Intraocular pressure and ocular biometric parameters changes in migraine.

BACKGROUND: The aim of this study was to assess the intraocular pressure and ocular biometric parameters in migraine patients during acute migraine attacks and compare them with painless period and healthy controls using a new optical biometer AL-Scan. METHODS: In this prospective, case-control study, the axial length, corneal curvature radius, anterior chamber depth, central corneal thickness, and pupil size of 40 migraine patients during acute migraine attacks and painless period and 40 age- and sex-matched healthy subjects were measured using a AL-Scan optical biometer (Nidek Co., Gamagori, Japan). All patients underwent a complete ophthalmic examination before the measurements. IOP and biometer measurements were taken at the same time of day (10:00-12:00) in order to minimize the effects of diurnal variation. RESULTS: There was not a statistically significant difference in intraocular pressure between the migraine patients during acute migraine attacks (15.07 mmHg), painless period (14.10 mmHg), and the controls (15,73 ± 0,81). Also, the ocular biometric parameters did not significantly vary during the acute migraine attacks. CONCLUSIONS: Further studies are needed to evaluate the etiopathologic relationship between intraocular pressure and ocular biometric parameters and acute migraine attack.

Effectiveness of the lower eyelid suspension using fascia lata graft for the treatment of lagophthalmos due to facial paralysis.

PURPOSE: To evaluate of functional and cosmetic effectiveness of lower eyelid sling technique with fascia lata graft in patients with lagophthalmos due to facial paralysis. MATERIAL AND METHOD: Ten patients with a mean age of 55.1 ± 19.77 years who underwent lower eyelid sling surgery with a fascia lata graft between September 2011 and January 2014 were included in this prospective study. Preoperatively and postoperatively patients were evaluated in terms of corneal epithelial defects, Schirmer's test, and tear break-up time (TBUT). Cosmetically, vertical eyelid aperture, margin reflex distances 1 and 2 (MRD1 and MRD2) and scleral show were evaluated preoperatively and postoperatively. RESULTS: One patient had facial paralysis on the right side whereas the other 9 patients had facial paralysis on the left side. Preoperatively, 3 patients were detected with corneal ulcer, whereas 7 patients were detected with persistent corneal epithelial defects localized in the lower half of the cornea. In the 3 patients with preoperative corneal ulcer, the ulcer recovered with corneal opacity, whereas in the 7 patients with punctate epitheliopathy, postoperative corneal transparency was obtained. DISCUSSION: Lower eyelid sling technique with fascia lata graft is an effective technique for the repositioning of the lower eyelid and preventing the corneal complications.

Isolated rectus muscle rupture following trauma.

BACKGROUND: Isolated rectus muscle ruptures are rare ophthalmic emergencies which may result in permanent diplopia. OBJECTIVE: To highlight updates on clinical features, surgical treatment options and potential complications for isolated inferior rectus ruptures. CASE: A 39-year-old man came to our emergency department complaining of diplopia and upward deviation of the right eye after experiencing an animal injury. Extraocular movements were limited in the right eye in the downgaze position. The alternate prism and cover test, both at distance and near testing, showed hypertropia of 40 prism diopters (PD) of the right eye. The right eye had periorbital swelling and conjunctival haematoma. An inferior rectus rupture repair was performed under local anesthesia and monitored sedation. Follow-up examination revealed a 20 PD hypertropia, causing diplopia in all gazes. A second surgical intervention was planned six months after the initial surgery, an inferior rectus 6 mm resection was performed, after which orthophoria was achieved in the primary position both at distance and near testing.

Bidirectional Synergistic Vergence.

A 14-year-old boy presented with left ptosis and squint since his childhood. In primary position he had left hypotropia with ptosis (levator function 2 mm). With elevation of the right eye, the left eye depresses and adducts; with depression of the right eye, the left eye elevates and abducts. Forced duction test revealed no restrictive pattern. The synergistic divergence described in the literature was unidirectional and wholly compatible with inferior rectus co-contraction. But this case is bidirectional, and the aberrant upward movement cannot be explained by rectus muscle co-contraction. The two vertical rectus muscles show reciprocal misinnervation, or this effect could be coming from co-contraction of one of the oblique muscles for the movement in one direction.

