Zafer Onaran

Intraocular Pressure Lowering Effect of Orbital Decompression is Related to Increased Venous Outflow in Graves Orbitopathy

Abstract Purpose: To investigate the effects of combined orbital bone and fat decompression on intraocular pressure (IOP) and superior ophthalmic vein blood flow velocity (SOV-BFV), and their association with the clinical features of Graves orbitopathy (GO). Methods: During the 2002–2008 period, 72 eyes of 36 GO cases demonstrating moderate to severe orbitopathy were evaluated according to their clinical features as: cases with or without dysthyroid optic neuropathy (DON), and underwent orbital decompression. A control group comprised 40 eyes of 20 healthy subjects. In both groups, a full ophthalmic examination including IOP and Hertel measurements was performed, and SOV-BFV was analyzed with color Doppler imaging. Examinations were repeated after orbital decompression in GO patients. Results: All the cases demonstrated clinical features of inactive disease. Among the patients 24 of 72 eyes (33.3%) showed clinical features of DON. After surgery, the mean decrease in Hertel values was 6.2 ± 1.8 mm (p = 0.001). The mean decrease in IOP was 3.0 ± 1.7 mmHg (from 17.3 ± 2.7 to 14.3 ± 2.0 mmHg) after orbital decompression where the post-operative values were comparable with the control group (12.9 ± 1.4 mmHg, p = 0.36). The mean increase in SOV-BFV achieved with decompression was 1.2 ± 0.6 cm/s (from 4.8 ± 1.7 to 6.0 ± 1.8 cm/s) and post-operative SOV-BFV values were also comparable with the control group (6.6 ± 1.3 cm/s, p = 0.26). The increase in SOV-BFV in cases with DON did not differ from cases without DON (p = 0.32), however, post-operative SOV-BFV of cases with DON was stil lower than cases without DON (p = 0.035). Conclusions: Combined orbital bone and fat decompression significantly reduced the IOP levels and increased the SOV-BFV in GO. This could be the confirmative finding of prediction that elevated IOP in GO is associated with increased episcleral venous pressure. The post-operative changes in IOP and SOV-BFV show differences regarding the clinical features of disease.

Simultaneous reconstruction of medial canthal area and both eyelids with a single transverse split forehead island flap.

In this report, we are presenting a case in which we have split the paramedian forehead flap, thus providing 2 axially perfused skin flaps for simultaneous reconstruction of the upper and lower lid structures after resection of basal cell carcinoma from the left medial canthal area. We found that split forehead flap seems to be a favorable option for simultaneous reconstruction of the upper and lower eyelid defects by enabling nicely vascularized and abundant amount of regional skin.

Bilateral punctum atresia and lacrimal sac fistula in a child with CHARGE syndrome

membrane closer, and thus facilitates migration of endothelial cells. Although intracameral gas is preferred to air for treating corneal hydrops, there is a risk of endothelial toxicity, Urrets-Zavalia syndrome and secondary glaucoma with the use of long-acting gases intracamerally. A fixed dilated pupil with iris atrophy (Urrets-Zavalia Syndrome) is an uncommon postoperative complication that was originally described after penetrating keratoplasty for keratoconus. Although the precise aetiology of the syndrome is unknown, it has been proposed that ischaemia of the iris may develop after raised intraocular pressure and leave a fixed dilated pupil. To the best of our knowledge this is the first report on the use of intracameral C2F6 for managing bilateral acute hydrops secondary to keratoglobus. We chose to use C2F6 as this had a shorter duration of action when compared with C3F8. In spite of the formation of a paracentesis to decompress the anterior segment and postoperative acetazolamide treatment our patient developed Urrets-Zavalia syndrome in the RE. In conclusion, we believe that pneumodescemetopexy can be a safe and effective option for the treatment of acute hydrops secondary to keratoglobus. This case demonstrates how the procedure can lead to rapid resolution of corneal oedema and improvement of vision.

Enophthalmos due to atelectasis of the maxillary sinus: silent sinus syndrome.

Silent sinus syndrome is a clinical entity with the constellation of progressive enophthalmos and hypoglobus due to gradual collapse of the orbital floor with opacification of the maxillary sinus, in the presence of subclinical maxillary sinusitis. It occurs secondary to maxillary sinus hypoventilation due to obstruction of the ostiomeatal unit. In this paper, a 35-year-old woman with a complaint of asymmetry in her left eye and denting of upper eyelid was reported. In the left eye, upper sulcus was deepened and there was 3-mm hypoglobus. There was no diplopia or restriction of eye movements in any gaze positions. Hertel exophthalmometry revealed a 4-mm enophthalmos on the left eye. Computed tomographic scan of the orbita and paranasal sinuses showed left maxillary sinusitis, air-fluid level, and collapse of left maxillary sinus walls. In addition, inferior bulging in the left orbital floor was also reported. The treatment was a 2-stage operation. In the first stage, she underwent endoscopic septoplasty plus left maxillary antrostomy, and in the second stage, she underwent a subciliary orbital floor repair of the iliac bone resulting in the improvement of the enophthalmos and her cosmetic appearance. Regarding this case, the literature is also reviewed in detail.

