Meltem F. Söylev

Anesthesia with EMLA® Cream for Botulinum A Toxin Injection into Eyelids

We investigated the efficacy of an eutectic mixture of local anesthetics (EMLA®) in reducing the pain of a botulinum toxin injection into eyelids. 17 patients with facial dyskinesia (9 blepharospasm and 8 hemifacial spasm) who had been treated regularly with botulinum toxin injections received EMLA cream and placebo. The pain was assessed by the ophthalmologist and the patient. Injection with EMLA cream showed lower pain scores (mean 1.82 ± 2.13, median 1) than injection with placebo (8.76 ± 2.17; p = 0.0001). Percutaneous anesthesia induced by EMLA cream is an effective and safe method which improves the comfort in patients who need repeated botulinum toxin injections for their facial dyskinesia.

Chemodenervation in Treatment of Upper Eyelid Retraction

Upper-eyelid retraction is a common sign of thyroid-associated eye disease (TAED), and these patients are highly bothered by the appearance of their eyes. In this study, botulinum toxin A (BTA) was injected into the levator palpebrae superioris muscle in 8 eyes of 4 patients in an attempt to control the abnormal elevation of the upper eyelid. BTA provided control of the upper-eyelid retraction, and the cosmetically acceptable effect lasted for 3-4 months. It was concluded that BTA is an effective method of treatment in this condition. Since it has a temporary effect, it can safely be used to provide relief of symptoms related to upper-eyelid retraction during unstabilized periods of TAED, which may last as long as several years in some patients.

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.

Intravitreal triamcinolone acetonide injection for acute non-arteritic anterior ischaemic optic neuropathy*

Non‐arteritic anterior ischaemic optic neuropathy is the most common optic neuropathy of the elderly, characterised by unilateral, sudden, painless visual loss. No effective treatment has been proven to reverse or limit the course of this disease. We evaluated the role of intravitreal triamcinolone acetonide injection in eyes with non‐arteritic anterior ischaemic optic neuropathy (NAION). Four eyes of four patients with acute NAION received a single intravitreal injection of triamcinolone acetonide (4 mg). The time between visual loss and intravitreal injection varied between four and 10 days. Mean age of patients was 57.25 years (range, 44 to 77 years). All patients experienced some visual gain. No complications related to the injection were observed during the following three months. Intravitreal triamcinolone injection may offer help in limiting the damage in this small group of patients with a relatively short history of visual loss due to NAION.

Early postoperative capsular block syndrome

Purpose: To report the results of early postoperative capsular block syndrome (CBS) after phacoemulsification and intraocular lens (IOL) implantation. Setting: Department of Ophthalmology, Dokuz Eylül University School of Medicine, Idot;zmir, Turkey. Methods: Thirteen eyes of 13 patients with CBS who had uneventful phacoemulsification were included in the study. Twelve patients had in‐the‐bag implantation of a foldable IOL, and 1 had implantation of a poly(methyl methacrylate) IOL in the ciliary sulcus. Continuous curvilinear capsulorhexis was performed in all eyes, and sodium hyaluronate 1.4% (Healon GV®) was used during all steps of surgery. The patients were closely followed without intervention during the first month after surgery. If resolution did not occur during follow‐up, a neodymium:YAG (Nd:YAG) laser peripheral anterior capsulotomy was performed first, followed by posterior capsulotomy if the anterior capsulotomy was not successful. Results: The CBS resolved without intervention in 2 eyes by 1 month postoperatively. A small Nd:YAG laser peripheral anterior capsulotomy was attempted in 10 cases after 1 month but could not be performed in 2 eyes because of inadequate pupil dilation. Peripheral anterior capsulotomy was successful in 5 of 8 eyes, with resolution of CBS in a few days. The Nd:YAG laser posterior capsulotomy was successful in 5 cases after the failure of the anterior capsulotomy. One patient chose to postpone treatment for 11 months, at which time posterior capsulotomy was performed successfully and the CBS resolved. Conclusions: Resolution of CBS occurred spontaneously in only a small percentage of cases during the first month after phacoemulsification with IOL implantation. Neodymium:YAG laser peripheral anterior capsulotomy and posterior capsulotomy were successful in treating CBS.

Colour Doppler Imaging of Superior Ophthalmic Vein in Thyroid-Associated Eye Disease

PURPOSE One of the possible etiologies of proptosis in patients with thyroid-associated eye disease is stated to be passive orbital venous congestion caused by the occlusive and constrictive changes of the superior ophthalmic vein (SOV). In an attempt to clarify the validity of this claim, quantitative information on the flow velocity of the SOV was obtained by colour Doppler imaging in 24 patients with thyroid-associated eye disease and compared with data from the control group. METHODS On clinical examination, ocular motility, proptosis, soft tissue involvement, and the presence of optic neuropathy were evaluated. The interaction of these signs with the flow velocity of the SOV was investigated in conjunction with computed tomographic (CT) findings such as extraocular muscle enlargement, dilatation of the SOV, and apical crowding of the orbit. RESULTS The mean blood flow velocity was significantly decreased in patients compared to the control group (P <.05). The CT measures that contributed to significant decreases in SOV blood flow velocity were apical crowding (P <.05) and the coexistence of horizontal and vertical extraocular muscle involvement (P <.05). Among the clinical measures, significant decreases could be attributed to soft tissue findings (P <.01) and to optic neuropathy (P <.05). CONCLUSIONS External compression of the SOV may contribute to the SOV blood flow decrease in orbits afflicted with thyroid eye disease, but proptosis is not relevant to the SOV blood flow decrease.

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.

Macular hole formation in Bietti's crystalline retinopathy: A case report

Three years after the initial diagnosis, a 21-year-old healthy man with Biettis crystalline retinopathy developed unilateral stage 4 macular hole with surrounding macular detachment. The mechanism of macular hole formation, which may or may not be a feature of Biettis crystalline dystrophy, is not clear.

Pre-Descemet’s membrane hemorrhage after secondary intraocular lens implantation

A 6.0 x 4.0 mm pre-Descemets membrane hemorrhage with very sharp borders appeared at the temporal portion of the cornea. There was no hyphema in the anterior chamber on the first day after secondary intraocular lens implantation. The hemorrhage resolved almost totally in 1 year without intervention, leaving slight, deep pigmentary changes and minimal diffuse corneal edema.