Effect of intracameral triamcinolone acetonide on postoperative intraocular pressure after cataract surgery.

PURPOSE: To evaluate the effect of 1 mg intracameral triamcinolone acetonide (TA) on postoperative intraocular pressure (IOP) after routine cataract surgery. PATIENTS AND METHODS: This prospective, randomized, placebo-controlled study comprised 120 eyes of 120 patients with uncomplicated cataract surgery. The patients were randomized into two groups. Eyes in group 1 (60 eyes) received an injection of 1 mg TA into the anterior chamber at the end of the surgery, but eyes in group 2 (60 eyes) did not. The biomicroscopic evaluation, visual acuity (VA), and IOP measurements were done at baseline (preoperatively) and 6, 20-24 h, 1 week, and permonthly until 6 months postoperatively. RESULTS: Mean IOP at 6 and 20-24 h postoperatively were significantly higher than baseline measurements in both groups (P<0.001). Also, the mean IOP values at postoperative 6 and 20-24 h were slightly higher in group 1 than in group 2 (P>0.05 for both). The mean IOPs at week 1 and 1-6 months after surgery were not significantly different from baseline values in both groups (P>0.05 for both time periods). At 6 and 20-24 h postoperatively, the number of eyes with an IOP increase>5 and 10 mm Hg with respect to baseline were not statistically different between the two groups (P>0.05). There were no statistically significant differences in mean VA and the amount of anterior chamber cells and flare between the two groups at any postoperative visit (P>0.05). CONCLUSION: Intracameral injection of 1 mg TA after uncomplicated phacoemulsification surgery had no significant effects on postoperative IOP.

Amniotic membrane transplantation using fibrin glue in pterygium surgery: a comparative randomised clinical trial.

PURPOSE: To compare the results of amniotic membrane transplantation (AMT) using fibrin glue vs vicryl sutures in pterygium surgery. METHODS: We carried out a prospective, randomised clinical study of 70 eyes (70 patients) with primary pterygium. After the removal of pterygium, patients were randomised to undergo AMT using fibrin glue (Tisseel, 32 eyes) or 8-0 vicryl sutures (38 eyes). Clinical examination and digital photographing were performed at each visit and the patients were followed up for at least 12 months. Post-operative symptoms in the first month were evaluated according to a five-point scale. Final appearances were graded from 1 to 4 in which grade 4 represented true (corneal) recurrence and grade 3 indicated conjunctival recurrence. RESULTS: The average operation time in the fibrin glue and suture groups were 11.2+/-2.4 min (mean+/-SD) and 18.7+/-2.2 min, respectively (P=0.018). Significantly fewer post-operative symptoms were observed in the fibrin glue group at post-operative days 1, 7, and 14 (P<0.05 for all). At the end of the follow-up, true recurrence (grade 4) was developed in three eyes (9.4%) in the fibrin glue group, and in four eyes (10.5%) in the suture group (P=0.33). The rates of conjunctival recurrence (grade 3) were 21.9% (seven eyes) and 23.7% (nine eyes) in the fibrin glue and suture groups, respectively (P=0.38). CONCLUSIONS: Amniotic membrane grafts can be successfully attached without any major complication in patients undergoing pterygium surgery. In addition, it is effective in shortening the duration of surgery and preventing post-operative discomfort. Although there seems to be no difference in the recurrence rates and cosmetic outcomes between both groups, neither technique represents best results.

Fibrin glue versus sutures for conjunctival autografting in pterygium surgery: a prospective comparative study.

