The Choice of Drainage Device in Complicated Glaucomas: Comparing Ahmed and Baerveldt Implants.

BACKGROUND/AIM: Glaucoma is a chronic and progressive optic neuropathy which leads to deterioration of visual function. It is estimated to be the second leading cause of severe vision loss and blindness worldwide. Failure of anti-glaucoma medication to sufficiently reduce intraocular pressure (IOP) and poor compliance with medication are indications for glaucoma surgery, for example using glaucoma drainage devices. Our aim was to compare the surgical outcomes following the implantation of Ahmed FP7 and Baerveldt 350 drainage devices. PATIENTS AND METHODS: Five hundred and fifty-two patients with primary or secondary glaucoma were enrolled in the study. All patients had a history of failed trabeculectomy or other intraocular surgery, and IOP ≥18 mm Hg. The implantation of Ahmed (266 patients) or Baerveldt (286 patients) devices was randomly performed in the patients, who were subsequently examined for a period of 5 years. Follow-up visits were scheduled 1 day; 1 week; 1, 3 and 6 months; and 1, 1.5, 2, 3, 4 and 5 years postoperatively. RESULTS: Significant reduction of IOP was achieved in both groups. Ahmed valve (28.3±9.3, 13.4±6.9, 14.2±6 and 12.7±4.5 mmHg at baseline, 1, 3, and 5 years postoperatively, respectively) resulted in significantly greater IOP reduction compared to Baerveldt implant (29.6±10.1, 15.4±5.5, 14.5±5.5 and 14.7±4.4 mmHg at baseline, 1, 3, and 5 years postoperatively, respectively). A significantly lower number of medications was required in the Ahmed group in comparison to the Baerveldt one (Ahmed group: 1.5±1.4, 1.4±1.5 and 1.8±1.5; Baerveldt group: 1.9±1.3, 1.9±1.3 and 2.2±1.4, respectively). The incidence of treatment failure and the rate of glaucoma reoperation were significantly higher in the Baerveldt group (40%) compared to the Ahmed group (17%). CONCLUSION: Ahmed drainage implantation seemed to outclass that using the Baerveldt device in our study, in terms of efficacy and success rate.

Prognostic factors of pediatric glaucoma: a retrospective study.

PURPOSE: To correlate the features of certain types of infantile glaucoma with the progression and the prognosis of the disease, highlighting probable risk factors. METHODS: Seventy-six patients with pediatric glaucoma were recruited in this retrospective study. All patients underwent ophthalmological examination in the Department of Ophthalmology of the Saarland University Medical Center from January 2001 to December 2012. Our pediatric patients were classified into four different categories of glaucoma: (1) primary congenital glaucoma (presenting buphthalmus), (2) aniridia-related glaucoma, (3) Peters/Rieger's anomaly-related glaucoma and (4) congenital cataract-related glaucoma. Personal data comprised age, sex, nationality, systemic diseases and gestational age. The best-corrected visual acuity (BCVA), the cup-disk ratio (CDR), the intraocular pressure (IOP), the corneal diameter and thickness, along with the Haab striae and corneal haze, were recorded. RESULTS: The majority of the children were male (58%) and suffered from aniridia-related glaucoma (38%). Children with aniridia exhibited the worst BCVA. The CDR and IOP were significantly higher in children with primary congenital glaucoma, compared to the other groups, at the first visit. Those children also were with the largest corneal diameter and prevalence of Haab striae compared to the rest groups, whereas corneal haze was found more often and was more pronounced in children with Peters/Rieger's syndrome. CONCLUSIONS: We concluded that glaucoma was earlier detected in children with primary congenital glaucoma, who exhibited increased corneal diameter and high percentage of Haab striae comparing to the other groups. However, these children responded successfully to any therapeutic intervention, exhibiting better BCVA and IOP values than the rest groups at the second visit.

Tear Film Osmolarity in Subjects with Acute Allergic Rhinoconjunctivitis.

