Murat Irkec

Long-term results and reasons for failure of intranasal endoscopic dacryocystorhinostomy.

The aim of this study was to evaluate the long-term results and the factors influencing the success in patients with nasolacrimal duct obstruction treated with intranasal endoscopic dacryocystorhinostomy (DCR) and silicone tube intubation (STI). We prospectively investigated 158 patients with lacrimal obstruction in two groups, one of which comprised 108 patients treated primarily with intranasal endoscopic DCR by experienced surgeons and the other comprised 50 patients who were operated on by inexperienced surgeons. In a mean follow-up time of 49 months the surgical success was 94.4% in experienced hands and 58.0% in inexperienced hands. The endoscopic examination of six patients with failure in the first group revealed granulation tissue around the tube in four, atonic sac in one and persistence of bone that was supposed to have been excised in the nasal cavity in one. There were 21 failures out of 50 patients in the second group: granulation tissue in 2 cases, fenestration to the nasolacrimal duct instead of the sac in 6 cases, synechia between the lateral nasal wall and the middle turbinate in 2 cases, bony spicles causing obstruction in 5 cases and fenestration anterior to the sac in 2 cases. In 4 cases no reasons were found for failure, but perhaps the small fenestration and failure to remove the medial half of the membranous sac wall was the reason. DCR and STI can be performed for primary treatment in lacrimal obstruction. There is a learning curve for the operation. False localization of the lacrimal sac, granulation tissue formation around the tubes, retained bony spicles, inadequate removal of the medial wall of the sac and the synechia between the lateral wall and the middle turbinate are the most common causes of failure.The aim of this study was to evaluate the long-term results and the factors influencing the success in patients with nasolacrimal duct obstruction treated with intranasal endoscopic dacryocystorhinostomy (DCR) and silicone tube intubation (STI). We prospectively investigated 158 patients with lacrimal obstruction in two groups, one of which comprised 108 patients treated primarily with intranasal endoscopic DCR by experienced surgeons and the other comprised 50 patients who were operated on by inexperienced surgeons. In a mean follow-up time of 49 months the surgical success was 94.4% in experienced hands and 58.0% in inexperienced hands. The endoscopic examination of six patients with failure in the first group revealed granulation tissue around the tube in four, atonic sac in one and persistence of bone that was supposed to have been excised in the nasal cavity in one. There were 21 failures out of 50 patients in the second group: granulation tissue in 2 cases, fenestration to the nasolacrimal duct instead of the sac in 6 cases, synechia between the lateral nasal wall and the middle turbinate in 2 cases, bony spicles causing obstruction in 5 cases and fenestration anterior to the sac in 2 cases. In 4 cases no reasons were found for failure, but perhaps the small fenestration and failure to remove the medial half of the membranous sac wall was the reason. DCR and STI can be performed for primary treatment in lacrimal obstruction. There is a learning curve for the operation. False localization of the lacrimal sac, granulation tissue formation around the tubes, retained bony spicles, inadequate removal of the medial wall of the sac and the synechia between the lateral wall and the middle turbinate are the most common causes of failure.

Morphologic alterations of both the stromal and subbasal nerves in the corneas of patients with diabetes

Purpose: To evaluate the subbasal and the stromal nerves of the corneas of patients with type 2 diabetes with in vivo confocal microscopy and to compare them with those of nondiabetic patients. Methods: Thirty-five corneas of patients with type 2 diabetes and 24 corneas of age-matched control subjects were included in the study. Patients with diabetes were further classified with respect to the stage of retinopathy. Subbasal and stromal nerve plexus morphology and thickness were evaluated with in vivo confocal microscopy. Subbasal long nerve fiber (LNF) and total nerve branch (NB) densities were calculated. Results: The mean stromal nerve thickness was significantly higher in patients with diabetes (8.99 ± 2.32 μm) than that of the control subjects (5.69 ± 1.49 μm; Mann-Whitney U test; P < 0.001). The proportion of curved stromal nerves in patients with diabetes (45.7%) was also higher than that of normal subjects (20.8%; χ2, P = 0.05). Subbasal LNF and NB densities were found to significantly lower in the corneas of patients with diabetes (28.3 ± 10.4 and 39.7 ± 13.2 nerve/mm2, respectively) than those of the control subjects (34.1 ± 5.7 and 58.5 ± 12.4 nerve/mm2, respectively; Mann-Whitney, P = 0.012 and P < 0.001). In addition, the subbasal nerve plexus of patients with diabetes appeared significantly thicker and more tortuous than those of the control subjects (Mann-Whitney, P = 0.002 and P = 0.001). Conclusion: Both stromal and subbasal nerves appear abnormal in the corneas of patients with diabetes. Patients with proliferative diabetic retinopathy show more pronounced nerve alterations than patients who do not have diabetic retinopathy.