Comparison of Medpor coated tear drainage tube versus silicon tear drainage tube in conjunctivodacryocystorhinostomy: problems and solutions.

PURPOSE: This study aims at comparing two different types of drainage tubes in conjunctivodacryocystorhinostomy, which are used for upper lacrimal system obstruction or damage, with respect to their respective postoperative problems and solutions. METHODS: Nineteen eyes of 17 patients who underwent conjunctivodacryocystorhinostomy (CDCR) or conjunctivorhinostomy (CR) surgery with a Medpor coated tear drainage tube or silicon tube placement between October, 2010, and February, 2014, were included in this retrospective comparative study. RESULTS: In the initial surgery, Medpor coated tear drainage tubes were used in 11 eyes by CDCR, whereas silicon tear drainage tubes were implanted into 2 eyes by CR and 6 eyes by CDCR. In group 1, proximal and distal obstructions developed postoperatively in 4 eyes, while 1 eye showed tube malposition and 3 eyes developed luminal obstruction by debris 3 times. In group 2, tube extrusion developed in 4 eyes, whereas tube malposition developed in 6 eyes and luminal obstruction by debris developed in 6 eyes at different times, for a total of 20 times. CONCLUSIONS: In our study, the most significant complication we observed in the use of silicon tear drainage tubes was tube extrusion,whereas the leading complication related to the use of Medpor coated tear drainage tubes was tube obstruction.

Comprasion of ICare rebound tonometer and Goldmann applanation tonometer in high myopia.

PURPOSE: To compare intraocular pressure (IOP) measurements with the Goldmann applanation tonometer (GAT) and the ICare rebound tonometer (RBT) in high myopic eyes. PATIENTS AND METHODS: This randomized prospective study included 40 eyes of 40 patients with high myopia. All patients' central corneal thickness (CCT), anterior chamber depth (ACD), axial length (AXL), keratometry, and refractive measurements were recorded and followed by IOP measurement with RBT and GAT. RESULTS: The average CCT, AXL, and ACD were determined to be 514.65 ± 32 µm, 27.65 ± 2.22 mm, and 3.25 ± 0.51 mm, respectively. Mean K was 43.27 ± 1.4 D and mean spherical equivalent was -11.31 ± 4.30 D. The mean IOP values obtained by RBT and GAT were 17.18 ± 3.72 mmHg and 16.48 ± 3.19 mmHg, respectively. The deviations of RBT readings from corrected GAT values were highly correlated with CCT values (r = 0.588, P = 0.0001). The mean corrected GAT reading was 17.49 ± 3.01 mmHg. Linear regression analysis showed that a CCT change of 10 µm resulted in an RBT reading deviation of 0.57 mmHg. The Bland-Altman scatter-plot and McNemar test showed a clinically good level of agreement between the two tonometers. CONCLUSION: This study found a good agreement level between the two tonometers in high myopic patients and that RBT measurements are influenced by CCT variations.

Elevated Intraocular Pressure due to Arteriovenous Fistula between External Carotid Artery and Facial Vein.

Aqueous outflow via the conventional outflow pathway is dependent on the pressure gradient between intraocular pressure (IOP) and episcleral venous pressure (EVP). Elevated IOP resulting from increased EVP is a well-known complication of arteriovenous fistulas, which are usually between the carotid artery and the cavernous sinus. Arteriovenous malformations usually occur spontaneously, after a trauma or from iatrogenic causes, and they manifest with findings of chemosis, dilatation of the conjunctival vessels, exophthalmos, and extraocular motility limitation. In this study, we present a case of elevated IOP due to facial arteriovenous malformations following a functional neck dissection surgery that caused intraocular pressure elevation.

Reduction of conjunctival fibrosis after trabeculectomy using topical α-lipoic acid in rabbit eyes.

