Saban Gonul

Comparison of the Effect of Unilateral Intravitreal Bevacizumab and Ranibizumab Injection on Diabetic Macular Edema of the Fellow Eye

PURPOSE To find out whether intravitreally administered bevacizumab and ranibizumab affect the contralateral, untreated, eyes of patients with bilateral diabetic macular edema (DME). METHODS A retrospective review of patients with bilateral DME, who were treated with intravitreal bevacizumab or ranibizumab, was performed. All enrolled patients received intravitreal 1.25 mg bevacizumab or 0.5 mg ranibizumab in the eye with more severe macular edema. As outcome measures, best-corrected visual acuity (BCVA) was assessed with the Early Treatment Diabetic Retinopathy Study chart and central foveal thickness (CFT) measurement was obtained using optical coherence tomography-3 before and at 2 and 4 weeks after injections. RESULTS The study included 55 eyes of 55 patients who received bevacizumab (group 1) and 32 eyes of 32 patients who received ranibizumab (group 2). The mean age of the 55 patients [35 female (63.6%), 20 male (36.4%)] in group 1 was 54.31±12.67 years, and the mean age of the 32 patients [20 female (62.5%), 12 male (37.5%)] in group 2 was 56.01±13.29 years. The median BCVA in the uninjected eye showed no statistically significant change at any visit after either bevacizumab or ranibizumab injection (P=0.302, P=0.582, respectively). In group 1, the median CFT in the uninjected eye was 417 μm at baseline; this was reduced to 401 μm at 2 weeks and 372 μm at 4 weeks. The change in CFT was found to be statistically significant (P=0.009). No statistically significant change was found in the median CFT of uninjected eyes of patients treated with ranibizumab (399, 403, and 407 μm before and at 2 and 4 weeks after treatment, respectively). CONCLUSIONS Compared with ranibizumab, intravitreal administration of bevacizumab resulted in a greater decrease in macular thickness in the untreated eye, in patients with bilateral DME.

Comparison of the ganglion cell complex and retinal nerve fibre layer measurements using Fourier domain optical coherence tomography to detect ganglion cell loss in non-arteritic anterior ischaemic optic neuropathy

Objective To evaluate the diagnostic ability of macular ganglion cell complex (GCC) and peripapillary nerve fibre layer (NFL) measurements to detect ganglion cell loss (GCL) in patients with non-arteritic anterior ischaemic optic neuropathy (NAION), at the chronic stage. Methods This study included 10 eyes from 10 patients with NAION and 15 eyes from 15 age-matched healthy subjects. The measurements included the GCC thicknesses as average, superior and inferior, the GCC parameters as focal loss volume (FLV) and global loss volume (GLV), the NFL thicknesses as average, superior hemisphere and inferior hemisphere, and the disc parameters as rim area and rim volume. The curves for the area under the receiver operator characteristic (AUROC) were generated to assess the ability of each parameter to detect GCL. Results The patient group had significantly lower GCC thicknesses than the control group (p<0.001, <0.001 and 0.004, for the GCC average, superior and inferior, respectively), and also significantly higher FLV and GLV measurements (p<0.001). The NFL thicknesses were found to be significantly lower in the patient group than the control subjects (p<0.001). Among all the parameters, the FLV and the GLV had the highest levels of AUROC values (1.000, 0.990, respectively). Conclusions The FLV and the GLV showed the strongest abilities to detect GCL in patients with NAION. In addition, peripapillary NFL thickness was comparable to macular GCC thickness in detecting GCL. Therefore, macular GCC scans may provide a good alternative or a complementary practice to NFL scans in the detection of GCL in patients with NAION.

Effect of religious fasting on tear osmolarity and ocular surface.

