Serhad Nalcaci

Surgically induced corneal refractive change following glaucoma surgery ☆: Nonpenetrating trabecular surgeries versus trabeculectomy

Purpose: To compare surgically induced corneal refractive change following trabeculectomy with the nonpenetrating trabecular filtering surgeries with and without implant. Setting: Department of Ophthalmology, Ege University School of Medicine, Izmir, Turkey. Methods: A consecutive series of 34 patients (34 eyes) with uncontrolled open‐angle glaucoma had trabecular filtering surgery. Patients were assigned randomly to receive viscocanalostomy (12 patients), nonpenetrating deep sclerectomy (NPDS) with T‐flux® implant (10 patients), and trabeculectomy (12 patients). Autokeratometry and computerized corneal videokeratoscopy with the Topcon KR‐7000P autokeratorefractometer were performed preoperatively and 1 day and 1, 3, and 6 months postoperatively to analyze surgically induced keratometric and topographic astigmatism. Results: Thirty patients (11 trabeculectomy, 11 viscocanalostomy, and 8 NPDS with nonabsorbable implant) completed the study. Mean patient age was 61.7 years ± 10.9 (SD) (range 37 to 81) and did not differ among groups. Postoperative intraocular pressure (IOP) levels and visual acuity (logMAR values) did not differ among groups compared with preoperative levels. Average induced astigmatism was lower in the NPDS group than the trabeculectomy group at postoperative month 3 and 6 based on autokeratometry values (P = .023 and .042, respectively). Nonpenetrating surgeries resulted in less induced astigmatism in the early postoperative period and less against‐the‐rule shift over 6 months. Conclusion: Despite larger flap size and surgical area, nonpenetrating trabecular surgeries induced less astigmatism than trabeculectomy.

Evaluation of posterior vitreous detachment after uneventful phacoemulsification surgery by optical coherence tomography and ultrasonography

The aim was to investigate the effect of uneventful phacoemulsification on vitreoretinal interface evaluated by optical coherence tomography (OCT) and ultrasound.

The Prevalence and Characteristics of Charles Bonnet Syndrome in Turkish Patients with Retinal Disease

Purpose: The aim of this study is to investigate the prevalence and clinical characteristics of Charles Bonnet syndrome (CBS) in a group of Turkish patients with various retinal diseases. Methods: Two hundred and sixty-four patients with a best-corrected visual acuity of ≤20/40 in the better-seeing eye were asked with a standardized question whether they had symptoms of CBS. If they responded positively, a questionnaire was verbally administered to learn more about the details of the symptoms. Results: There were 125 (47.3%) females and 139 (52.7%) males with a mean age of 72.1 years (range 31-90). Seventeen (6.4%) patients were diagnosed with CBS. Three (17.7%) patients had noncomplex hallucinations and 14 (82.3%) had complex hallucinations. Conclusion: CBS is not uncommon in visually impaired patients with retinal disease. Clinicians who care for visually impaired patients should be aware of CBS.

Choroidal malignant melanoma with no extraocular extension presenting as orbital cellulitis

ABSTRACT This report describes a patient with choroidal malignant melanoma presenting as orbital cellulitis without extraocular tumor extension. It is an interventional case report with histopathologic correlation. A 68-year-old male presented with a 3-day history of painful hyperemia and swelling in the right eye. The examination showed edematous eyelids, mechanical ptosis and chemosis with conjunctival injection. B-scan ultrasonography showed a mass with medium level echogenicity that filled the vitreous cavity. Magnetic resonance imaging showed a solid choroidal mass with hemorrhagic and inflammatory changes with no obvious extraocular extension. Due to these suggestive findings of choroidal melanoma the right eye was enucleated. A spindle cell choroidal melanoma including intense pigmentation and necrosis was confirmed by histopathological examination. Although rare; choroidal melanoma may present as orbital cellulitis, particularly when the tumor is necrotic.

Fundus fluorescein angiographic findings in patients who underwent ventricular assist device implantation.