PURPOSE: To evaluate the efficacy of α-lipoic acid (ALA) in reducing scarring after trabeculectomy. MATERIALS AND METHODS: Eighteen adult New Zealand white rabbits underwent trabeculectomy. During trabeculectomy, thin sponges were placed between the sclera and Tenon's capsule for 3 minutes, saline solution, mitomycin-C (MMC) and ALA was applied to the control group (CG) (n=6 eyes), MMC group (MMCG) (n=6 eyes), and ALA group (ALAG) (n=6 eyes), respectively. After surgery, topical saline and ALA was applied for 28 days to the control and ALAGs, respectively. Filtrating bleb patency was evaluated by using 0.1% trepan blue. Hematoxylin and eosin and Masson trichrome staining for toxicity, total cellularity, and collagen organization; α-smooth muscle actin immunohistochemistry staining performed for myofibroblast phenotype identification. RESULTS: Clinical evaluation showed that all 6 blebs (100%) of the CG had failed, whereas there were only 2 failures (33%) in the ALAG and no failures in the MMCG on day 28. Histologic evaluation showed significantly lower inflammatory cell infiltration in the ALAGs and CGs than the MMCG. Toxicity change was more significant in the MMCG than the control and ALAGs. Collagen was better organized in the ALAG than control and MMCGs. In immunohistochemistry evaluation, ALA significantly reduced the population of cells expressing α-smooth muscle action. CONCLUSIONS: ΑLA prevents and/or reduces fibrosis by inhibition of inflammation pathways, revascularization, and accumulation of extracellular matrix. It can be used as an agent for delaying tissue regeneration and for providing a more functional-permanent fistula.

Toxic effects of chronic mercury exposure on the retinal nerve fiber layer and macular and choroidal thickness in industrial mercury battery workers.

BACKGROUND: The aim of this study was to evaluate the toxic effects of mercury on retinal nerve fiber layer thickness (RNFLT), macular thickness (MT), and choroidal thickness (CT) by using spectral-domain optical coherence tomography (SD-OCT) in battery industry workers who had been chronically exposed to mercury. MATERIAL/METHODS: Battery factory workers (n=31) and healthy non-factory employee controls (n=15) participated in the study. Participants were divided into 3 groups: Group 1 (n=15) was factory workers who had worked for more than 5 years in a mercury battery factory; Group 2 (n=16) was factory worker who had worked for less than 5 years in a mercury battery factory; and Group 3 (n=15) was healthy non-employees. Systemic symptoms were recorded. Ophthalmic examination included best-corrected visual acuity test, color vision test, full ophthalmologic examination, and SD-OCT of the RNLF, macula, and choroid. To determine mercury exposure, venous blood samples were collected and mercury levels were assessed. RESULTS: In our study group the most common systemic symptoms were insomnia (67.7%) and fatigue (67.7%). There were no significant differences between Group 1 and Group 2, but there were significant differences between Group 3 and both Group 1 and Group 2 in best-corrected visual acuity values (1=2<3), color vision scores, blood mercury levels, and duration (mean ±SD, range) of mercury exposure(1>2>3). OCT values of RNFLTs, MTs, and CTs of all 3 groups were statistically different from each another (1<2<3). CONCLUSIONS: SD-OCT can be useful for evaluating the toxic effects of chronic exposure to mercury.

Clinical, radiological, microbiological, and histopathological aspects of acquired dacryocystoceles.

Purpose. The aim of this study is to investigate the etiology and the clinical, microbiological, histopathological, and radiological findings of acquired dacryocystoceles. Methods. In this retrospective study, we reviewed the clinical records of 10 eyes of 8 patients with dacryocystoceles who underwent external dacryocystorhinostomy (DCR) surgery. Etiology, presenting symptoms and radiological findings as well as microbiological and histopathological assessment results and outcome were analyzed. Results. The records of 8 patients with dacryocystoceles were included in this study. In the histopathological evaluations of the samples collected from the lacrimal sac wall, chronic inflammation was found in all biopsied samples and fibrosis was observed in two histopathological evaluations. Computerized tomography (CT) imaging showed fluid collection separated from adjacent tissues by a thin rim, corresponding to dacryocystoceles in the sac. In the microbiological culture examination of samples collected from the fluid within the cyst, no bacterial growth in 5 eyes, gram-negative bacillus growth in 3 eyes, and gram-positive cocci growth in 2 eyes were found. Conclusions. Acquired dacryocystoceles were observed extremely rarely and a definite pathogenic agent could not be identified in any of the cases, either microbiologically or histologically, whereas chronic inflammation was detected in all cases in our study.