Central corneal thickness in patients with mild to moderate rosacea

OBJECTIVE We aimed to evaluate central corneal thickness (CCT) in patients with rosacea in comparison to a healthy control group and to investigate any correlations by using the Schirmer test, tear break-up time (TBUT), and disease severity. DESIGN Prospective nonrandomized study. PARTICIPANTS Patients with mild to moderate rosacea (n = 51) and a group of healthy individuals (n = 51) were included. METHOD Patients were evaluated by a dermatologist; disease severity was determined and total rosacea severity score was calculated for each patient. CCT measurements were performed using ultrasonic pachymetry. Tear function tests, including Schirmer and TBUT, were also performed. RESULTS The mean CCT value was significantly lower in patients with rosacea than in the control group (544.91 ± 29.41 μm vs 559.40 ± 24.18 μm, p = 0.003). The mean Schirmer test value was significantly lower in patients than in controls (10.54 ± 6.09 mm vs 19.13 ± 4.24 mm, p < 0.0001), and the mean TBUT was shorter in the group with rosacea than in the controls (8.32 ± 3.50 s vs 16.67 ± 5.76 s, p < 0.0001). CCT values were found to be correlated with the Schirmer test values in the rosacea group (r = 0.33, p = 0.01). CONCLUSIONS Patients with rosacea have thinner corneas, which could be attributed to the observed deteriorated tear function parameters. Candidates for corneal photoablation surgery should be evaluated regarding rosacea disease because the postoperative period could be complicated by decreased ocular wetting and corneal thinning, even in overlooked mild forms.

Bilateral non-arteritic anterior ischemic optic neuropathy following second-trimester spontaneous abortion-related haemorrhage

Bilateral anterior ischemic optic neuropathy is a rare complication of massive haemorrhage and related hypotension and anaemia in young individuals. We report a 34-year-old woman with bilateral non-arteritic ischemic optic neuropathy (NAION) after a massive spontaneous abortion-related haemorrhage who presented with sudden painless visual loss in her left eye. Visual acuity was 20/20 in the right eye with only hand motion discernible in the left eye. There was a left relative afferent papillary defect (RAPD). Fundus examination revealed bilateral swollen, hyperaemic optic discs and nerve fiber layer haemorrhages. Brain MRI and magnetic resonance venography were normal. The diagnosis of bilateral NAION was made and intravenous pulse corticosteroid therapy (1000 mg/day) was administered for three days. On the sixth day, optic disc oedema regressed bilaterally and on the third week, the visual acuity improved to 20/80 in the left eye. The visual field showed only a small spared area in the nasal region, and persistent RAPD was present. After two months, fundus examination showed a small and crowded optic disc on the right and a pale optic disc on the left. Severe acute haemorrhage is an important risk factor for NAION in healthy young individuals. In addition to correction of hypotension and anaemia, intravenous high dose corticosteroid might be beneficial for treatment.

Retinal vasculitis following pars plana vitrectomy for retained lens material

Retained lens fragments or dropped nucleus after cataract surgery are uncommon complications. Pars plana vitrectomy (PPV) is an effective treatment with late complications such as epimacular proliferation, retinal detachment and cystoid macular oedema. Though retinal vasculitis has been reported as the early sign of post-operative endophthalmitis following uneventful cataract surgery and trauma from a penetrating foreign body, there is only one documented report of retinal vasculitis with lens-induced uveitis with pars plana vitrectomy for retained lens fragments. We describe two consecutive cases of retinal vasculitis in patients who underwent PPV for retained lens fragments and dropped nucleus.

Corneal and conjunctival sensitivity in rosacea patients

Purpose To assess corneal and conjunctival sensitivity in rosacea patients. Methods A total of 55 patients with rosacea and 37 control subjects participated in the study. Corneal and conjunctival sensitivity was determined by Cochet-Bonnet esthesiometer. Subjective symptoms of ocular dryness were evaluated using Ocular Surface Disease Index (OSDI). Schirmer’s I test (ST), tear breakup time (tBUT) and ocular surface staining with fluorescein were carried out to measure objective signs. Results The mean corneal and conjunctival sensitivity did not differ significantly between rosacea patients and controls (all p > 0.05). Schirmer’s I test and tBUT were significantly reduced (p = 0.004 for OD and p < 0.001 for OS) and grade of ocular surface staining was significantly high (p = 0.018 for OD and p = 0.038 for OS) in rosacea patients. Corneal and conjunctival sensitivity did not show significant correlation with ST, tBUT, ocular surface staining (Oxford Schema), duration of rosacea and OSDI score. Conclusions Corneal and conjunctival sensitivity did not change significantly in rosacea.