AIM: To compare the use of fibrin glue versus sutures for fixating conjunctival autografts in patients undergoing pterygium excision. METHODS: Fifty patients (50 eyes) with primary pterygium were randomised to undergo pterygium surgery using either fibrin glue (25 eyes) or 8-0 Vicryl sutures (25 eyes) to attach the conjunctival autograft. The patients were followed up for 12 months. Outcome measures were postoperative patient comfort, duration of surgery and recurrence of pterygium. RESULTS: In the fibrin glue group, the mean operation time was 15.7 (SD 2.4) min (range 12-18 min) and in the suture group (p<0.001) it was 32.5 (6.7) min (range 25-40 min). The intensity of the postoperative pain, foreign-body sensation, irritation and epiphora were significantly lower in the fibrin glue group than in the suture group (p<0.001). The intensity of itchy sensation at the first two postoperative visits was lower among patients in the fibrin glue group (five patients, 20%) than in the suture group (12 patients, 48%) (p<0.05). Two patients in the fibrin glue group had partial graft dehiscence; these grafts were successfully reattached with fibrin glue. At the end of follow-up, pterygium recurrence was observed in one eye (4%) in the fibrin glue group and in three eyes (12%) in the suture group (p<0.05). CONCLUSION: The use of fibrin glue in pterygium surgery with conjunctival autografting significantly reduces surgery time, improves postoperative patient comfort and results in a lower recurrence rate compared with suturing.

Comparative clinical trial of topical anaesthetic agents for cataract surgery with phacoemulsification: lidocaine 2% drops, levobupivacaine 0.75% drops, and ropivacaine 1% drops.

PURPOSE: To assess the safety and efficacy of topical lidocaine, levobupivacaine, and ropivacaine in cataract surgery with phacoemulsification. METHODS: One hundred and five patients scheduled for cataract surgery with topical anaesthesia were randomly allocated into 3 groups of 35 patients each to receive eye drops of lidocaine 2%, levobupivacaine 0.75%, or ropivacaine 1% every 5 min starting 30 min before surgery. Patients graded their pain using a 0-10-point verbal pain score (VPS) at different stages of the procedure. The levels of patient and surgeon satisfaction, the duration of surgery, complications, and the need for supplemental anaesthesia were recorded. RESULTS: There was no significant difference in duration of surgery and demographic variables among the groups. At the intraoperative period, end of surgery, and postoperative first hour the mean VPS in the lidocaine group was significantly higher than the others (P<0.01), but no significant difference was found between the levobupivacaine and ropivacaine groups. At incision and 24 h after surgery, it was not significantly different among the groups. Surgeon and patient satisfaction scores were significantly better in the levobupivacaine and ropivacaine groups than in the lidocaine group (P<0.01). CONCLUSIONS: Topical anaesthesia with levobupivacaine and ropivacaine were safe, feasible and more effective than lidocaine in cataract surgery. Levobupivacaine and ropivacaine provided sufficient and long-lasting analgesia without the need of supplemental anaesthesia for each patient.

Relationship between optokinetic nystagmus response and recognition visual acuity.

PURPOSE: The aim of this study was to investigate the relation between recognition visual acuity (RVA) and optokinetic nystagmus (OKN) response exhibited to different bar sizes with varying contrast. METHODS: OKN testing was performed in 52 children aged between 3 and 11 years. The children were evaluated in two groups according to their RVA. Group I consisted of 22 eyes with RVA equal to or better than 0.1 logMAR units. Group II consisted of 30 eyes with RVA 0.2-1 logMAR units. Each subject was seated 60 cm from the screen of Ophthimus device, and was exposed to consecutive black and white stripes of seven different spatial frequencies (0.08-1.6 cycle/degree). The narrowest bar that elicited OKN was identified, and then the OKN contrast threshold at this bar size was established. RESULTS: Twenty-one of the 22 eyes in Group I, and 26 of the 30 eyes in Group II exhibited 1.6 cycle/degree spatial frequency (P=0.287). In Group II, 88.9% of the 18 eyes with RVA 0.2-0.5 logMAR responded at this maximum spatial frequency, whereas the corresponding figure for the 12 eyes with RVA 0.6-1 logMAR was 83.3% (P=0.531). Contrast sensitivity (CS) significantly changed with age in Group I (P=0.006). When the eyes that responded at maximum spatial frequency in the two groups were compared, the mean CS in Group II was significantly lower than that in Group I (P=0.005). CONCLUSIONS: The results indicate no relation between spatial frequency threshold for OKN response and RVA in children. However, the children with RVA deficits had significantly lower CS.

Decision-making in second-eye cataract surgery: can presence of Pulfrich phenomenon help?