BACKGROUND/AIM: Acute allergic rhinoconjuctivitis is the most common form of ocular allergies. The pathogenetic mechanisms are based on an immunoglobulin E (IgE)-mediated hypersensitivity reaction. On the other hand, tear osmolarity has been suggested to be an index of ocular surface damage and inflammation. These data were the motive to investigate the levels of tear osmolarity in subjects with acute allergic rhinoconjuctivitis, before and after administration of artificial tears. PATIENTS AND METHODS: Forty-five subjects with acute allergic rhinoconjuctivitis were randomly divided into three groups, based on the type of artificial tears that they received: Group A (Thera tears), Group B (Wet therapy) and Group C (Tears Naturale free). The eye drops were administered six times a day for 60 days and all subjects underwent grading of subjective symptoms and clinical examination at baseline and at the end of the treatment. RESULTS: The diagnosis of severe eye disease, which was based on ocular surface disease index (OSDI; Allergan, Inc, Irvine, CA, USA) and tear osmolarity values, concerned all patients at baseline. Although the administration of artificial tears significantly ameliorated the symptoms and the ocular variables in all groups, the results were better in the first group. Tear osmolarity was strongly and negatively correlated with tear film breakup time (BUT) and Schirmer I test at 2 months. Contrariwise, symptoms were eliminated, when tear osmolarity was decreased. CONCLUSION: Acute allergic rhinoconjuctivitis is characterized by tear hyperosmolarity, which can be rehabilitated with the administration of hypotonic artificial tears.

The Role of mf-ERG in the Diagnosis and Treatment of Age-Related Macular Degeneration: Electrophysiological Features of AMD.

INTRODUCTION: Age-related macular cegeneration (AMD) is the leading cause of visual dysfunction worldwide, affecting 9-25% of individuals between 65 and 75 years old. METHODS: We have reviewed the published articles investigating the role of multifocal electroretinogram (mf-ERG) in the diagnosis and treatment of AMD. RESULTS: Visual evoked potentials have revealed decreased amplitudes and higher latencies in patients with AMD, while the degeneration of photoreceptors and abnormalities of retinal pigment epithelium can be identified by electro-oculogram recordings. Moreover, ERG can detect the functional abnormalities observed in AMD and evaluate each therapeutic approach. The record of local electrophysiological responses coming from different retinal areas can be accurately performed by mfERG. CONCLUSION: The accuracy of mfERG in detecting the degeneration of photoreceptors, as well the disturbances of macular function, could be useful both in the early diagnosis of AMD and the assessment of treatment efficacy.

The impact of combined oral contraceptives on ocular tissues: a review of ocular effects.

The aim of this manuscript is to review the action and adverse effects of combined oral contraceptives (COCs) on ocular tissues. The percentage of unwanted pregnancies and the subsequent abortions make contraception crucial worldwide. Over 100 million women around the world use common contraceptive methods, including intrauterine devices, combined estrogen and progestin oral contraceptives, as well as progestin only preparations (oral contraceptives, implants or injections). COCs are widely used for contraception, but they are also indicated in menorrhagia, endometriosis, acne and hirsutism, fibroid uterus and premenstrual syndrome. However, they have been associated with high rates of cardiovascular events, venous thromboembolic disease, ischemic strokes and breast cancer. The incidence of COCs-related ocular complications is estimated to be 1 in 230 000, including dry eye symptoms, corneal edema, lens opacities and retinal neuro-ophthalmologic or vascular complications. We may infer that the serious ocular complications of COCs can be prevented by eliminating the estrogen dosage and choosing third-generation progestins. In any case, doctors should take into consideration the systemic and ocular history of the patients before selecting any method of contraception.

Contact Lenses for Keratoconus- Current Practice.

