Özkan Sever

Endothelial cell loss: Biaxial small-incision torsional phacoemulsification versus biaxial small-incision longitudinal phacoemulsification

PURPOSE: To compare clinical results of biaxial small‐incision torsional phacoemulsification and biaxial small‐incision longitudinal phacoemulsification. SETTING: Department of Ophthalmology, School of Medicine, Namik Kemal University, Tekirdag, Turkey. DESIGN: Randomized controlled clinical trial. METHODS: Eyes with high‐density nuclear cataract were assigned to have biaxial longitudinal (microburst mode) or biaxial torsional phacoemulsification. The main outcomes included corrected distance visual acuity (CDVA), central corneal thickness (CCT), central endothelial cell density (ECD), total ultrasound time (UST), cumulative dissipated energy (CDE), percentage total equivalent power in position 3, and balanced salt solution volume. Postoperative follow‐up was at 1 day, 1 week, and 1 and 3 months. RESULTS: Each group comprised 35 patients (35 eyes). Three months postoperatively, the mean CDVA for each group was 0.02 logMAR and the mean CCT returned to the preoperative level (P=.589 and P=.554, respectively). During the postoperative follow‐up, the percentage of mean endothelial cell loss in both groups was between 35.4% and 39.1%; there was no statistically significant difference between the groups (P>.05). The mean CDE, UST, percentage total equivalent power in position 3, and balanced salt solution volume values were similar in the 2 groups (P>.05). CONCLUSION: The risk for high endothelial cell loss should be considered when the phacoemulsification of high‐density nuclear cataracts is performed using either method. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Intravitreal tigecycline treatment in experimental Acinetobacter baumannii endophthalmitis.

Abstract Purpose: To investigate the clinical and microbiological effectivity of intravitreal tigecycline in an experimental rabbit endophthalmitis model caused by imipenem resistant Acinetobacter baumannii. Materials and Methods: Forty-eight eyes of 24 New Zealand white albino rabbits were divided into six groups (n = 8 in each). The right eyes were divided into three groups and defined as infected group; left eyes were divided into three groups and defined as uninfected group. Infected group received 0·1 ml intravitreal A. baumannii suspension. Twenty-four hours after bacterial inoculation, group 1 received 1 mg/0·1 ml tigecycline and group 2 received 0·5 mg/0·1 ml tigecycline. Group 3 eyes received no treatment. In group 4, 0·1 ml of saline solution was injected. Groups 5 and 6 were received intravitreal tigecycline injection of 1 mg/0·1 ml and 0·5 mg/0·1 ml respectively. The eyes were enucleated for histopathological evaluation on the sixth day. Clinical and histological scoring systems were used to evaluate clinical and histological severity of the intraocular infection. Results: The mean clinical scores of the six groups at the sixth day were 11±1·92, 12·4±6·2, 8·5±2·7, 0, 3±1·3, and 3±1·4 respectively. Mean histopathological scores were 7·8±2·8, 7·0±1·5, 5·6±1·4, 0, 0, and 0 respectively. There was no significant difference in mean clinical and histopathological scores of infected group (groups 1, 2 and 3). There was significant difference in mean clinical scores of groups 5 and 6 compared with group 4. Groups 4, 5 and 6 showed normal histological structure in histopathological evaluation and showed no significant difference. Microbiological cure was achieved in all infected eyes. Conclusions: Experimental rabbit endophthalmitis model caused by imipenem resistant A. baumannii was microbiologically cured by intravitreal tigecycline injection. However, a hypersensitivity-like reaction due to intravitreal application of tigecycline limits the use of this antimicrobial agent in A. baumannii endophthalmitis.

Anti-inflammatory and ultrastructural effects of Turkish propolis in a rat model of endotoxin-induced uveitis.

INTRODUCTION Experimental animal models of acute uveitis, an inflammatory eye disease, can be established via endotoxin-induced inflammation. Propolis, a natural substance collected by honeybees from buds and tree exudates, has antioxidant, antibacterial, antiviral, and anti-inflammatory effects. We investigated the effects of propolis, obtained from the Sakarya province of Turkey, on endotoxin-induced uveitis using immunohistochemical, ultrastructural, and biochemical approaches. MATERIAL AND METHODS Male Wistar albino rats (n = 6/group) received intraperitoneal (ip) lipopolysaccharide (LPS) endotoxin (150 μg/kg) followed by aqueous extract of propolis (50 mg/kg ip) or vehicle; two additional groups received either saline (control) or propolis only. After 24 h, aqueous humor (AH) was collected from both eyes of each animal for analysis of tumor necrosis factor-α (TNF-α) and hypoxia-inducible factor-1α (HIF-1α). Right eyeballs were paraffin-embedded for immunohistochemical staining of nuclear factor κB (NF-κB)/p65 and left eyeballs were araldite-embedded for ultrastructural analysis. RESULTS Treatment of LPS-induced uveitis with propolis significantly reduced ciliary body NF-κB/p65 immunoreactivity and AH levels of HIF-1α and TNF-α. Ultrastructural analysis showed fewer vacuoles and reduced mitochondrial degeneration in the retinal pigment epithelium, as compared to the uveitis group. The intercellular spaces of the inner nuclear layer and outer limiting membrane were comparable with those of the control group; no polymorphonuclear cells or stasis was observed in intravascular or extravascular spaces. CONCLUSIONS This is the first report demonstrating an anti-inflammatory effect of Turkish propolis in a rat model of LPS-induced acute uveitis, suggesting a therapeutic potential of propolis for the treatment of inflammatory ophthalmic diseases.