PURPOSE: To determine whether testing for the Pulfrich phenomenon (PP) can be used as a tool to assess the need for and optimal timing of second-eye cataract surgery. METHODS: A total of 61 patients with logMAR 0 visual acuity (VA) after cataract surgery in one eye and logMAR 0.2-0.7 VA in the other eye were tested for PP using a computer-generated oscillating target at Baskent University Hospital. Only patients who had no ophthalmologic or systemic problem that could cause PP were included. In all, 15 normal patients with logMAR 0 VA in both eyes served as controls. The main outcome measures were presence and magnitude (measured by neutral density filters) of PP and presence of complaints related to binocular vision. RESULTS: Of the 61 patients, 36 (59%) and none of the controls were PP (+) (P<0.001). A total of 27 (75%) of the PP (+) patients had logMAR 0.7-0.4 VA, and nine (25%) had logMAR 0.3-0.2 VA (P=0.01). In all, 16 patients (all PP (+)) had developed binocular vision-related complaints since cataract surgery. The mean PP magnitude in these cases was significantly greater than the mean for the 20 patients without complaints (1.2+/-0.5 vs0.6+/-0.4 log units, respectively; P<0.001). There was no significant difference between the mean VA in the complaint (+) and complaint (-) subgroups (P=0.213). CONCLUSION: PP testing may detect binocular visual dysfunction after first-eye cataract surgery; thus, it could help assess the need for second-eye cataract surgery on this basis.

[Papilloedema and brain abscess associated with isolated left superior vena cava draining in to the left atrium]. / Stauungspapille bei Gehirnabszess assoziiert mit isolierter persistierender linker Vena cava superior mit Drainage in den linken Vorhof.

BACKGROUND: Papilloedema and brain abscess associated with persistent left superior vena cava draining into the left atrium without sinus coronarius and atrium septum defect is rare and until now in only few cases have been reported. PATIENT: A 12 year-old girl was admitted because she had suffered from headache and blurred vision for 2 weeks. Fundus examination revealed papilloedema with peripapillary intraretinal haemorrhages. Pupillary reaction to light was normal. An afferent pupillary defect was negative. Neurological examination was without any focal neurological signs. Cerebral magnetic resonance imaging showed the characteristic features of a brain abscess in the left frontal lobe (3.5 x 3.0 x 2.8). Cardiological examination showed the presence of an isolated left superior vena cava draining into the left atrium in the absence of coronary sinus and atrial septum defect. CONCLUSION: Congenital heart disease such as LSVC is rare. The association of LSVC with papilloedema and brain abscess is very rarely seen. However, the complications of LSVC can be life-threatening. Therefore in children with papilloedema, intraocular and intraorbital reasons as well as congenital heart disease as the underlying reason should be included in the differential diagnosis.

[Hemicentral retinal artery occlusion associated with moyamoya syndrome]. / Hemizentralarterienverschluss bei Moyamoya-Syndrom.

Moyamoya syndrome is a rare cerebrovascular disorder characterized by bilateral progressive supraclinoidal stenosis or occlusion of the internal carotid artery and development of collateral vessels in the lenticulostriate region. The syndrome manifests itself in association with another disease or other clinical symptoms. We present the case of a 12-year-old girl with hemicentral retinal artery occlusion due to moyamoya syndrome associated with clinical and laboratory findings of presumed systemic lupus erythematosus.

Opportunistic posterior uveal infections in renal transplant patients.

AIMS: To describe the cases of opportunistic posterior uveal infection diagnosed in renal transplant recipients at a single center over a 10-year period. METHODS: The study involved 1156 patients who underwent renal transplantation. Five of the recipients were diagnosed with posterior uveal infection. The specific diagnoses were acute retinal necrosis (two cases), cytomegalovirus retinitis (one case), nocardial chorioretinitis (one case), or tuberculoid granuloma (one case). RESULTS: The five patients were aged 27 to 55 years, and the interval from renal transplantation to uveal infection ranged from 7 months to 16 years. All patients were receiving immunosuppressive treatment at the time of the posterior uveal infection. Acute retinal necrosis was diagnosed in cases I and II at 2 and 3 years after transplantation, respectively. In both cases, fundus examination revealed moderate vitritis and yellow-white lesions representing confluent retinitis. In case III (cytomegalovirus retinitis), 7 months after transplantation the patient developed extensive hemorrhage and confluent white exudates, periphlebitis, and perivascular sheathing in the right eye. In case IV, culture of a fine-needle aspirate from a well-demarcated, white-yellow, elevated choroidal lesion in the superotemporal region of the macula revealed nocardial infection. Fundus examination of the right eye of case V revealed a small, hypopigmented choroidal lesion superior to the optic disc. The lesion was identified as a choroidal tuberculoid granuloma. CONCLUSIONS: Opportunistic chorioretinal infections can occur at any time after renal transplantation. So it is important that every kidney recipient undergo regular ophthalmic examinations throughout his or her lifetime.