Objective: To evaluate the effects of religious fasting on tear secretion, tear osmolarity, corneal topography, and ocular aberrations. Methods: This prospective controlled study comprised 29 eyes of 29 healthy men. Before ophthalmologic examination, all subjects underwent corneal topography by a placido disc corneal topography and aberrometry device (OPD Scan II). Tear osmolarity was measured using OcuSense TearLab osmometer. Ocular surface disease index (OSDI) scores, tear break-up time (BUT), Schirmer I test, and lissamine green staining were evaluated. The measurements taken before and during Ramadan at the same hours between 4.00 and 5.00 PM were compared using paired sample t test, and a P value less than 0.05 was accepted as statistically significant. Results: The mean age of the study group was 27.8±5.9 years (range, 20–47 years). The mean tear osmolarity values were measured as 285.6±8.2 mOsm/L and 293.3±16.0 mOsm/L, whereas the mean Schirmer I values were 14.8±6.0 mm and 10.6±5.3 mm in nonfasting and fasting periods, respectively. Tear osmolarity, OSDI, and Oxford grading scores significantly increased (P=0.02, P=0.002, P=0.003, respectively), whereas Schirmer I values and intraocular pressure decreased (both, P<0.001) during the fasting period compared with the nonfasting period. There were no significant differences in tear BUT, keratometry values, and corneal aberration measurements between nonfasting and fasting periods (P>0.05, for all). Conclusion: Fasting significantly decreases tear production and increases tear osmolarity; however, it does not deteriorate corneal topographic parameters and ocular aberrations in healthy subjects.

Topiramate-induced acute-onset myopia and central corneal thickening: Pentacam Scheimpflug imaging findings.

Topiramate is a second-line antiepileptic drug that is also used for prophylaxis of migraine and cluster headache. The most widely recognized ocular side effect of topiramate is ciliochoroidal effusion with forward displacement of the lens– iris diaphragm and anterior chamber shallowing, resulting in acute myopia and angle-closure glaucoma. To the best of our knowledge, corneal changes have not been reported in this group of patients. We report a patient who presented with acute-onset myopia and shallowing of the anterior chamber without angle-closure glaucoma secondary to topiramate use and her follow-up with the Pentacam Scheimpflug imaging system (Oculus Inc, Lynnwood, Wash.). A 29-year-old woman with a history of migraine headache presented with blurred vision. She had used topiramate (25 mg/day) for 10 days and she experienced blurred vision in both eyes early in the morning. She was asked by her ophthalmologist to stop topiramate and was referred to our clinic. Her ophthalmic examination revealed uncorrected visual acuity of 20/200 bilaterally and her bestcorrected visual acuity (BCVA) was 20/20 in both eyes, with −8.00−1.50 × 160 in the right eye and −9.00−1.25 × 20 in the left eye. Her anterior chamber depths were strikingly shallow, especially in the left eye, with forward displacement of the lens–iris diaphragm (Fig. 1A). Although there were no visible angle structures on gonioscopy, her intraocular pressures were normal, measured as 19 mm Hg OD and 18 mm Hg OS. Her undilated fundus examination was normal but B-scan ultrasonography revealed choroidal effusion. Her baseline measurements were obtained with the Pentacam Scheimpflug imaging system (Table 1). She was warned about the symptoms of angle-closure glaucoma and sent to the referring ophthalmologist to be followed with intraocular pressure measurements on a daily basis. Three days later, anterior chamber depths were better, as were iridocorneal angles (Fig. 1B). Despite improvement in anterior chamber depth and angle parameters, there was no significant change in central corneal thickness (Table 1). At her 3-week visit, her anterior chamber parameters were normalized despite a marked decrease in central corneal thickness (Fig. 1C and Table 1). Her BCVA was 20/20 in out neurosensory detachment; a presumptive diagnosis of CSCR was offered. Despite 1 intravitreal injection of triamcinolone in 2005, the clinical and angiographic appearance had remained stable for the following 4 years, at which time he presented to our institution. In December 2006, ETDRS (Early Treatment Diabetic Retinopathy Study) visual acuity was 20/16 in the right eye and 20/50 in the left eye. Examination of the asymptomatic right eye revealed only a small PED superotemporal to the optic nerve without subretinal fluid. The left eye had a 1 disc area subfoveal serous PED with pigmentary abnormalities, without subretinal fluid, lipid, or hemorrhage. On fluorescein angiography, there was pooling of fluorescein in the serous PED with no leakage. No subretinal fluid or interstitial edema was seen on optical coherence tomography (OCT) (Fig. 1). As the patient had decreased visual function, symptomatic distortion, and excellent documentation of the longstanding nature of the PED, we recommended photodynamic therapy. A 10-minute intravenous infusion of verteporfin (6 mg/m) was followed by application of a 689 nm laser (Coherent Inc, Santa Clara, Calif.) delivering 30 J/cm for 83 seconds, with a spot size of 2600 μm to cover the entire PED. No complications ensued. Within 3 weeks of treatment, the patient noticed a marked reduction in distortion and improvement in clarity. On follow-up 6 weeks later, visual acuity had improved to 20/20 with collapse of the PED. OCT images confirmed complete absence of retinal pigment epithelium elevation and retention of normal foveal contour (Fig. 2). Only mild attenuation of retinal thickness in the inner nasal subfield was seen. Fourteen weeks after treatment, no symptoms were present, visual acuity remained at 20/20, and the clinical and OCT findings remained unchanged. Fluorescein angiography showed late staining of the retinal pigment epithelium in the region of the original PED. Despite the chronic nature of the PED, this eye had only slightly attenuated retinal thickness on OCT after resolution of the PED. Limitation in visual recovery in eyes with chronic CSCR has been attributed to atrophic neurosensory retinal changes identified on OCT that are presumed to occur from longstanding neurosensory detachment. It is possible that since this eye never had documented subretinal fluid, the retinal architecture and function were relatively preserved, allowing recovery of vision to 20/20.