Disruption of microcirculation in various tissues as a result of deformed blood rheology due to ventricular assist device (VAD) implantation causes novel arteriovenous malformations. Capillary disturbances and related vascular leakage in the retina and choroidea may also be seen in patients supported by VADs. We aimed to evaluate retinal vasculature deteriorations after VAD implantation. The charts of 17 patients who underwent VAD implantation surgery for the treatment of end-stage heart failure were retrospectively reviewed. Eight cases (47.1%) underwent pulsatile pump implantation (Berlin Heart EXCOR, Berlin Heart Mediprodukt GmbH, Berlin, Germany); however, nine cases (52.9%) had continuous-flow pump using centrifugal design (HeartWare, HeartWare Inc., Miramar, FL, USA). Study participants were selected among the patients who had survived with a VAD for at least 6 months, and results of detailed ophthalmologic examinations including optic coherence tomography (OCT) and fundus fluorescein angiography (FA) were documented. All of the 17 patients were male, with a mean age of 48.5 ± 14.8 years (15-67 years). Detailed ophthalmologic examinations including the evaluation of retinal vascular deteriorations via FA were performed at a mean of 11.8 ± 3.7 months of follow-up (6-18 months). Mean best-corrected visual acuity and intraocular pressure were found as logMAR 0.02 ± 0.08 and 14.6 ± 1.9 mm Hg, respectively in the study population. Dilated fundoscopy revealed severe focal arteriolar narrowing in two patients (11.8%), and arteriovenous crossing changes in four patients (23.5%); however, no pathological alteration was present in macular OCT scans. In patients with continuous-flow blood pumps, mean arm-retina circulation time (ARCT) and arteriovenous transit time (AVTT) were found to be 16.8 ± 3.0 and 12.4 ± 6.2 s, respectively; whereas those with pulsatile-flow blood pumps were found to be 17.4 ± 3.6 and 14.0 ± 2.1 s in patients (P=0.526 and P=0.356, respectively). FA also revealed a tendency for increased frequency of dye leakage from the optic disc in our study population. Except for remarkable delays in both ARCT and AVTT as well as a tendency for increased frequency of dye leakage from the optic disc, ophthalmologic evaluations revealed no other significant pathology or vascular deterioration in the retina that could be attributed to artificial heart systems.

The Importance Of The Peripheral Retina In Patients With Central Serous Chorioretinopathy

Purpose: This research investigated the peripheral retinas of patients with central serous chorioretinopathy (CSCR). Methods: Sixty patients with CSCR and 60 age- and gender-matched controls were included in this prospective cross-sectional study. All 120 participants underwent ocular examinations and peripheral retinal evaluations using a Goldmann three-mirror lens. Results: The examinations demonstrated peripheral retinal degeneration, atrophic or hyperplastic retinal pigment epithelial changes, and retinal breaks. The peripheral retinal degeneration rate was 39% in the CSCR group and 15% in the control group, and the CSCR group reported significantly more lattice degeneration than the control group (22 vs. 3%) (P = 0.004, odds ratio = 1.97, confidence interval = 0.68–5.65 and P = 0.002, odds ratio = 4.55, confidence interval = 0.77–26.83, respectively). Symptomatic U-shaped retinal breaks were found in three eyes (5%) in the CSCR group, and the rate of peripheral retinal degeneration was higher in the patients with chronic CSCR (vs. acute CSCR). However, this difference was not significant (P = 0.244). Conclusion: This study showed that peripheral retinal abnormalities, particularly lattice degeneration, are more common in patients with CSCR. Therefore, the authors recommend regular retinal examinations, with the inclusion of peripheral retinal assessments, for patients with CSCR.

Characteristics of Fundus Autofluorescence in Active Polypoidal Choroidal Vasculopathy

Objectives: To define characteristic fundus autofluorescence (FAF) findings in eyes with active polypoidal choroidal vasculopathy (PCV). Materials and Methods: Thirty-five eyes of 29 patients with active PCV who were diagnosed at Ege University Faculty of Medicine, Department of Ophthalmology, Retina Division between January 2012 and November 2014 were included in the study. All the patients underwent a complete ophthalmological examination including fundus photography, spectral-domain optical coherence tomography, fluorescein angiography, FAF photography, and indocyanine green angiography (ICGA). ICGA was used to diagnose active PCV and identify lesion components. FAF findings were described at the retinal site of the corresponding lesions identified and diagnosed using ICGA. Results: The mean age of the 29 study patients (15 men, 14 women) was 64.6±7.5 years (range, 54-82 years). ICGA revealed active PCV in 35 eyes, consisting of polypoid lesions in 11 eyes (31.4%), branching vascular networks (BVN) in 10 eyes (28.6%), and a combination of polypoid lesions and BVNs in 14 eyes (40%). On FAF images, 4 different patterns were detected at the corresponding retinal sites of 25 polypoid lesions detected by ICGA: confluent hypoautofluorescence with a hyperautofluorescent ring in 18 eyes (72%), hyperautofluorescence with hypoautofluorescent ring in 2 eyes (8%), confluent hypoautofluorescence in 1 eye (4%), and granular hypoautofluorescence in 1 eye (4%). The remaining 3 eyes (12%) demonstrated blocked hypoautofluorescence because of the excessive hemorrhaging in the macula. The FAF images showed the granular hypoautofluorescent FAF pattern in all 24 BVNs (100%) consistent with the location of the lesions on ICGA. Conclusion: The typical PCV lesions, polypoid lesions and BVNs had characteristic autofluorescent findings on FAF imaging. Non-invasive, quick, and repeatable FAF imaging can be considered a reliable and helpful diagnostic technique for the diagnosis of active PCV.

Minor trauma resulting in subretinal haemorrhage with choroidal rupture: a case of subtle pseudoxanthoma elasticum in a child.