Ocular side-effects of tolterodine and oxybutynin, a single-blind prospective randomized trial.

AIM: To evaluate the effects of tolterodine and oxybutynin on visual accommodation, pupillary diameter, intraocular pressure and tear secretion in women with overactive bladder. METHODS: One hundred and four eyes from 52 consecutive female patients (age range: 22-60 years) with a urodynamic diagnosis of overactive bladder were prospectively investigated. Patients with a history of ocular disease or surgery were excluded. The subjects were randomly assigned to one of two groups: Group I received 2 mg tolterodine bid and Group II received 5 mg oxybutynin tid. All patients were evaluated at baseline (day 0) and after 1 month of treatment (day 28) by an ophthalmologist who was blinded to the medication. At each time point, a complete ophthalmic examination was performed and accommodation amplitude (AA), and pupillary diameter (PD) in dim and bright light were recorded. As well, tear secretion was assessed based on tear film break-up time and Schirmer I-test results. Statistical comparisons were made using the chi-square test, Student's t-test and Mann-Whitney U-test, as appropriate. RESULTS: Twenty-eight patients (56 eyes) received tolterodine and 24 patients (48 eyes) received oxybutynin. The mean ages of the two groups were similar (P = 0.523). After 4 weeks of treatment, AA was significantly lower in the oxybutynin treated group (P = 0.003, 95% CI 0.15, 0.62) whereas there was no significant change in AA in the tolterodine treated group (P = 0.155, 95% CI -0.042, 0.86). At day 28, PD in dim light was significantly larger in the tolterodine treated group (P = 0.031, 95% CI -0.82, -0.06), whereas no significant change in PD in dim light was noted in the oxybutynin treated group (P = 0.330, 95% CI -0.38, 0.18). Neither group showed a significant change in PD in bright light values on day 28 (P > 0.05 for both). In each group, the differences from day 0 to day 28 for intraocular pressure, and Schirmer-I results were insignificant (P > 0.05 for all). Both groups had significantly shorter tear film break-up time after 1 month of therapy (P = 0.014 (95% CI 0.47, 3.81) and P = 0.02 (95% CI 1.14, 4.61) for the tolterodine and oxybutynin treated groups, respectively). CONCLUSION: Four weeks of standard-dose oxybutynin treatment in women with overactive bladder decreases AA significantly, whereas the same duration of standard-dose tolterodine does not have this effect. However, tolterodine seemed to affect PD in dim light. One month of treatment with either of these anticholinergic drugs shortens tear film break-up time significantly. Concerning ocular side-effects, tolterodine seems to offer an advantage over oxybutynin because it does not affect AA, however, the shorter tear film break-up time with both agents suggests potential problems for patients who already have dry eye.

Comparison of additional intraocular pressure-lowering effects of latanoprost vs brimonidine in primary open-angle glaucoma patients with intraocular pressure uncontrolled by timolol-dorzolamide combination.