Bilateral acute depigmentation of the iris (BADI): first reported case in Brazil

Bilateral acute depigmentation of the iris (BADI) is a recently described entity characterized by acute onset of pigment dispersion in the anterior chamber, depigmentation of the iris, and heavy pigment deposition in the anterior chamber angle. Involvement is always bilateral, simultaneous, and symmetrical. We report the case of a 61-year-old man who presented with bilateral ocular pain, red eyes, and severe photophobia. Examination revealed a dense Krukenberg spindle, heavy pigment dispersion in the anterior chamber, extensive transillumination iris defects, and a heavy pigment deposition in the trabecular meshwork bilaterally. Intraocular pressure increased to 48 mmHg in both eyes. The patient received topical steroids, maximum hypotensive treatment and oral valacyclovir. Intraocular pressure gradually decreased throughout the second and third months, and medications were gradually tapered. The time to complete resolution of pigment dispersion was 18 weeks. Visual acuity and visual fields remained normal, but the photophobia was permanent.

Bilateral acute iris transillumination (BAIT) initially misdiagnosed as acute iridocyclitis

Bilateral acute iris transillumination (BAIT) is a relatively new clinical entity characterized by bilateral acute loss of iris pigment epithelium, iris transillumination, pigment dispersion in the anterior chamber, and sphincter paralysis. We report the case of a 30-year-old male who was initially diagnosed with acute iridocyclitis in a different clinic and treated with topical and systemic corticosteroids. He was referred to our clinic to seek another opinion because his symptoms did not improve. An ocular examination revealed bilateral pigment dispersion into the anterior chamber, diffuse iris transillumination, pigment dusting on the anterior lens capsule, atonic and distorted pupils, and increased intraocular pressure, suggesting a diagnosis of BAIT rather than iridocyclitis. Clinicians should be aware of the differential diagnosis of syndromes associated with pigment dispersion from iridocyclitis to avoid aggressive anti-inflammatory therapy and detailed investigation for uveitis.

Association of Apolipoprotein E Polymorphism with Intravitreal Ranibizumab Treatment Outcomes in Age-Related Macular Degeneration.

Abstract Purpose: Genetic factors are known to influence the response to anti-vascular endothelial growth factor (VEGF) treatment in exudative age-related macular degeneration (AMD). The current study was conducted to investigate the association of Apolipoprotein E (ApoE) polymorphism with the treatment response to ranibizumab for exudative AMD. Methods: One hundred nine eyes (109 patients, 59.6% male, mean age 63.84 ± 7.22 years) treated with intravitreal ranibizumab injections were included in the analysis. Smoking status and lesion type were recorded. Patients were categorized into three groups according to visual acuity (VA) change at 6 months after the first injection: VA loss >5 Early Treatment Diabetic Retinopathy Study (ETDRS) letters (Group 1); VA change between five ETDRS letters gain and loss (Group 2); VA improvement >5 ETDRS letters (Group 3). The association of ApoE gene polymorphisms with the three groups was evaluated. Results: Both smoking status and lesion type showed no significant association with VA change (p = 0.12 and p = 0.64, respectively). A lower frequency of ɛ2 and a higher frequency of ɛ4 were observed in Group 3 (2.9 and 25.7%, respectively). VA improvement with more than five ETDRS letters was significantly associated with the presence of the ɛ4 genotype (p = 0.01). Conclusions: This study demonstrated that carriers of the ApoE ɛ4 polymorphism genotype show demonstrable improvement in VA after treatment with ranibizumab in exudative AMD. ApoE polymorphism identification may be used as a genetic screening to tailor individualized therapeutic approach for optimal treatment in neovascular AMD.