Hyaluronic acid coated poly-ɛ-caprolactone nanospheres deliver high concentrations of cyclosporine A into the cornea

The objective of this study was to determine cyclosporine A (Cy A) levels in ocular tissues and fluids after topical administration of poly-epsilon-caprolactone (PCL)/benzalkonium chloride (BKC) nanospheres and hyaluronic acid (HA) coated PCL/BKC nanospheres onto healthy rabbit corneas. Nanospheres were prepared by nanoprecipitation and purified by gradient-rate centrifugation. Cy A (0.1%) in either castor oil solution (group 1), PCL/BKC nanosphere formulation (group 2) or HA coated PCL/BKC nanosphere formulation (group 3) was instilled onto rabbit corneas. Tear samples were adsorbed onto Schirmer tear strips. Cy A concentrations of fluid (blood, aqueous humor, tear) and specimen extracts (cornea, conjunctiva, iris/ciliary body) were determined by high performance liquid chromatography-mass spectrometry (LC-MS). The mean corneal Cy A concentration obtained at 0.5, 1, 2, 4, 8 and 24h following instillation of the formulations ranged between 0.12 and 1.2 ng/mg tissue for group 1, 5.9-15.5 ng/mg tissue for group 2 and 11.4-23.0 ng/mg for group 3 (one-way analysis of variance (ANOVA) and pairwise tests (SNK (Student-Newman-Keuls) and Tukey); p<0.05). Conjunctival Cy A levels of group 2 and 3 were not significantly different at any of the time points tested. However, there was a significant difference between Cy A concentration of castor oil formulation and that of PCL/BKC nanosphere formulation at 1 and 8h (p<0.05). The mean iris/ciliary body concentrations obtained with the three formulations were not significantly different at any time point with the exception of group 2 levels being higher than those of groups 1 and 3 at 1h (p<0.05). The lowest ocular tear Cy A concentrations (16-114 ng/ml) were found following the instillation of HA coated PCL/BKC nanoparticles (group 3) during the time period tested. Cy A loaded PCL/BKC and HA coated PCL/BKC nanospheres are able to achieve high levels of Cy A in the cornea that is 10-15-fold higher than that is achieved with Cy A solution in castor oil. Nanosphere formulation and HA may play an important role in delivering high levels of cyclosporine A into the cornea.

Juvenile xanthogranuloma of the corneal limbus: report of two cases and review of the literature.

PURPOSE To report the clinical and histopathologic findings of limbal juvenile xanthogranuloma lesions in 2 pediatric cases. METHODS Case report and literature review. RESULTS Two cases (a 7-month-old girl and a 7-year-old boy), both of whom developed a yellowish corneoscleral limbal mass not associated with other ocular or systemic findings, were evaluated. Both cases underwent simple excision of the lesion followed by local steroid treatment. Histopathologic examination in both cases revealed foamy histiocytes within an inflammatory infiltrate. One of the lesions also harbored multinucleate giant cells. Immunohistochemical staining was positive for CD68 and negative for S-100 and CD1a in both cases. CONCLUSIONS Juvenile xanthogranuloma may rarely present with an isolated lesion occurring only at the corneoscleral limbus. The diagnosis in the early stages of this disorder may be established with immunophenotyping and characteristic histopathologic features even without the presence of the multinucleate giant cells.

Diagnosing the severity of dry eye: a clear and practical algorithm

Dry eye disease (DED) is a distressing ocular condition. Due to its multifactorial nature, clinical and biological signs of DED can be inconsistent and sometimes discordant with symptomatology. Consequently, no gold-standard model for determining DED severity exists. This can impact treatment decisions and complicate evaluation of disease progression, particularly within the stringent context of clinical trials. The multinational ODISSEY European Consensus Group is comprised of ophthalmologists who contend with ocular surface disease issues on a daily basis. This group convened to establish a clear and practical algorithm for evaluation and diagnosis of severe DED. Using a consensus-based approach, they assessed 14 commonly used DED severity criteria. The panel agreed that following confirmed DED diagnosis, just two criteria, symptom-based assessment and corneal fluorescein staining were sufficient to diagnose the presence of severe DED in the majority of patients. In the event of discordance between signs and symptoms, further evaluation using additional determinant criteria was recommended. This report presents the ODISSEY European Consensus Group recommended algorithm for DED evaluation, which facilitates diagnosis of severe disease even in the event of discordance between signs and symptoms. It is intended that this algorithm will be useful in a clinical and developmental setting.