Topical anesthesia for cataract surgery: the patients' perspective.

Purpose. To evaluate the analgesic efficacy of 0.5% propacaine hydrochloride as topical anesthesia during phacoemulsification surgery. Methods. Intraoperative pain intensity was assessed using a 5-category verbal rating scale during each of three surgical stages. Pain scores from each surgical stage and total pain scores were compared for the factors of patient age, gender, cataract laterality, and type. Results. In comparison of cataract type subgroups, the mean total pain scores and mean stage 2 pain scores in both white mature cataract (WMC) and corticonuclear plus posterior subcapsular cataract (CN + PSC) groups were significantly higher than in the PSC-only (PSC) group (P < 0.05). Conclusion. Phacoemulsification with topical anesthesia is not a completely painless procedure. Pain intensity varies with cataract type and stage of surgery.

Retinal nerve fibre layer, ganglion cell layer and choroid thinning in migraine with aura.

BACKGROUND: The aim of this study was to investigate the thickness of the retinal nerve fiber layer (RNFL), the ganglion cell layer (GCL), and choroid thickness (CT) in patients who have migraines, with and without aura, using spectral optical coherence tomography (OCT). METHODS: Forty-five patients who had migraines without aura (Group 1), 45 patients who had migraines with aura (Group 2), and 30 healthy participants (control group) were included in the study. Spectral OCT was used to measure the RNFL, GCL and CT values for all patients. RESULTS: The mean age of Group 1, Group 2, and the control group was 34.6 ± 4.3, 32.8 ± 4.9, and 31.8 ± 4.6 years, respectively. The mean attack frequency was 3.6/month in Group 1 and 3.7/month in Group 2. The mean age among the groups (p = 0.27) and number of attacks in migraine patients (p = 0.73) were not significantly different. There was significant thinning in the RNFL and GCL in Group 2 (p < 0.05, p < 0.001 respectively), while there were no significant differences in RNFL and GCL measurements between Group 1 and the control group (p > 0.05). All groups were significantly different from one another with respect to CT, with the most thinning observed in Group 2 (p < 0.001). When all migraine patients (without grouping) were compared with the control group, there were significant differences on all parameters: RNFL thickness, GCC thickness and CT (p < 0.05). CONCLUSIONS: RNFL and GCL were significantly thinner in the migraine patients with aura as compared with both the migraine patients without aura and the control subjects. In migraine, both with aura and without aura, patients' choroid thinning should be considered when evaluating ophthalmological findings.

The use of polypropylene suture as a frontalis suspension material in all age groups of ptosis patients.

PURPOSE/AIM: To evaluate the use of 2-0 polypropylene suture for frontal suspension in ptosis patients with poor levator function. MATERIALS AND METHODS: This retrospective study included 20 eyelids of 16 patients (5 female, 11 male) with 4 mm or less levator function. The operation was considered successful when the difference between the two upper lids was ≤ 1 mm, and the upper lid covered the upper limbus by <3 mm. RESULTS: Median patient age was 22.94 years (2 to 59). Mean follow-up time was 18.06 months (12-29). A successful result was obtained in 14 patients (87.5%). Ptosis recurrence was observed in two patients (12.5%). Lagophthalmos with punctate epithelial keratitis and subsequent spontaneous recovery occurred during the first postoperative week in six patients (37.5%). Two patients with hypocorrection underwent revision surgery in the first postoperative week. Granuloma and material exposition at the forehead incision site observed in one patient at the postoperative fifth month were repaired by excision of the granuloma and suture reposition. CONCLUSIONS: Polypropylene suture as a frontalis suspension material in ptosis patients with poor levator function maintained satisfactory results at follow-up. This material allows easy and repeatable eyelid height adjustment and does not obviate future eyelid procedures.