PURPOSE: To compare the additive intraocular pressure (IOP)-lowering effects of latanoprost 0.005% and brimonidine 0.2% in primary open-angle glaucoma (POAG) patients uncontrolled on fixed combination of timolol 0.5% and dorzolamide 2% (TDC) alone. METHODS: In all, 80 eyes of 80 POAG patients with IOP inadequately controlled by TDC were randomly assigned to receive either latanoprost 0.005% or brimonidine 0.2%. IOP measurements were recorded at 1000 (peak effect) and 1600 (trough effect) on day 0 (baseline) and at 1 and 3 months. At each stage and time point, the mean IOP reductions from baseline were evaluated for both groups, and success rates (minimum 15% reduction) were determined. RESULTS: At baseline, the mean peak/trough IOPs with TDC were 20.2/21.6 and 19.9/21.4 mmHg in latanoprost and brimonidine groups, respectively. Latanoprost+TDC reduced the mean peak/trough IOP by 4.4/3.4 and 5.2/3.5 mmHg at 1 and 3 months. The corresponding values for brimonidine+TDC were 3.9/2.9 and 4.6/2.9 mmHg. Each of these results represented a significant reduction from baseline (P<0.001 for all); however, the groups' peak/trough reductions from baseline did not differ at any time point (P>0.05 for all). With the latanoprost+TDC combination, the peak/trough success rates at 1 and 3 months were 76.3%/42.1% and 77.1%/40%. The corresponding values with the brimonidine+TDC combination were 71.8%/41% and 77.7%/41.7%. There were no significant differences in the groups' success rates at any time point (P>0.05 for all). CONCLUSION: Addition of latanoprost 0.005% or brimonidine 0.2% to TDC reduces peak/trough IOPs significantly and the effects of these combinations are comparable.

Refractive outcome of single running suture adjustment in penetrating keratoplasty.

PURPOSE: To evaluate the effectiveness of single running suture adjustment in reducing postoperative astigmatism and improving visual acuity in patients who have undergone penetrating keratoplasty. METHODS: Eighteen eyes of 18 patients who underwent penetrating keratoplasty at the Department of Ophthalmology, Baskent University between May 1997 and December 2000 and who had an astigmatism over 2 diopters (D) at the fourth postoperative week were included. All eyes underwent suture adjustment at the fourth week and eight eyes with residual astigmatism above 3 D underwent a second adjustment at the eighth week. Final astigmatism and visual acuity findings were evaluated 28 weeks postoperatively. RESULTS: The mean postoperative keratometric and refractive astigmatism were 5.76 +/- 0.88 D (range=4.50-7.76) and 5.22 +/- 0.78 D (range=4.0-7.0) at the fourth week, which were decreased to 2.82 +/- 0.99 D (range=1.25-4.62, p=0.0001) and 2.61 +/- 1.01 D (range= 1.0-4.5, p=0.0001) after suture adjustment, respectively. In eight eyes at the eighth week, a second suture adjustment reduced the average keratometric and refractive astigmatism from 3.86 +/- 0.65 D (range=2.75-4.62) and 3.81 +/- 0.44 D (range=3.25-4.50) to 2.33 +/- 0.91 D (range=0.87-3.50, p=0.012) and 2.06 +/- 0.68 D (range=1.0-2.75, p=0.011), respectively. At the 28th week, the average keratometric and refractive astigmatism levels for the entire cohort, which were 2.39 +/- 1.06 D (range=1.0-3.50) and 2.25 +/- 0.96 D (range=1.0-3.25), respectively, showed a statistically significant decrease when compared with the levels before the first suture adjustment (p=0.0001 for both data). The mean best-corrected visual acuity was 20/25 on the Snellen chart at the 28th week. CONCLUSIONS: Postoperative adjustment of single running suture is a safe and effective way of reducing postkeratoplasty astigmatism.

Glare disability in patients with hydrophilic and hydrophobic acrylic intraocular lens implants.

