Sunay Duman

Primary viscocanalostomy versus trabeculectomy for primary open-angle glaucoma Three-year prospective randomized clinical trial

Purpose: To compare the efficacy and safety of viscocanalostomy and trabeculectomy in patients with primary open‐angle glaucoma (POAG). Setting: Department of Ophthalmology, Ankara Education and Research Hospital, Ankara, Turkey. Methods: In this prospective randomized trial, 50 eyes of 50 patients with medically uncontrolled POAG were randomized to have a trabeculectomy (25 eyes) or a viscocanalostomy (25 eyes). Visual acuity, intraocular pressure (IOP), and slitlamp examinations were performed before surgery and 1 day, 1 week, 1, 3, and 6 months, and 1, 2, and 3 years postoperatively. Results: At 3 years, the mean IOP was 16.0 mm Hg ± 7.07 (SD) in the trabeculectomy group and 17.8 ± 4.6 mm Hg in the viscocanalostomy group (P = .694). Complete success (IOP 6 to 21 mm Hg without medication) was achieved in 66.2% of eyes at 6 months and 55.1% at 3 years in the trabeculectomy group and in 52.9% and 35.3%, respectively, in the viscocanalostomy group (P>.05). Qualified success (IOP 6 to 21 mm Hg with medication) was achieved in 95.8% of eyes at 6 months and 79.2% at 3 years in the trabeculectomy group and in 90.7% and 73.9%, respectively, in the viscocanalostomy group (P>.05). Postoperative hypotony and cataract formation occurred more frequently in the trabeculectomy group than in the viscocanalostomy group (P = .002). Conclusions: Primary trabeculectomy lowered IOP more than viscocanalostomy in POAG patients. However, the complication rate was lower in the viscocanalostomy group.

Long-term results of Ahmed glaucoma valve and Molteno implant in neovascular glaucoma

AimsTo evaluate the surgical success results of Ahmed glaucoma valve (AGV) and Molteno single-plate implant (MSPI) in cases of neovascular glaucoma (NVG).MethodsBetween May 1997 and May 2002, 38 of 38 NVG patients that underwent implantation of AGV and 27 eyes of 27 NVG patients that underwent MSPI (a total 65 eyes of 65 patients) included to the study.ResultsThe cumulative probabilities of success were 63.2% at 1 year, 56.2% at 2 years, 43.2% at 3 years, 37.8% at 4 years, and 25.2% at 5 years in AGV group whereas the cumulative probabilities of success were 37.0% at 1 year, 29.6% at 2 years, 29.6% at 3 years, 29.6% at 4 years, and 29.6% at 5 years in MSPI group (P=0.141). Preoperative visual acuity <2/200 (P=0.003), diagnosis of diabetes mellitius (P=0.050), and preoperative IOP≥35 mmHg (P=0.038) were found to be poor prognostic factors for surgical success.ConclusionsBoth AGV and single plate MSPI were successful for early and intermediate-term of IOP control but in long term both implants were failed to achieve control of IOP in patients with NVG.

Microbial keratitis following penetrating keratoplasty

PURPOSE To investigate the prevalence of microbial keratitis, predisposing risk factors and treatment modalities in patients who developed keratitis following penetrating keratoplasty (PK). PATIENTS AND METHODS The records of 285 patients who had undergone PK between January 1991 and December 1995 in a tertiary care center were reviewed. Patients who developed postoperative microbial keratitis were evaluated for predisposing risk factors, microbiological etiology, response to broad spectrum antibiotic therapy and subsequent PK. Patients were mainly treated with fortified topical antibiotics with or without repeat PK. RESULTS Of the 285 patient records reviewed, microbial keratitis developed in 21 eyes of 21 patients (7.4%). Seventy-one percent of infections occurred within 6 months after grafting. Keratitis initially began from the donor-recipient border in 16 cases (76.2%) and were central or paracentral in 5 patients. Predisposing risk factors included loose or exposed suture (9), suture removal (1), persistent epithelial defect (3), graft failure (3), contact lens wear (1), Stevens-Johnson syndrome (1). Fifteen (71.4%) patients were culture-positive consisting of Streptococcus pneumoniae (7), Staphylococcus aureus (5), Pseudomonas aureginosa (2), and Hemophilus influenzae (1). Forty-three percent of patients were successfully treated with medical therapy only. Seven patients underwent second PK for visual rehabilitation and 4 for tectonic purposes. After medical and surgical therapy, graft clarity was achieved in 17 (81%) of patients. CONCLUSIONS The microbial keratitis following PK is a major postoperative problem affecting the long term prognosis. Careful selection of patients, and preoperative and postoperative control of risk factors, may decrease the frequency of this complication. Several factors, including loose or exposed sutures, epithelial defects, ocular surface disorders, and graft failure, may predispose patients to develop microbial keratitis following PK.