BACKGROUND: Keratoconus is a chronic, bilateral, usuallly asymmetrical, non-inflammatory, ectatic disorder, being characterized by progressive steepening, thinning and apical scarring of the cornea. Initially, the patient is asymptomatic, but the visual acuity gradually decreases, resulting in significant vision loss due to the development of irregular astigmatism, myopia, corneal thinning and scarring. The classic treatment of visual rehabilitation in keratoconus is based on spectacles and contact lenses (CLs). OBJECTIVE: To summarize the types of CLs used in the treatment of keratoconus. This is literature review of several important published articles focusing on the visual rehabilitation in keratoconus with CLs. METHOD: Gas permeable (GP) CLs have been found to achieve better best corrected visual acuity than spectacles, eliminating 3rd-order coma root-mean-square (RMS) error, 3rd-order RMS, and higher-order RMS. However, they have implicated in reduction of corneal basal epithelial cell and anterior stromal keratocyte densities. Soft CLs seem to provide greater comfort and lower cost, but the low oxygen permeability (if the lens is not a silicone hydrogel), and the inability to mask moderate to severe irregular astigmatism are the main disadvantages of them. On the other hand, scleral CLs ensure stable platforms, which eliminate high-order aberrations and provide good centration and visual acuity. Their main disadvantages include the difficulties in application and removal of these lenses along with corneal flattening and swelling. RESULT: The modern hybrid CLs are indicated in cases of poor centration, poor stability or intolerance with GP lenses. Finally, piggyback CL systems effectively ameliorate visual acuity, but they have been related to corneal neovascularization and giant papillary conjunctivitis. CONCLUSION: CLs seem to rehabilitate visual performance, diminishing the power of the cylinder and the high-order aberrations. The final choice of CLs is based on their special features, the subsequent corneal changes and the patient's needs.

Impact of prostaglandin glaucoma drops on platelet-activating factor action: an in vitro study.

AIM: The aim of this study was to investigate the effect of different prostaglandin analogs on platelet-activating factor (PAF) levels. METHODS: Three prostaglandin analogs were selected: bimatoprost 0.3 mg/mL, latanoprost 50 µg/mL, and tafluprost 15 µg/mL. Each drug sample was tested for its ability to cause platelet aggregation, which was measured as PAF-induced aggregation, before and after the addition of various concentrations of the examined sample, creating a linear curve of percentage inhibition (ranging from 0% to 100%) versus different concentrations of the sample. The concentration of the sample that inhibited 50% PAF-induced aggregation was calculated based on this curve, and this value was defined as IC50. In addition, the effect of eye drops on PAF metabolism was examined, through an in vitro analysis on PAF basic metabolic enzymes (PAF-cholinephosphotransferase, PAF-acetyl-CoA:1-O-alkyl-sn-glycero-3-phosphocholine acetyltransferase, and PAF-acetylhydrolase). RESULTS: The IC50 values for Lumigan UD® (bimatoprost 0.3 mg/mL), Monoprost® (latanoprost 50 µg/mL), and Saflutan (tafluprost 15 µg/mL) were 8.7, 0.28, and 1.4 µg/mL, respectively. DISCUSSION: All three prostaglandin analogs suspended PAF, but bimatoprost induced the most potent inhibition, compared to tafluprost and to the weak effect of latanoprost.

Pathophysiology of visual disorders induced by phosphodiesterase inhibitors in the treatment of erectile dysfunction.

AIM: The aim of this review was to summarize the ocular action of the most common phosphodiesterase (PDE) inhibitors used for the treatment of erectile dysfunction and the subsequent visual disorders. METHOD: This is a literature review of several important articles focusing on the pathophysiology of visual disorders induced by PDE inhibitors. RESULTS: PDE inhibitors have been associated with ocular side effects, including changes in color vision and light perception, blurred vision, transient alterations in electroretinogram (ERG), conjunctival hyperemia, ocular pain, and photophobia. Sildenafil and tadalafil may induce reversible increase in intraocular pressure and be involved in the development of non-arteritic ischemic optic neuropathy. Reversible idiopathic serous macular detachment, central serous chorioretinopathy, and ERG disturbances have been related to the significant impact of sildenafil and tadalafil on retinal perfusion. DISCUSSION: So far, PDE inhibitors do not seem to cause permanent toxic effects on chorioretinal tissue and photoreceptors. However, physicians should write down any visual symptom observed during PDE treatment and refer the patients to ophthalmologists.

