSC percentage (79.9%) whereas hydrophilic acrylic IOLs were the least silicone-covered IOLs (7.8%) compared to the other IOL types tested in this study. It is not the concentration of silicone oil that affects silicone oil coverage. When performing small-incision cataract surgery in patients who may require silicone oil injection, foldable hydrophilic acrylic or hydrophobic acrylic lenses should be preferred over standard foldable silicone lenses.