Effect of 1% brinzolamide and 0.5% timolol fixed combination on intraocular pressure after cataract surgery with phacoemulsification.

AIM To evaluate the effect of brinzolamide-timolol fixed combination on intraocular pressure (IOP) after cataract surgery. METHODS The study included 92 eyes of 87 patients who underwent cataract surgery and intraocular lens implantation. Patients scheduled for phacoemulsification were assigned to 1 of 2 groups. The treatment group received 1 drop of brinzolamide-timolol fixed combination immediately after surgery, and the control group received no treatment. The IOP was measured preoperatively and at 2h and 24h postoperatively. RESULTS The mean IOP change was lower in the treatment group than in the control group at 2h postoperatively. The difference between the mean IOP values of the two groups at 2h postoperatively was found to be statistically significant. Twenty-four hours after the surgery, the mean IOP change was still higher in the control group when compared to the treatment group. CONCLUSION The fixed combination brinzolamide-timolol can effectively reduce IOP after cataract surgery.

Anterior uveitis associated with fixed-combination latanoprost and timolol.

Once-daily administration of fixed-combination latanoprost and timolol in patients with open-angle glaucoma and ocular hypertension is well tolerated and reduces intraocular pressure (IOP) more effectively than either individual component alone. The safety of this combination has been demonstrated previously.1 The association of uveitis and latanoprost has been shown in various studies.2,3 A combination of timolol-LA and travoprost has been reported to induce a unilateral uveitis in a healthy eye.4 We report a patient who developed unilateral anterior uveitis as a possible complication of fixed-combination latanoprost and timolol treatment for glaucoma. A 46-year-old man referred as a glaucoma suspect was found to have IOP of 13 mm Hg OD and 28 mm Hg OS. He had no history of ocular trauma, surgery, or inflammation. He was not taking any medication. Anterior segments were unremarkable and gonioscopy showed grade IV open angles on both sides. Fundoscopy showed optic discs with cup/disc ratios of 0.4 OD and 0.7 OS. Perimetry revealed glaucomatous visual field loss in the left eye. He was started on fixed-combination latanoprost and timolol (Xalacom, Pfizer Inc, New York, N.Y.) in the left eye. During followups, IOP in his left eye was also found to be lowered (15 mm Hg) and he was advised to continue the drops. Ten days after the introduction of the fixed combination, the patient’s left eye showed signs of anterior uveitis with conjunctival injection, keratic precipitates, and +1 white blood cells in the anterior chamber (Fig. 1). IOP was 17 mm Hg in both eyes. Gonioscopy and fundoscopy showed no change. Drug-related anterior uveitis was suspected and the medication was stopped in the left eye. As a treatment for uveitis, the patient was started on topical steroids and cyclopentolate. Two weeks later, the uveitis had resolved completely. After the patient was given detailed information, the left eye was rechallenged with the same combination; the uveitis developed again and resolved following the same treatment. A combination of β-blockers and dorzolamide eye drops was started to control the IOP. The new combination lowered the IOP and was well tolerated. Several cases of latanoprost-induced uveitis have been well documented.2,3 To the best of our knowledge, this is the first case of anterior uveitis associated with fixedcombination latanoprost and timolol treatment. Vishwanath and Charles4 reported a case of anterior uveitis caused by travoprost and timolol-LA. The authors proposed that the combination could increase the drug-related damage to the blood–aqueous barrier. Mori and Araie5 showed that timolol induces elevation of protein concentration in human eyes. In our case, timolol may have been synergistic with latanoprost as a risk factor for inducing anterior uveitis. To conclude, further studies with larger sample sizes and longer follow-up periods are necessary to establish the incidence of anterior uveitis in glaucoma patients treated with fixed-combination latanoprost and timolol. Fig. 1—Anterior uveitis with conjunctival injection and keratic precipitates. slight inferotemporal decentration of the bag toward the point of fixation of the capsular tension ring to the sclera. In summary, the association of acute ACG and anterior lens subluxation in patients with RP is rare. The attack responded to medications and laser iridotomy. Fixation of the capsular bag using a Cionni capsular tension ring is useful for intraocular lens centration.