Pseudoxanthoma elasticum (PXE) is a rare autosomal recessive inherited multisystem disease primarly affecting the skin, cardiovascular system and retina with a prevalence of one in 25,000 to 70,000 births. Pseudoxanthoma elasticum is attributed to mutations in the ABCC6 gene on chromosome 16p13.1 and is characterised by slow, progressive abnormalmineralisation and fragmentation of elastic fibres in affected tissues. Because of its slow progression, PXE is usually diagnosed in the second or third decade of life. The presentation of PXE in children or in young adults is often limited to subtle, asymptomatic cutaneous lesions. Furthermore, early retinal changes typical of PXE, including peau d’orange appearance and subsequent angioid streaks are asymptomatic and often overlooked in children. PXE-related severe ocular complications are very rare before the age of 15 years. We report here an unusual initial presentation of PXE in a child. To our knowledge, this is the first case of PXE in which minor eye trauma resulted in serious ophthalmologic findings before the onset of angioid streaks.

Vitreoretinal Interface Characteristics in Eyes with Idiopathic Macular Holes: Qualitative and Quantitative Analysis

Objectives: To determine the qualitative and quantitative vitreoretinal interface characteristics with spectral domain optical coherence tomography (SD-OCT) in eyes with macular hole (MH) and investigate their relation with best corrected visual acuity (BCVA) and MH duration. Materials and Methods: Sixty-one eyes of 46 consecutive patients diagnosed with idiopathic MH were included in the study. The mean age of the patients was 66.7±7.5 (51-79) years. Complete ophthalmologic examination and SD-OCT examination were performed in all eyes and MH stages were determined according to SD-OCT findings. Qualitative characteristics of the vitreoretinal interface were investigated, including vitreomacular traction, vitreopapillary traction, maculopapillary traction, vitreoschisis, intraretinal cyst, presence of epiretinal membrane, and the integrity of the photoreceptor inner segment-outer segment junction (IS/OS) and external limiting membrane (ELM). In addition, MH diameter, MH base diameter (MHBD), ELM defect diameter, IS/OS defect diameter, and MH height were quantitatively measured and the MH index was calculated. Results: Out of 61 eyes, 9.8% were classified as stage 1a, 19.7% as stage 1b, 18% as stage 2, 23% as stage 3, and 29.5% as stage 4. Mean BCVA was 0.28±0.24 (1 mps-1.0) Snellen and MH duration was 10.08±18.6 (1-108) months. The most common interface characteristics associated with MH were determined as intraretinal cyst (91.8%), IS/OS defect (78.7%) and ELM defect (63.9%). Duration and stage of MH were inversely proportional to BCVA but directly proportional to the presence and diameter of IS/OS and ELM defects. BCVA was significantly lower in eyes with IS/OS and ELM defects (p<0.0001; p<0.0001 Mann-Whitney U test). Conclusion: We determined that the most important factors affecting BCVA in cases with idiopathic MH were MH stage, MH duration, MHBD, and the presence and diameter of IS/OS and ELM defects, which suggests that these parameters should be considered while making decisions about prognosis and treatment.

Direct Treatment Costs of Neovascular Age-related Macular Degeneration and Comparison of Gained and/or Preserved Vision with Expenditure

Objectives: The aim was to quantify the direct medical cost of neovascular age-related macular degeneration (AMD) versus gained or preserved vision. Materials and Methods: Data of patients treated for neovascular AMD between January 2009 to January 2014 were reviewed. Patients with complete follow-up for two years, treated with only intravitreal ranibizumab injections and with no intraocular surgery were included. Demographics, diagnostic investigations, the number of visits and injections, changes in visual acuity (VA) at one year and two years from baseline were noted. Total cost was calculated for the first and second years, and the cost of improving or preserving initial vision level was determined with subgroup analysis. Results: Two-hundred eyes of 175 patients (86 male and 89 female) with a mean age of 72.3±7.8 years were included. Mean VA was 0.67 logMAR at baseline, 0.60 logMAR at the end of the first year, and 0.67 logMAR at the end of the second year. At the end of the 2 years, VA increased in 82 eyes (41%), remained the same in 42 eyes (21%), and decreased in 76 eyes (38%). The mean number of visits in the first and second years were 6.56 (3-12) and 5.74 (3-10), respectively. An average of 4.42 (1-8) injections were performed in the first year and 2.25 (0-7) in the second. The total direct medical cost for AMD was 9,628 TL (Turkish Lira) per patient for 2 years, which consisted of 529 TL in visit costs, 115 TL in fluorescein and indocyanine angiography costs, 611 TL in injection procedure costs, and 8,371 TL in drug costs. The cost of one line of VA gain was 11,911 TL in the first year. Conclusion: This study showed that treatment increased or stabilized vision in a reasonable proportion of patients, that cost of management decreases in the second year, and that drug expenses are the leading item in reimbursement.