Mehmet Ali Sekeroglu

Quantitative assessment of corneal clarity in keratoconus: a case control study of corneal densitometry.

Purpose To evaluate corneal clarity quantitatively by corneal densitometry measurement in treatment-naive keratoconus patients and to compare these results with those of healthy control subjects. Methods Corneal densitometry measurement of consecutive treatment-naive keratoconus patients and healthy control subjects was performed by Scheimpflug corneal topography (Pentacam®HR). Corneal densitometry measurements were expressed in gray scale unit (GSU) and the data from the right eyes of subjects were used for statistical analysis. Results A total of 102 subjects (51 patients with keratoconus [27 male, 24 female] and 51 healthy control subjects [24 male, 27 female]) were included in the study. There was no statistically significant difference with regard to the mean age (p = 0.910) or distribution of sex (p = 0.552) between the groups. There were significant differences in corneal densitometry values of the groups in central 2 mm (17.95 ± 0.33 GSU in keratoconus and 16.43 ± 0.24 GSU in controls, p<0.001) and in annulus of 2 to 6 mm in diameter (15.88 ± 0.26 GSU in keratoconus and 15.02 ± 0.22 GSU in controls, p = 0.015). When considering the measurements in different depths, the anterior layer displayed the highest densitometry value compared to that of both the central and posterior layers. Corneal densitometry of anterior 0-2 mm was positively correlated with simulated K value (r = 0.446, p = 0.001), whereas it was negatively correlated with central corneal thickness (r = −0.361, p = 0.016) in keratoconus patients. Conclusions Treatment-naive keratoconus patients have significantly higher corneal densitometry values in central cornea when compared to healthy control subjects. The clinical relevance should be further studied in detail.

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

Evaluation of Refractive Errors and Ocular Biometric Outcomes after Intravitreal Bevacizumab for Retinopathy of Prematurity

ABSTRACT Purpose: To assess ocular biometric outcomes following intravitreal bevacizumab (IVB) monotherapy for retinopathy of prematurity (ROP) and compare these results with those of laser photocoagulated infants and with the ones with spontaneously regressed ROP. Materials and methods: Premature infants including those who underwent IVB monotherapy (Group 1) or laser photocoagulation (Group 2) for ROP and infants with spontaneously regressed ROP (Group 3) were recruited for the study. Refractive errors and ocular biometric parameters (Axial length [AL], anterior chamber depth [ACD], and lens thickness [LT]) were measured at adjusted 1 year of age in all subjects. Results: There was no significant difference of spherical equivalent (SE) value between the groups (P = 0.781). The incidence of high myopia was 7.4% in Group 1 and 12.7% in Group 2 (P = 0.081). No infants exhibited high myopia in Group 3. LT was greater in Group 2 when compared to Group 1 and Group 3 (P = 0.011). Lower SE was significantly correlated to longer AL in Group 1 (r = −0.656, P = 0.015). There was a significant positive correlation between SE and ACD values in Group 2 (r = 0.391, P = 0.005). Conclusion: The study showed no significant difference of SE between the groups. High myopia was only present among the treated infants either with IVB or laser. Infants who received laser treatment significantly had thicker lenses.

Intralenticular Sustained-Release Dexamethasone Implant: Is It Still Effective on Macular Edema?

Purpose: To report the therapeutic efficacy of an accidentally injected intralenticular sustained-release dexamethasone implant in a patient with macular edema secondary to branch retinal vein occlusion and shortly discuss the management strategy of this rare complication. Methods: Complete ophthalmological examination and optical coherence tomography imaging were performed at each visit. Results: The implant accidentally caused a posterior capsular tear during the procedure and was injected into the crystalline lens because of an involuntary head movement of the patient. Since the anterior segment was normal, and the resultant cataract and implant itself did not obscure the visual axis, the decision was made to observe the patient with intralenticular implant, preserve the therapeutic effect and avoid reinjection. The macular edema resolved within time, while visual acuity did not show significant improvement due to an increase in lens opacification. The patient underwent phacoemulsification surgery at 7 months after the injection with implantation of posterior chamber IOL into the capsular bag. Conclusion: Inadvertent injection of sustained-release intravitreal dexamethasone implant into the crystalline lens is an uncommon but possible complication that is mostly caused by surgeon inexperience, improper technique and uncontrolled head movement during the procedure. Once this complication occurs, early phacoemulsification and repositioning of the implant into the vitreous is the frequently preferred management strategy. However, remarkable decrease in macular edema and visual acuity improvement can also be achieved without an immediate surgical intervention.