The Correction of Aphakia Using Anterior Chamber Intraocular Lens.

Senile cataract is the leading cause of severe vision loss and blindness worldwide, affecting approximately 20 million people. Anterior chamber intraocular lens (AC IOLs) remain a surgical option for visual rehabilitation required after surgical extraction of the cataract lens. Relevant publications in the PUBMED database were searched for articles regarding the types, visual outcomes and the complications followed the surgical implantation of AC IOLs. AC IOLs, which can be iris- (iris-claw) or angle-supported, increase visual acuity in most patients. However, complications, such as raised intraocular pressure, hyphaema, distorted pupil shape, iris pigment precipitates, endothelial cell loss, corneal oedema, neovascular glaucoma, retinal detachment and cystoid macular oedema, can unfavorably affect the surgical outcome. Although AC IOLs have been found to improve the visual acuity of patients with cataract, they have been also implicated in several complications.

Ophthalmological Assessment of OCT and Electrophysiological Changes in Migraine Patients.

BACKGROUND: A cross-sectional study to investigate the morphological and functional changes of the visual pathway taking place in patients with migraine. METHODS: Fifteen patients (14 female, 1 male) diagnosed with migraine with aura and 23 patients (21 female, 2 male) diagnosed with migraine without aura were compared with 20 healthy volunteers (18 female, 2 male). All the participants underwent optical coherence tomography scan, electroretinogram (ERG), visual evoked potentials, and multifocal electroretinogram (mf-ERG) recording. RESULTS: Assessing ERG recordings, no significant differences in mean N1-P1 amplitudes were measured among the groups. The mean visual evoked potentials N80-P100 amplitudes were not significantly different among the three groups (one way analysis of variance: P = 0.075, F = 2.718). No significant difference was found in P100 latency times among groups. The mean retinal response density of mf-ERG in ring 1 was higher in healthy individuals compared with migraineurs, with statistical significance (Kruskal-Wallis analysis of variance and Dunn multiple comparisons test; P < 0.001, mean rank difference = -24.857 and P < 0.001, mean rank difference = -20.9, for migraine with aura-control and migraine without aura-control comparisons, respectively). In migraine with aura subjects, retinal nerve fiber layer thickness in superior and inferior quadrants was significantly decreased compared with healthy individuals, whereas in migraine without aura group, only the superior quadrant was significantly thinner compared with the control group. CONCLUSIONS: Retinal response density in mfERG of all migraineurs was significantly lessened compared with healthy individuals. There was no significant difference in visual evoked potentials N80-P100 amplitudes or P100 latencies among the groups. Moreover, retinal nerve fiber layer thinning observed in patients with migraine compared with control subjects, appeared statistically significant in some quadrants. The authors may be able to defend the retinal blood flow decrease theory in migraine. The results also indicate that several levels of the visual pathway seem to be affected in migraineurs.

The Impact of Chronic Tobacco Smoking on Retinal and Choroidal Thickness in Greek Population.

Aim. To investigate the effect of more than 25-year cigarette smoking on choroidal and retinal thickness, using spectral domain optical coherence tomography (SD-OCT). Methods. Thirty-one smokers and 25 age- and sex-matched nonsmokers, serving as control group, were submitted to slit-lamp biomicroscopy and dilated fundoscopy, SD-OCT, measurements of intraocular pressure (IOP), central corneal thickness (CCT), and axial length (AL). Heidelberg Spectralis was used to calculate choroidal thickness (CT), ganglion cell complex (GCC), outer retina layers (ORL), and macular thicknesses (MT). Results. The smokers' group consisted of 17 males and 14 females with mean age of 57.8 ± 4.5 years, while the controls' group consisted of 14 males and 11 females with mean age of 68.0 ± 4.1 years. CT and GCC thicknesses were significantly reduced in smokers compared to control group. The differences in thicknesses of ORL were marginally significant between two groups. The measurements of MT, IOP, CCT, and AL had the same distributions between smokers and nonsmokers. Conclusions. Tobacco smoking seems to result in thinner choroid and retina compared to nonsmokers. This is the first study in literature that investigates the anatomical effect of smoking for more than 25 years on the choroid and retina.