In vivo confocal microscopy for the evaluation of corneal microstructure in keratoconus.

Purpose: To evaluate the corneal microstructure in keratoconus with in vivo confocal microscopy (IVCM). Methods: Unscarred corneas of 68 patients with keratoconus and 22 controls were evaluated with slit lamp examination, corneal topography, and IVCM (Confoscan 3.0, Vigonza, Italy). One eye was randomly chosen for analysis. Keratocyte, endothelial cell and basal epithelial densities, sub-basal and stromal nerve structure, and severity of stromal haze were evaluated. Results: Compared with corneas of control subjects, patients with keratoconus had a significantly lower anterior stromal keratocyte density (1279 ± 197 cells/mm2 vs. 1132 ± 178 cells/mm2, p = 0.002), lower midstromal keratocyte density (904 ± 213 cells/mm2 vs. 770 ± 120 cells/mm2, p < 0.001), lower posterior stromal keratocyte density (935 ± 113 cells/mm2 vs. 725 ± 113 cells/mm2, p < 0.001), lower endothelial cell density (2924 ± 300 cells/mm2 vs. 2719 ± 279 cells/mm2, p = 0.004), lower basal epithelial cell density (5987 ± 699 cells/mm2 vs. 4365 ± 537 cells/mm2, p < 0.001), lower sub-basal long nerve density (32.0 ± 6.5 nerves/mm2 vs. 19.6 ± 6.5 nerves/mm2, p < 0.001), thicker sub-basal (3.2 ± 0.4 μm vs. 3.7 ± 1.1 μm, p = 0.01) and stromal nerves (5.0 ± 1.2 μm vs. 8.0 ± 2.9 μm, p < 0.001), and higher proportion of corneas with haze (40.9% vs. 92.6%, p < 0.001). A history of contact lens use (n = 12) was not associated with lower keratocyte, endothelial cell, or basal epithelial cell counts. Conclusions: Corneal microstructure is abnormal in patients with keratoconus. Keratocyte and endothelial cell loss appears to be present in keratoconic corneas.

Intraoperative and Postoperative Use of Mitomycin-C in the Treatment of Primary Pterygium

BACKGROUND AND OBJECTIVE The effectiveness of 0.04% mitomycin-C, either postoperatively for 2 weeks or intraoperatively as a single dose, as an adjunct in the surgical treatment of primary pterygium was evaluated. PATIENTS AND METHODS Mitomycin-C was used in addition to the bare sclera technique in 43 eyes with pterygia. The mean follow-up time was 18.5 months for the 24 eyes in the postoperative mitomycin-C group, 10.3 months for the 19 eyes in the intraoperative mitomycin-C group, and 17.3 months for the 17 eyes in the control group (eyes that had undergone surgical excision only). RESULTS The recurrence rate was 4.2% with postoperative administration, 5.3% with intraoperative application, and 41.2% in the control group. There was a significant reduction in recurrence rates for both the postoperative and the intraoperative mitomycin-C groups compared with the control group (P = .005 and P = .01, respectively). However, recurrence rates were not statistically different according to the type of application. No serious side effect occurred during the follow-up period. CONCLUSION Topical mitomycin-C, either intraoperatively or postoperatively, as an adjunct decreases the recurrence rate of primary pterygium. Intraoperative application seems advantageous because it decreases the symptomatic side effects and restricts the inappropriate use by the patient.

Diurnal IOP control with bimatoprost versus latanoprost in exfoliative glaucoma: a crossover, observer‐masked, three‐centre study