Intravitreal Bevacizumab and Ranibizumab in the Treatment of Acute Central Serous Chorioretihopathy: A Single Center Retrospective Study

ABSTRACT Objectives: To evaluate and compare the anatomical and functional outcomes of patients with acute central serous chorioretinopathy (CSC) who did not receive any intervention or treatment with intravitreal bevacizumab or ranibizumab. Methods: A single-center retrospective comparative study. Seventy eyes of 70 patients were recruited for the study; 27 patients were only observed without any medication or intervention (observation group), 23 were treated with intravitreal bevacizumab (IVB group), and the remaining 20 were treated with intavitreal ranibizumab (IVR group). The best-corrected visual acuity (BCVA) and central macular thickness (CMT) obtained by spectral-domain optical coherence tomography were compared between the groups. Results: There were no significant differences between the groups with regard to age, sex, and follow-up periods (p>0.05). The mean time from baseline to initial complete resolution of subretinal fluid was 3.52±1.64 months in the observation group, 1.19±0.60 months in the IVB group, and 1.11±0.47 months in the IVR group; the resolution time was significantly longer in the observation group (p<0.001). While the CMT was significantly thicker in the observation group when compared to the IVB and IVR groups in the first month (p=0.001), it was similar between the groups in the third, sixth, and twelfth months (p>0.05). Additionally, pairwise comparisons of the IVB and IVR groups revealed that there were no significant differences between these groups regarding CMT at any follow-up time (p>0.05). Conclusions: Compared with observation alone, neither IVB nor IVR had a positive effect in terms of anatomical and functional outcomes for acute CSC. Although the resolution time of SRF is shorter by using ranibizumab, both the ranibizumab and bevacizumab could be effective in achieving rapid resolution of serous detachment in patients with acute CSC.

Corneal Densitometry in Healthy Corneas and Its Correlation With Endothelial Morphometry

Purpose: To evaluate the correlations between corneal endothelial cell properties and corneal densitometry values and to investigate whether corneal densitometry may be used as an indicator of the health of corneal endothelium. Methods: Two hundred fifty-three eyes were analyzed in this prospective cross-sectional study. Corneal densitometry was measured with densitometry software of Pentacam HR-Scheimpflug corneal topography over a 12-mm diameter of the cornea. Furthermore, corneal endothelial cell properties including cell density (CD), average cell area, SD of the cell area, coefficient of variation (CV) of the cell area, maximum cell area, minimum cell area, and percentage of hexagonal cells (HEX) were measured by a specular microscope. The correlations were calculated using Pearson correlation tests. Results: The average cell area, SD, maximum cell area, and minimum cell area values were not statistically significantly correlated with the corneal densitometry values in any layer or concentric annulus. CD, CV, and HEX were statistically significantly correlated with the corneal densitometry values in all layers and concentric annuli (P < 0.05 for each one). Moreover, CD and HEX were inversely and moderately correlated with total corneal densitometry (r = −0.403, P < 0.001, and r = −0.327, P < 0.001, respectively), whereas the CV was positively and moderately correlated with total corneal densitometry (r = 0.349, P < 0.001). Conclusions: Corneal densitometry might have potential to be used as an indicator of the health of corneal endothelium in the future.

An overlooked effect of systemic anticholinergics: alteration on accommodation amplitude.

AIM To investigate the effect of oral solifenacin succinate, tolterodine-L-tartarate and oxybutinin hydrochloride (HCl) on accommodation amplitude. METHODS Female overactive bladder syndrome (OAB) patients who were planned to use oral anticholinergics, patients that uses solifenacin succinate 5 mg (Group I, n=25), tolterodine-L-tartarate 4 mg (Group II, n=25), and oxybutinin HCl 5 mg b.i.d (Group III, n=25) and age matched healthy female subjects (Group IV, n=25) were recruited and complete ophthalmological examination and accommodation amplitude assessment were done at baseline and 4wk after initiation of treatment. RESULTS The mean age of 100 consecutive female subjects was 51.6±5.7 (40-60)y and there were no statistically significant difference with regard to the mean age (P=0.107) and baseline accommodation amplitude (P=0.148) between study groups. All treatment groups showed a significant decrease in accommodation amplitude following a 4-week course of anticholinergic treatment (P=0.008 in Group I, P=0.002 in Group II, P=0.001 in Group III), but there was no statistically significant difference in Group IV (P=0.065). CONCLUSION A 4-week course of oral anticholinergic treatment have statistically significant effect on accommodation amplitude. Clinicians should avoid both overestimating this result, as this would unnecessarily restrict therapeutic possibilities, and also underestimating it which may lead to drug intolerance.

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.

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.