Reply: Gas-forced infusion prevents endothelial cell loss in phacoemulsification.

Gas-forced infusion prevents endothelial cell loss in phacoemulsification In their recent study comparing endothelial cell loss in longitudinal and torsional biaxial smallincision phacoemulsification techniques, Gonen et al. found no significant difference between the 2 techniques. In this context, we would like the authors to clarify whether gas-forced infusion (air pump) was an option in any of these eyes during surgery. The use of gas-forced infusion prevents endothelial cell loss by decreasing the intraoperative surge. A gas-forced infusion system is connected through a nitrocellulose membrane air filter to the infusion fluid bottle. The air filter prevents contaminants in the operating room air from entering the eye. The air pump produces a positive pressure head above the fluid in the bottle, significantly increasing the amount of fluid entering the eye and balancing the excess outflow occurring when the occlusion is broken. It also blunts the fluctuations in intraocular pressure. In our prospective study of gas-forced infusion in longitudinal phacoemulsification, we noted that the mean endothelial cell loss was lower in the infusion group than in the control group (6.98% G 8.46% [SD] versus 10.54% G 11.24%, PZ.045). Gonen et al. used a 19-gauge irrigating chopper for irrigation and a 20-gauge phaco tip for aspiration. The intraoperative vacuum was set at 250 mm Hg and the flow rate at 30 mL/min. However, despite the claimed anterior chamber stability, the endothelial cell loss exceeded 35% in both groups. In our study, the cell loss was 6.98% G 8.46% in eyes that had phacoemulsification with gas-forced infusion but 10.54% G 11.24% in eyes without gas-forced infusion. Gonen et al. should have calculated the incidence of intraoperative surge, which can affect the endothelial loss. From our experience with phakonit, we noted that an air pump deepens the anterior chamber, increasing the surgical space available for maneuvering, and thus prevents complications such as posterior capsule tears and corneal endothelial damage. The phenomenon of surge is neutralized by rapid inflow of fluid at the time of occlusion break. The irrigating chopper and the bimanual irrigation/aspiration of a 22-gauge will provide better chamber stability. In our analysis of wound architecture, we noted that good endothelial alignment was seen in eyes with microphakonit (with gas-forced infusion) as early as 3 days postoperatively. We would like to recommend the use of air-forced infusion during phacoemulsification. A built-in device for pressurized infusion has been adapted in various phacoemulsification systems.

Choroidal Thickness of Helicobacter-Positive Patients without Central Serous Chorioretinopathy

ABSTRACT Purpose: To evaluate the effect of Helicobacter pylori (H. pylori) infection on subfoveal choroidal thickness (SFCT) in patients without clinical central serous chorioretinopathy (CSC). Materials and Methods: This prospective study included 50 patients with pathologically proven H. pylori infection (H. pylori (+)) and 50 patients without H. pylori infection (H. pylori (−)). All of the recruited patients were previously admitted to the Gastroenterology Department of the Namik Kemal University School of Medicine over the period of July 2014 to September 2015. All patients had 20/20 vision and underwent complete ophthalmological examination, macular optical coherence tomography (OCT), and enhanced depth imaging OCT. Results: All patients had 20/20 vision and similar macular thicknesses. The mean SFCT of patients in the H. pylori (+) group was 309 ± 41.1 µm and 315 ± 18.2 µm in the H. pylori (−) group (p = 0.174). The right and left eyes of patients in the H. pylori (+) and (−) groups were not statistically significantly different (p = 0.852, p = 0.937). The age, sex, and choroidal thicknesses of patients in the H. pylori (+) and (−) groups were not correlated. Conclusion: H. pylori infection does not have an effect on choroidal thickness in patients without any ocular pathology.