"Association between platelet activating factor acetylhydrolase and diabetic retinopathy: Does inflammation affect the retinal status?".

AIM: To assess the role of plasma platelet activating factor acetylhydrolase (PAF-AH) in pathogenesis and progression of diabetic retinopathy (DR). MATERIALS AND METHODS: Sixty eight diabetics and 23 age-frequency-matched non-diabetic patients underwent blood sampling and the plasma PAF-AH activity was calculated. The diabetic patients were further classified into two groups, according to the Early Treatment Diabetic Retinopathy Study (ETDRS) classification, based on indirect fundoscopy and fluorescein angiography. Thirty seven patients with non-proliferative DR (NPDR) and 31 patients with proliferative DR (PDR) were finally included in the study. RESULTS: The plasma PAF-AH activity was increased in diabetic patients with PDR (0.206 µmol/min/ml) compared to control group (0.114 µmol/min/ml, post-hoc Bonferroni comparison test: p<0.0001) and to NPDR group (0.147 µmol/min/ml, post-hoc Bonferroni comparison test: p=0.012). CONCLUSIONS: The activity of PAF-AH in the plasma increases in parallel with DR severity.

Estimation of depression prevalence in patients with Stargardt disease using PHQ-9 and Zung scores.

PURPOSE: To evaluate the psychological impact and depression prevalence in patients with Stargardt disease. METHODS: We conducted a case-control study including 39 patients with Stargardt disease and 32 age- and sex-matched healthy controls. All participants underwent a complete ophthalmologic examination and completed the Patient Health Questionnaire-9 (PHQ-9) and the Zung Depression Inventory questionnaire. Results were analyzed using IBM SPSS 22.0 software. RESULTS: The patient group consisted of 19 men and 20 women with mean age of 36.9 ± 5.4 years and control group of 19 men and 13 women with mean age of 42.5 ± 10.1 years. The mean values of PHQ-9 and Zung scores for patients and healthy individuals were 10.9 ± 4.9, 46.7 ± 11.1, 6.7 ± 5.4, and 41.1 ± 8.5, respectively. There were statistically significant differences between the 2 groups in PHQ-9 scores (independent samples t test: p = 0.001), but not in Zung scores (Mann-Whitney test: p = 0.053). The PHQ-9 and Zung scores appeared to be moderately but significantly correlated (Pearson coefficient 0.44, p<0.0001). In addition, PHQ-9 score seems to be raised along with age, whereas both scores are low when best-corrected visual acuity is high. CONCLUSIONS: Patients with Stargardt disease exhibited more depressive symptoms compared to healthy individuals according mainly to PHQ-9 scores. Moderate depression was significantly correlated visual function decline.

Assessment of hydroxychloroquine maculopathy after cessation of treatment: an optical coherence tomography and multifocal electroretinography study.