Postoperative fungal endophthalmitis caused by Trichosporon asahii treated with voriconazole

Postoperative fungal endophthalmitis is a rare but devastating complication of cataract surgery. Vitrectomy and intravitreal amphotericin B injection as well as administration of systemic antifungal agents have been suggested as optimal treatments for fungal endophthalmitis. However, this therapy may fail to eliminate fungal species resistant to current antifungal agents. The saprophytic fungus Trichosporon asahii is frequently observed as a cause of endogenous endophthalmitis in immunosuppressed patients. We report a case of postoperative endophthalmitis caused by T. asahii, resistant to amphotericin B. To the best of our knowledge, this is the first report of T. asahii endophthalmitis successfully treated with intravitreal and systemic voriconazole, pars plana vitrectomy, and removal of the intraocular lens and entire lens capsule.

Quantitative Assessment of Anterior Chamber Inflammation in Patients with Retained Presumed Intraocular Cotton Fiber after Phacoemulsification

Abstract Purpose: To evaluate anterior chamber inflammation in eyes with retained presumed intraocular cotton fibers after small-incision cataract surgery. Methods: Fourteen patients with retained presumed intraocular cotton fibers after phacoemulsification were evaluated for anterior chamber inflammation. The control group consisted of 15 patients with no postoperative intraocular cotton fibers. An aqueous flare meter was used to evaluate anterior chamber reaction 1 day, 1 week, and 1 month postoperatively. Results: Retained cotton fibers were detected in the anterior chamber in 6 cases, and in the corneal incision site, extending into the anterior chamber, in 8 cases. The mean flare values at each postoperative visit were statistically similar between two groups. Conclusions: Following cataract surgery, retained presumed intraocular cotton fibers did not cause any additional inflammation in the eye within the short term. In contrast to other intraocular foreign bodies, which may cause severe inflammation, retained intraocular cotton fibers seem to be well tolerated following cataract surgery.

The effect and safety of intravitreal injection of ranibizumab and bevacizumab on the corneal endothelium in the treatment of diabetic macular edema.

Abstract Objective: To investigate the effect and safety of intravitreal injection (IVI) of bevacizumab and ranibizumab on corneal endothelial cell count and morphology in patients with diabetic macular edema. Materials and methods: A total of 60 eyes from 60 consecutive patients who received 0.5 mg/0.05 ml IVIs of bevacizumab (n = 30, IVB group) or 1.25 mg/0.05 ml ranibizumab (n = 30, IVR group) for three consecutive months were investigated prospectively. Specular microscopy was performed to evaluate endothelial cell count, the percentage of hexagonal cells (pleomorphism), and the coefficient of variation of the cell size (polymegathism); optical biometry was performed to evaluate central corneal thickness. Results before injection and 1 month after the first and third injections were compared. Results: The groups were matched for age (p = 0.11) and gender (p = 0.32). There was no significant difference in endothelial cell count (IVB group, p = 0.66; IVR group, p = 0.74), pleomorphism (IVB group, p = 0.44; IVR group, p = 0.88) and polymegathism (IVB group, p = 0.21; IVR group, p = 0.24) before injection or 1 month after the first and third injections. There was also no difference in central corneal thickness (IVB group, p = 0.15; IVR group, p = 0.58) before injection or 1 month after the first and third injections. Conclusion: Monthly 1.25 mg/0.05 ml IVIs of bevacizumab or 0.5 mg/0.05 ml of ranibizumab for three consecutive months in the treatment of diabetic macular edema does not affect corneal morphology and has no harmful effects on the endothelium.