Penetration of topically applied ciprofloxacin and ofloxacin into the aqueous humor and vitreous

Purpose: To determine the intraocular penetration of topical drops of 2 antibiotics, ciprofloxacin 0.3% and ofloxacin 0.3%, into the aqueous humor and vitreous and to relate these levels to the miminum inhibitory concentration (MIC90) for organisms associated with ocular bacterial infections. Setting: Department of Ophthalmology, Ankara Hospital, and Department of Pharmacology, Faculty of Medicine, Hacettepe University, Ankara, Turkey. Methods: This prospective randomized clinical trial comprised 18 patients having cataract surgery, all with an intact corneal epithelium. The patients were randomly assigned to receive topical ciprofloxacin 0.3% (n = 10) or topical ofloxacin 0.3% (n = 8) 1 drop every 15 minutes 5 times and every 30 minutes 3 times before surgery. Aqueous and vitreous samples (if vitreous loss occurred during the cataract surgery) were collected 30 minutes after the administration of the last dose. Drug concentrations were determined by high‐performance liquid chromatography (HPLC) fluorescence. Results: All patients had detectable drug concentrations in the aqueous humor and vitreous measurable by HPLC. The mean aqueous humor concentration of ciprofloxacin was 1.13 &mgr;g/mL ± 1.90 (SD) and the mean vitreous concentration, 0.23 ± 0.06 &mgr;g/mL. Topical administration of ciprofloxacin yielded 4.9 times more drug concentration in the anterior chamber than in the vitreous. The mean aqueous concentration of ofloxacin was 2.06 ± 1.06 &mgr;g/mL and the mean vitreous concentration, 0.46 ± 0.10 &mgr;g/mL. Topical administration of ofloxacin yielded 4.7 times more drug concentration in the anterior chamber than in the vitreous. Aqueous humor concentrations of ofloxacin and ciprofloxacin were not statistically significantly different (P = .353). Intravitreal concentrations of ofloxacin were statistically significantly higher than those of ciprofloxacin (P = .001). Conclusions: Topical ofloxacin 0.3% penetrated better than topical ciprofloxacin 0.3% into the anterior chamber and vitreous in noninflamed eyes. Both drugs were above the MIC90 for most ocular pathogens in the anterior chamber. The mean concentration in the vitreous of topically applied ofloxacin 0.3% was statistically significantly higher than that of ciprofloxacin 0.3%, but it was not sufficiently above the MIC90 for most ocular pathogens in terms of empirical endopthalmitis therapy.

Aqueous humor nitric oxide levels in patients with Behçet disease.

Purpose The purpose of this study was to quantify aqueous humor nitric oxide levels in patients with Behçet uveitis and age-matched controls to assess how nitric oxide is involved in this ocular condition. Methods Samples of aqueous humor were collected from 11 patients with Behçet uveitis who were undergoing cataract surgery. Sampling was done by paracentesis at the beginning of the operation. Similar samples were collected from 20 age-matched normal patients (controls). For each sample, we used the spectrophotometric method based on the Griess reaction to determine the amount of nitrite, which is the stable metabolite of nitric oxide. Results The amount of nitrite in aqueous humor samples from patients with Behçet disease was above the detection limit in 8 of 11 cases; the mean level ± SEM was 2.13 ± 0.621 &mgr;mol/L. Levels in the control group were below the detection limit in all cases (<0.08 &mgr;mol/L). There was a statistically significant difference between the aqueous humor nitrite levels in patients with Behçet disease and those in controls (P = 0.00002). Conclusions Aqueous humor nitric oxide levels are elevated in patients with a history of Behçet disease.

Conjunctival impression cytology and tear-film changes in patients with psoriasis.

PURPOSE In this study, we evaluated ocular-surface changes and tear-film functions in patients with plaque-type psoriasis. METHODS This study was performed on two groups. Group I included 100 eyes of 50 subjects with chronic plaque-type psoriasis whose diagnoses were confirmed with skin biopsy. Group II included 100 eyes of 50 healthy volunteers who were in the same age and sex distribution. Ocular-surface changes were evaluated on the cell content of the surface conjunctival epithelium by conjunctival impression cytology and tear-film functions by the Schirmer I test and break-up time (BUT). RESULTS Of the patients with psoriasis, 50% had a grade 0, 30% had a grade I, and 20% had a grade II conjunctival impression cytology differentiation compared with 95, 3, and 2%, respectively in the control group (p < 0.001). Snake-like appearance of nuclear chromatin in conjunctival epithelial cells was demonstrated in 12% of eyes in group I but in 2% of eyes in group II. The Schirmers test results showed that average values were 10.1 +/- 5.8 mm in group I and 12.6 +/- 5.5 mm in group II (p > 0.001). The mean break-up time was 7.8 +/- 3.7 s in group I and 12.5 +/- 4.6 s in group II (p < 0.001). CONCLUSIONS We showed the early conjunctival changes in patients with psoriasis. According to these results, primary etiologic factors may contribute to ocular lesions in psoriasis.