OBJECTIVE: This study was conducted to evaluate the macular status of patients treated with hydroxychloroquine before and after cessation of treatment. METHODS: Forty-two patients with systemic lupus erythematosus underwent ocular examination based on visual acuity evaluation, optical coherence tomography retinal thickness measurements, and multifocal electroretinography (mfERG) records at first visit. The tests were repeated 6 months after treatment withdrawal and compared to the findings at their first visit. RESULTS: Mean visual acuity (measured in log minimum angle of resolution) of both eyes was statistically increased after hydroxychloroquine discontinuation (difference in means: 0.06 [P<0.0001] and 0.01 [P=0.003] for the right and left eyes, respectively). Retinal response amplitudes of central and peripheral areas were significantly improved for both eyes. The following values were observed for central responses: the difference in means was -19.9 (P<0.0001) and -13.6 (P<0.0001) for the right eye and the left eye, respectively; for peripheral responses, difference in means was -10.3 (P<0.0001) and -9.5 (P<0.0001) for right eye and left eye, respectively, after the 6-month examination. There were no statistically significant differences in the retinal thickness of patients after cessation of treatment. The visual acuity of the patients was correlated to central and peripheral mfERG responses (r=-0.53 [P<0.0001] and r=-0.53 [P<0.0001], for the right eye and the left eye, respectively). CONCLUSION: The visual acuity of patients receiving hydroxychloroquine improves along with the amplitudes of the mfERG responses 6 months after discontinuation of the drug, but no difference in retinal thickness is identified.

Correlation of platelet activating factor and age-related macular degeneration.

OBJECTIVE: To investigate the role of Platelet Activating Factor (PAF) in the pathogenesis and development of Age-Related Macular Degeneration (ARMD). RESEARCH DESIGN AND METHODS: Fifty six patients with ARMD (24 patients with dry ARMD and 32 patients with wet ARMD) and 25 age-matched control participants underwent ophthalmological examination, including visual acuity measurement and evaluation of the retina. The participants were classified into three groups according to their retinal status, based on indirect fundoscopy, Optical Coherence Tomography and fluorescein angiography findings. In order to evaluate the concentrations of PAF in serum, blood samples were collected from all participants and were analyzed with ELISA technique. RESULTS: The concentrations of PAF differed significantly according to macular lesions and were found to be lower in patients with ARMD than control participants. CONCLUSIONS: PAF levels are decreased along with the severity of ARMD. Understanding the role of PAF in pathogenesis of ARMD could be the impetus for the development of new therapies field of treatment of ARMD or even other retinal diseases.

Visual field examination using a video projector: comparison with Humphrey perimeter.

PURPOSE: To present a method of visual field examination using a video projector. Also, we compare our results with those of a Humphrey perimeter, which is accepted as standard in automated perimetry. MATERIALS AND METHODS: Software implementing a full-threshold 4-2-step staircase algorithm for the central 30-2 of the visual field (76 points) has been developed and tested in nine eyes of seven patients using an Epson TW 700 video projector. The results were compared to those obtained from the same patients using the Humphrey perimeter. RESULTS: High correlation between the video projector visual fields and those of the Humphrey perimeter was found. The point-to-point correlation coefficient ranged from 0.75 to 0.90, with P<0.0001 for each eye. CONCLUSION: Visual field examination results using a video projector have high correlation with those of a Humphrey perimeter. The method is possibly suitable for clinical use.

Ocular actions of platelet-activating factor: clinical implications.

INTRODUCTION: To summarize the currently available evidence of platelet-activating factor (PAF) implication in the pathogenesis of inflammatory ocular diseases. AREAS COVERED: PAF is a potent mediator of inflammation, implicated in the pathogenesis of chronic inflammatory disorders, allergic reactions, oncogenic transformation, wound repair and hypoxia-induced angiogenesis. It seems to be involved in the protection of ocular surface against various harmful agents through inflammatory processes, which can lead to chronic allergic reactions or even corneal neovascularization and haze, if they do not undergo regulation. Pathogenesis of uveitis, which is significant cause for the blurring of the visual system, has also been associated with PAF's activity. The hypoxia and the breakdown of the blood-retina barrier, observed in severe vascular retinal diseases, such as age-related macular degeneration and diabetic retinopathy, are associated with PAF ocular activity. EXPERT OPINION: Understanding the pathophysiology of vision threatening diseases could enhance clinical treatment and encourage experimental studies, which could be based on potential beneficial effects of new agents, such as PAF antagonists.