PURPOSE: To compare glare disability test results in patients with hydrophilic and hydrophobic acrylic intraocular lenses (IOL). METHODS: Sixty eyes of 60 patients were studied in three groups of 20. Each eye in Group 1 had a single-piece hydrophilic acrylic (Bioacryl, Biotech, France) IOL implant, and each eye in Group 2 had a three-piece hydrophobic acrylic (AcrySof, Alcon, USA) IOL implant. Group 3 was the control group, and consisted of eyes without cataracts. Glare disability was tested using the Ophthimus glare sensitivity test (Ophthimus, Sweden). For each eye, we determined log contrast sensitivity values without exposure to glare source and with exposure to glare source. The difference between these values was recorded as the threshold contrast increase. An infrared camera was used to measure pupil diameter during glare disability testing, and pupil diameter greater than 4 mm was used as an exclusion criterion to eliminate edge design as a potential contributor to glare disability. RESULTS: The respective mean log contrast sensitivity scores for Groups 1, 2, and 3 in the absence of the glare source were 0.80 +/- 0.03, 0.81 +/- 0.04, and 0.79 +/- 0.08. The corresponding findings with glare source were 0.84 +/- 0.07, 0.89 +/- 0.07, and 0.84 +/- 0.03. The threshold contrast increase in Group 2 (0.070 +/- 0.035) was significantly higher than that in both Group 1 (0.043 +/- 0.040) and the control group (0.045 +/- 0.026) (p < 0.05 for both comparisons). There were no significant differences between Group 1 and the control group regarding log contrast sensitivity values with glare source and threshold contrast increase (p > 0.05 for both comparisons). CONCLUSIONS: The eyes with hydrophilic acrylic IOL showed better glare disability results than those with hydrophobic acrylic IOL. The superior performance of the hydrophilic acrylic IOL could be related to their lower refractive index and equi-convex design.

Tear function tests and conjunctival impression cytology before and after hormone replacement therapy in postmenopausal women.

PURPOSE: To investigate the effect of hormone replacement therapy (HRT) on postmenopausal tear function and the conjunctival epithelium. METHODS: Schirmer I-Jones test, tear film break-up time (BUT), and impression cytology findings were analyzed in 34 eyes of 17 women who were at least two years postmenopausal and not taking HRT: This series of tests was repeated after three months on HRT. RESULTS: The patients' average age was 53.82 +/- 3.6 years, and the mean time postmenopause was 35.29 +/- 11.59 months. There was no significant difference in the Schirmer I-Jones test results before and after three months of HRT (p > 0.05). However, the BUT (p < 0.05) and impression cytology (p < 0.05) findings were significantly affected by HRT. CONCLUSIONS: HRT may alleviate postmenopausal dry eye symptoms by increasing goblet cell density.

Results of cataract surgery in renal transplantation patients.

PURPOSE: To evaluate the results of conventional extracapsular cataract extraction and phacoemulsification cataract surgery, in renal transplant patients. METHODS: A total of 11 eyes of eight renal transplant recipients who underwent cataract surgery in Ankara between 1995 and January 2001 were evaluated. Each individual underwent routine ophthalmologic examination including visual acuity with Snellen chart testing, slit-lamp examination, intraocular pressure measurement, and fundus examination. Of these, seven patients had posterior subcapsular cataracts and four had nuclear cataracts. Conventional extracapsular cataract extraction (cECCE) was performed in four eyes with single-piece all-polymethylmethacrylate posterior chamber intraocular lens implantation. The other seven eyes were treated with small-incision phacoemulsification and implantation of a foldable hydrophilic acrylic lens. RESULTS: We observed intraoperative posterior capsule rupture and vitreous loss in one patient, postoperative intraocular tension elevation in one patient, and sterile suture infiltration in one patient in our series. Average of the visual acuities 6 months after the operation was 20/30 (range, 20/60-20/20). CONCLUSIONS: In this, the first published report to describe outcomes of cataract surgery in renal transplant patients, most complications were associated with high of steroids use and immunosuppressives, and were independent of the type of cataract surgery used, either ECCE or phacoemulsification surgery. The study suggests the need for additional care before, during, and after operation.

Granulomatous anterior uveitis in a patient with CREST syndrome.

The CREST syndrome is a variant form of progressive systemic sclerosis. Apart from the occurrence of keratoconjunctivitis sicca, other types of ocular involvement associated with this variant are quite rare. We present the case of a 73-year-old woman with the CREST variant of progressive systemic sclerosis who developed unilateral granulomatous anterior uveitis. Systemic and laboratory testing failed to suggest evidence for any other associated systemic disease as a possible cause of the granulomatous uveitis. The inflammation was successfully controlled with topical steroids and mydriatics. While a small number of cases of uveitis have been reported in other variant forms of progressive systemic sclerosis, to date there have been no descriptions of uveitis associated with the CREST syndrome.