Oculogyric crisis in a patient taking metoclopramide.

Oculogyric crisis is an acute dystonic reaction of the ocular muscles characterized by bilateral dystonic elevation of visual gaze lasting from seconds to hours. This reaction is most commonly explained as an adverse reaction to drugs such as antiemetics, antipsychotics, antidepressants, antiepileptics, and antimalarials. Although the incidence of metoclopramide-induced acute dystonic reactions has been reported as 25% in children, there have been few published cases on oculogyric crisis in general. It is important to be able to recognize this ocular side effect because, without a thorough patient history, symptoms can be confused with other diseases such as versive seizures, paroxysmal tonic upward gaze, and encephalopathy. In this paper, we report a case of oculogyric crisis induced by metoclopramide.

Late hyperbaric oxygen treatment of cilioretinal artery occlusion with nonischemic central retinal vein occlusion secondary to high altitude.

AIM: To report a case of cilioretinal artery occlusion (CRAO) with central retinal vein occlusion (CRVO) after a journey to high altitude region and the use of late period hyperbaric oxygen (HBO) therapy successfully. CASE REPORT: A previously healthy 48-year-old lowlander woman was admitted to our department for sudden blurred vision in her right eye started at 2 weeks prior to examination. The patient had a history of 1-month exposure to high altitude that finished a day before the onset of her complaints. The best corrected visual acuity (BCVA) was 10/20 in the right eye (RE) and 10/10 in the left eye. Fundus examination of the RE revealed whitening of the retina along the distribution of cilioretinal artery, sparing fovea, flame-shaped hemorrhages, and roth spots with minimally dilated and tortuous retinal veins. Visual field analysis revealed centrocecal scotoma. The patient was treated by a daily session of 2 h of HBO at 2.5 atmosphere absolute for 11 days. BCVA rised to a level of 20/20 for the RE and the scotomas were disappeared immediately after using of the HBO treatment. CONCLUSION: CRVO related CRAO should be regarded as a rare complication of exposure to high altitude and HBO seems to be the treatment of choice of high altitude related co-occurence of CRVO and CRAO in the late period.

Long-term comparison of fibrin tissue glue and vicryl suture in conjunctival autografting for pterygium surgery.

PURPOSE: Pterygium is a common clinical entity that usually causes visual impairment, astigmatism and cosmetic problems. Although many surgical techniques to treat pterygium have been proposed, no single method, with minimal patient complications, has yet been accepted and established. Excision combined with conjunctival autograft is the most often used procedure for the treatment of primary pterygium, and the technique is associated with minimized recurrence rates in patients. The purpose of our study was to compare visual and refractive outcomes, complications, and recurrence rates with the use of fibrin glue versus 8.0 vicryl suture in pterygium surgery performed with conjunctival autograft. MATERIALS AND METHODS: Our retrospective, comparative study included 106 eyes of 106 patients operated on for primary pterygium, between the years 2011 and 2012, and followed for ≥ 12 months. Patients were divided into 2 treatment groups: Group 1, vicryl suture use (n = 53), and Group 2, fibrin tissue glue (n = 53). Patient follow-up periods were 21.15 ± 5.3 months for Group 1 and 22.06 ± 5.2 months for Group 2. RESULTS: Demographics and preoperative/follow-up clinical characteristics of patients revealed no significant differences between the 2 patient groups. Additionally, no significant differences were found between the patient groups in visual acuity level changes and refractive values. Although the rates of recurrence (7.5% in Group 1 and 1.9% in Group 2; P = 0.36) and graft dehiscence (Group 1, 7.5% compared with Group 2, 3.8%; P = 0.67) were slightly higher for patients in the suture group, differences did not reach significance. CONCLUSIONS: Our study results suggest that conjunctival autografting with fibrin glue has favorable visual and refractive results for patients, and is associated with lower complication rates, compared with use of the traditional 8.0 vicryl suturing technique. We suggest that fibrin tissue glue provides adequate adhesion and that graft loss will not be a problem if protective shields are used in patients postoperatively. The appropriate surgery technique should be selected by considering the advantages and disadvantages of each procedure.