Aim: To evaluate the diurnal intraocular pressure (IOP) control and safety of bimatoprost versus latanoprost in exfoliative glaucoma (XFG). Methods: One eye of 129 consecutive patients with XFG (mean (SD) age 66.5 (8.3) years) was included in this prospective, observer-masked, three-centre, crossover comparison. After a 4–6 week medicine-free period patients were randomised to bimatoprost or latanoprost monotherapy for 3 months. Patients were then switched to the opposite treatment for another 3 months. At the end of the washout and the treatment periods diurnal IOP was measured at 0800, 1300, and 1800. Results: At baseline the IOP (mean (SD)) was 28.0 (4.0), 26.9 (3.6), and 25.9 (3.6) mm Hg, at the three time points, respectively. Both treatments significantly reduced mean diurnal IOP at month 3. Mean diurnal IOP was 26.9 (3.5) mm Hg at baseline, 17.6 (3.3) mm Hg with bimatoprost, and 18.6 (3.6) mm Hg with latanoprost (p<0.0001). Furthermore, lower IOP values were obtained with bimatoprost at all time points (17.9 (3.4), 17.3 (3.3), and 17.6 (3.5) mm Hg, respectively) compared with latanoprost (18.7 (3.6), 18.5 (3.6), and 18.6 (4.1) mm Hg, respectively). The corresponding mean differences (0.8, 1.1, and 1.0 mm Hg, respectively) were all significant (p<0.001 for each comparison). Significantly more patients with XFG obtained a target diurnal IOP <17 mm Hg with bimatoprost than with latanoprost, 55/123 (45%) v 34/123 (28%); (p = 0.001), and significantly fewer patients were non-responders with bimatoprost than with latanoprost (5 v 13, p = 0.021). More patients reported at least one adverse event with bimatoprost than with latanoprost (58 v 41 at 3 months; p = 0.0003). Conclusion: This crossover study suggests that better diurnal IOP control is obtained with bimatoprost than with latanoprost in patients with XFG.

Twenty-four-hour intraocular pressure control with bimatoprost and the bimatoprost/timolol fixed combination administered in the morning, or evening in exfoliative glaucoma

Aim To compare 24 h intraocular pressure (IOP) control of morning and evening administered bimatoprost/timolol fixed combination (BTFC) and evening administered bimatoprost in exfoliative glaucoma (XFG). Methods One eye of 60 XFG patients was included in this prospective, observer-masked, crossover comparison. Following wash-out, all patients received bimatoprost monotherapy for 6 weeks. They were then randomised to morning, or evening, administered BTFC for 3 months and then switched to the opposite therapy. Results At baseline, mean 24 h pressure was 29.0 mm Hg. Bimatoprost reduced the mean IOP by 8.1 mm Hg (27.8%, p<0.001). The evening administration of BTFC reduced 24 h IOP to a statistically lower level than morning administration (10.2 mm Hg (35.3%) vs 9.8 mm Hg (33.8%); p=0.005). Both dosing regimens reduced IOP significantly more than bimatoprost (p≤0.006, for all time points). A 24 h IOP reduction ≥30% was seen in 43 patients (72%) with evening BTFC compared with 39 patients (65%) with morning BTFC (p=0.344) and only 24 patients (40%) with bimatoprost monotherapy (p<0.001 vs both BTFC regimens). Conclusion Both BTFC dosing regimens significantly reduce 24 h IOP in XFG compared with bimatoprost monotherapy. The evening dosing gives rise to statistically better 24 h IOP control and could be considered in these patients.

Effect of glycemic control on refractive changes in diabetic patients with hyperglycemia

Purpose: To investigate the effect of intensive glycemic control on hyperglycemia- induced changes in refraction, corneal topography, lenticular and corneal thickness in diabetic patients. Methods: Eighteen diabetic patients with plasma glucose >300 mg/dl were enrolled in the study consecutively. Autorefraction, C-Scan corneal topography, Javal keratometry, corneal pachymetry and ultrasonic biometric measurements were carried out at presentation and after metabolic control of blood sugar (plasma glucose profile <200 mg/dl). One eye of each patient was selected randomly for statistical analysis. Results: Mean plasma glucose levels were 356.00 mg/dl before and 133.78 mg/dl after treatment. The median values of the autorefractometric measurements were - 0.125 D on admission and + 0.375 D at the second examination. The difference in the refraction was statistically significant (P = 0.022). Nine of 18 patients became hyperopic, 2 became myopic and 7 showed no change after treatment. There was a significant change in the corneal topographic keratometric measurements at the flattest corneal meridian after treatment (P = 0.037). After treatment no statistically significant changes were observed in the pachymetric corneal thickness, anterior chamber depth, biometric dioptric lens calculations and Javal keratometric data. Conclusions: Hyperglycemia is the major cause of the transient refractive changes in diabetic patients. Following intensive medical treatment, a considerable number of patients tend to become more hyperopic compared with the hyperglycemic state. During the treatment period, changes in the corneal topographic parameters might be a potential source of error for keratorefractive and cataract surgery.