Penetration of second-, third-, and fourth-generation topical fluoroquinolone into aqueous and vitreous humour in a rabbit endophthalmitis model

AimsThis study was designed to investigate the penetration of second-, third- and fourth-generation topical fluoroquinolone into aqueous and vitreous humour in a rabbit endophthalmitis model.MethodsThirty New Zealand white rabbits were divided into six groups. Left eye was infected with an intravitreal inoculum of Staphylococcus aureus. Groups 1, 2, 3, 4, and 5 received topical ofloxacin, ciprofloxacin, lomefloxacin, levofloxacin, or moxifloxacin treatment 24 h after the inoculation, respectively. No treatment was given to group 6 as the control group (n=5). Aqueous and vitreous samples were obtained 30 min after the last drop. High-performance liquid chromatography was used to determine the fluoroquinolone concentration.ResultsIn the normal and inflamed eyes, mean aqueous concentrations of ofloxacin were 1.90 and 2.69 μg/ml, ciprofloxacin were 2.16 and 3.65 μg/ml, lomefloxacin were 3.54 and 1.19 μg/ml, levofloxacin were 2.89 and 9.41 μg/ml, and moxifloxacin were 4.92 and 43.33 μg/ml, respectively. Mean vitreous concentrations of ofloxacin were 0.25 and 0.07 μg/ml, ciprofloxacin were 0.08 and 0.32 μg/ml, lomefloxacin were 0.001 and 0.03 μg/ml, levofloxacin were 0.03 and 0.09 μg/ml, and moxifloxacin were 0.28 and 2.68 μg/ml, in normal and inflamed eyes, respectively. Moxifloxacin achieved a significantly higher concentration in aqueous and vitreous humour of infected eyes compared with ofloxacin (P<0.01), ciprofloxacin (P<0.05), lomefloxacin (P<0.01), and levofloxacin (P<0.05).ConclusionThis study demonstrated that fourth-generation fluoroquinolone, moxifloxacin, seems to have better penetration to inflamed ocular tissues in rabbit.

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.

Trabeculectomy with mitomycin-C in uveitic glaucoma associated with Behcet disease

Purpose:To determine the effect of intraoperative application of Mitomycin-C (MMC) with trabeculectomy in uveitic glaucoma associated with Behçet disease. Materials and Methods:Twenty-six eyes of 26 patients with uveitic glaucoma associated with Behçet disease who underwent trabeculectomy with MMC between 1996 and 2001 were reviewed in this retrospective, noncomparative study. Trabeculectomy + MMC in concentration of 0.4 mg/mL for 3 minutes was performed to all patients. Main outcome measures were control of IOP, the number of antiglaucoma medications required to achieve the desired IOP, visual acuity and complications. The surgical success was defined as IOP less than 22 mm Hg and greater than 5 mm Hg without additional further glaucoma surgery or loss of light perception. Results:The cumulative probability of success was 83.3% at 1 year, 76.2% at 2 years, 70% at 3 years, 66.7% at 4 years and 62.5% at 5 years after surgery. The mean follow-up was 40.0±18.0 months. At last follow-up 23% of the patients required no antiglaucoma medications. Best-corrected visual acuity improved or remained within two lines of preoperative visual acuity in 19 eyes (73.1%). Glaucomatous (1 eye 3.8%) and nonglaucomatous optic atrophy (3 eyes 11.5%) was the most frequent reason for visual decrease (total 4 eyes 15.2%). The most common complications were cataract formation in 6 eyes (23.1%), bleb leakage in 4 eyes (15.3%) and choroidal effusion in 3 eyes (11.5%). Phthisis bulbi was found in one (3.8%) patient. Conclusion:Trabeculectomy and intraoperative application of MMC appears to provide long term safety and effectiveness in uveitic glaucoma associated with Behçet disease.

Limbal relaxing incisions in congenital astigmatism: 6 month follow-up

Purpose: To evaluate the effectiveness of limbal relaxing incisions (LRIs) for correcting naturally occurring astigmatism. Setting: Ankara Hospital, Ankara, Turkey. Methods: This prospective analysis of the results of the first LRIs in 22 eyes of 13 patients with congenital astigmatism was done using a modified Gills nomogram and was based on preoperative refractive astigmatism determined by manifest and cycloplegic refractions. There were no adjustments based on sex or age. Results: An absolute decrease of 0.91 diopter (D) (44%) in mean astigmatism was achieved after 6 months in 22 eyes. The mean uncorrected visual acuity (logMAR) increased from 0.42 to 0.26 from preoperatively to 6 months postoperatively. No patient lost best corrected visual acuity. Most regression occurred in eyes with more than 3.50 D of astigmatism and between the first and third postoperative months. Conclusion: Limbal relaxing incisions are a practical, simple, and forgiving approach for the correction of lower degrees of astigmatism.