Toxic Anterior Segment Syndrome following Phacoemulsification Secondary to Overdose of Intracameral Gentamicin.

Objective. To report a case of toxic anterior segment syndrome (TASS) that was caused by inadvertent anterior chamber and cornea stromal injection with high dose gentamicin following cataract surgery. Methods. Case report. Results. We report a 72-year-old female patient who developed TASS that was caused by high dose gentamicin (20 mg/0.5 mL), which was inadvertently used during the formation of the anterior chamber and hydration of the corneal incision. Unlike previous cases, hyphema and hemorrhagic fibrinous reaction were seen in the anterior chamber. Despite treatment, bullous keratopathy developed and penetrating keratoplasty was performed. The excised corneal button was sent for histopathological examination. Conclusions. Subconjunctival gentamicin is highly toxic to the corneal endothelium and anterior chamber structures. Including it on the surgical table carries a potentially serious risk for contamination of the anterior chamber.

Retrospective analysis of 132 patients with orbital fracture.

BACKGROUND: The aim of this study was to evaluate the clinical and epidemiological features of 132 patients with orbital wall fracture who were treated at Sisli Etfal Teaching and Research Hospital, Istanbul, between 2005-2012. METHODS: The medical records of the patients with a diagnosis of orbital fracture were reviewed and analyzed. The patients were evaluated by age, gender, etiology, symptoms, examination findings, fracture location, associated injuries, treatment, and complications. RESULTS: The mean follow-up time was 9 (6-16) months. The male-to-female ratio was 5.3-1. The average age was 32 (6-82) years. The leading causes of orbital fractures were traffic accidents (36%) followed by assaults (32%). The most frequently affected orbital wall was the medial wall (33%). The main symptom was throbbing pain in the traumatized area (100%), and the main examination finding was periorbital edema and ecchymosis (100%). The most frequent associated injury was cerebral trauma (14%). Sixty-seven patients (50.1%) were managed with medical treatment, and 65 patients (49.9%) underwent surgical treatment. The most common complication in the late period was dermatomal sensory loss (11%). CONCLUSION: This study makes clear that the frequency of orbital injuries may be decreased by preventing traffic accidents, by taking precautions in the event they occur, and by promulgating social and educational work against violence.

The long-term follow-up results of external dacryocystorhinostomy skin incision scar with "W incision".

OBJECTIVE: To determine the effect of "W incision" instead of classical vertical incision at external DCR on scar formation. MATERIALS AND METHODS: Patients with acquired nasolacrimal duct obstruction (NLDO) who were treated with external DCR with classical vertical incision, and patients who were treated with external DCR with "W incision" were included in the study. The first 39 eyes were operated with a vertical incision, and the remaining 37 eyes were operated with a "W incision". All the skin incision scars of the patients were assessed and scored by at least the 6th month. The assessment was made by both the patients themselves, and by an ophthalmologist other than the surgeon himself, each scored the incision scar separately (single-masked study). Scores for both groups were compared, and statistical analyses were performed. RESULTS: Self-assessment scores for the incision scar were Grade 2.28 ± 0.94 in the Vertical incision group, and Grade 1.68 ± 0.57 in the "W incision" group (p < 0.01). The "W incision" scar formation was significantly less noticable than the Vertical incision scar formation. Similarly, the assessment scores of the ophthalmologist other than the surgeon himself were significantly lower for the "W incision" group than for the Vertical incision group. The mean scar assessment scores were Grade 2.13 ± 0.95 in the Vertical incision group, and Grade 1.57 ± 0.68 in the "W incision" group (p < 0.01). CONCLUSION: Skin scar tissue was found to be significantly reduced with a "W incision" in external DCR operations.