Effect of intravitreal ranibizumab on serous retinal detachment in branch retinal vein occlusion

Purpose The aim of this study was to evaluate the effect of initial intravitreal ranibizumab injection on visual acuity (VA) and central macular thickness (CMT) for the treatment of macular edema (ME) with and without serous retinal detachment (SRD) secondary to branch retinal vein occlusion (BRVO). Materials and methods Fifty-two BRVO eyes, treated with intravitreal ranibizumab injection for ME with and without SRD, were retrospectively reviewed. Patients were divided into two groups according to spectral domain optical coherence tomography (SD-OCT). The efficacy of intravitreal ranibizumab injection at first month was assessed by analyzing the change in best-corrected VA and reduction in CMT with SD-OCT. Results There were 21 patients with SRD and 31 patients with only CME (no-SRD). CMT was significantly greater in the SRD group than in the CME group (451±62.2 µm vs 383.5±37.2 µm, respectively, P<0.05). After initial intravitreal ranibizumab injection, mean VA improved from 0.87±0.26 logarithm of the minimum angle of resolution (LogMAR) to 0.54±0.27 LogMAR (P<0.01) and CMT decreased from 451±62.2 µm to 379.3±58.6 µm (P<0.001) in the SRD group. In the no-SRD group, mean VA improved from 0.69±0.25 LogMAR to 0.44±0.25 LogMAR (P<0.001) and the CMT decreased from 383.5±37.2 µm to 337.7±39.4 µm (P<0.001) at the first month visit. Eyes with SRD revealed better anatomic results and greater reduction of CMT after intravitreal ranibizumab injection (P<0.01). Conclusion VA and CMT can be improved by intravitreal ranibizumab injection in BRVO patients with and without SRD. However, more marked improvement in macular morphology was achieved in patients with SRD than those without SRD.

Early Retinal and Choroidal Coat Thickness Changes After Intravitreal Dexamethasone Implant Injection for Diabetic Macular Edema.

Background: Intravitreal steroid injection is one of the treatment options for diabetic macular edema. Dexamethasone implant is the most novel form of intravitreal steroid therapy. Improvement in macular thickness is a well-known effect of Dexamethasone implant however, subfoveal choroidal coat thickness changes require investigation. Aims: To evaluate the early central macular thickness and subfoveal choroidal thickness alterations after single-dose dexamethasone implant injection in diabetic macular edema. Study Design: Cross-sectional study. Methods: We identified 29 patients with diabetic macular edema (29 eyes) who underwent optical coherence tomography and fundus fluorescein angiography. All patients received a single-dose intravitreal Dexamethasone implant and were followed up for central macular thickness and subfoveal choroidal thickness alterations for 1 hour, 1 week, 1 month, and 3 months post-injection. Results: The preoperative mean central macular thickness and subfoveal choroidal thickness measurements were 592.3±122.3 (412–879) μm and 264.8±53.7 (165–397) μm, respectively. Central macular thickness measurements decreased significantly in the first hour (p<0.050) and continued to decrease until the third month (p<0.001), whereas the subfoveal choroidal thickness decrement was only significant on the first day (p<0.05). Decreases in subfoveal choroidal thickness and central macular thickness of 1.5% and 5% were observed at 1 hour; however, the difference was not significant (p>0.050). The decrease in central macular thickness was significantly greater than that in subfoveal choroidal thickness at 1 day, 1 week, 1 month, and 3 months (p<0.001). Conclusion: Intravitreal Dexamethasone implant has a meaningful effect on central macular thickness in patients with diabetic macular edema, while subfoveal choroidal thickness decreases significantly at first day.

Segmentation and removal of fibrovascular membranes with high-speed 23 G transconjunctival sutureless vitrectomy, in severe proliferative diabetic retinopathy

Aim To evaluate the effectiveness and safety of high-speed (5,000 cuts per minute) 23 G transconjunctival sutureless vitrectomy (TSV) in severe diabetic fibrovascular proliferation (DFVP). Patients and methods In this retrospective consecutive case series, patients who underwent 23 G TSV for severe DFVP between October 2011 and March 2014 at our institution were evaluated. 23 G TSV was performed with a high-speed (5,000 cuts per minute) cutter without a chandelier light. Results The mean follow-up period was 8 months (range: 4–23 months). Of the 27 eyes of 27 patients, 14 eyes (52%) underwent concomitant phacoemulsification with posterior chamber intraocular lens implantation, nine eyes (33%) were pseudophakic, and four eyes were phakic (15%). DFVP was removed with ease in all, and visual acuity was improved in 18 (67%) eyes. Iatrogenic retinal tear was observed in four eyes (15%) and treated successfully during surgery. Suture placement to a single sclerotomy was performed in eight eyes (30%). Postoperative intraocular hemorrhage was observed in five eyes (18%). Cataract formation was observed in two of the four phakic eyes. Three (11%) patients had postoperative intraocular pressure rise. Postoperative hypotony (≤6 mmHg) and endophthalmitis were not observed in any eye. Conclusion The segmentation and removal of fibrovascular membranes with high-speed 23 G TSV seems to be a safe and easy method in severe diabetic eye disease.