A Rare Presentation of Anthrax: A Pediatric Patient with Palpebral Anthrax.

Anthrax is a rare zoonotic disease in humans caused by Bacillus anthracis. The most common form of this disease is cutaneous anthrax. Rarely, eye involvement may occur. In this case, a nine-year-old male patient with anthrax on his left eyelids is presented. From the patient's history, it was learned that a slight papular reaction occurred on the left side of the eye, then the lesion enlarged within three days, and edema developed around the eye. On the fifth day of the patient's preseptal cellulitis diagnosis, progress in eye lesions and necrosis and eschar formation around the eyes were detected, while Bacillus anthracis polymerase chain reaction (PCR) positivity was detected on the fifth day of the patient's complaints. The patient was treated with ciprofloxacin and clindamycin and a clinical response was achieved. Anthrax should be kept in mind in the differential diagnosis of preseptal and orbital cellulitis, especially in patients who have close contact with animals. If palpebral anthrax is not treated effectively on time, it can leave scars on the eyelids and cause permanent deformities and loss of function. Early diagnosis and initiation of antibiotic therapy significantly reduce the occurrence of complications. In this case report, a pediatric case with eyelid anthrax, which is rarely seen in anthrax disease, is presented.

Prognostic factors and clinical features of rhino-orbital-mucormycosis cases: an update for patient and visual survivals.

AIM: To determine the frequency of patients' vision survival and prognostic factors and evaluate clinical features in rhino-orbital mucormycosis. METHODS: Forty-three eyes of 43 patients followed up with orbital mucormycosis infections were included in the study. Demographic characteristics of the patients, symptoms at admission, ophthalmologic and non-ophthalmologic examination findings, clinical findings during follow-up, medical and surgical procedures, and complications were recorded. Patient survival was determined by assessing the incidence of mortality, and vision survival was defined as achieving a final visual acuity of at least light perception. RESULTS: Twenty-seven (62.8%) patients were male, and 16 (37.2%) were female. When the underlying disease status of the patients was examined, it was observed that all patients had an underlying disease and diabetes constituted the majority (65.2%). Periorbital swelling (69.8%) and ophthalmoplegia (53.5%) were the most common symptoms and findings at the admission of patients with mucormycosis infection. The disease resulted in death in 22 (51.2%) patients. The presence of fever and shorter duration of antifungal therapy were associated with lower patient survival. Exenteration surgery was not found to be associated with the survival of the patients. Frozen eye, loss of pupillary light reflex, and development of central retinal artery occlusion were associated with lower vision survival. CONCLUSION: This study presents one of the most extensive patient series in the literature on rhino-orbital mucormycosis. Knowing the patients' symptoms at the time of admission and the clinical findings during the infection process will increase awareness about the disease.

Alternating pattern of rhino-orbital-cerebral mucormycosis with COVID-19 in diabetic patients.

PURPOSE: Our aim was to analyze the patients with diabetic rhino-orbital-cerebral mucormycosis that we have treated in our clinic in the last 5 years, and to reveal the altering conditions with COVID-19. MATERIALS AND METHODS: A retrospective study was conducted on 39 rhino-orbital-cerebral mucormycosis (ROCM) patients with diabetes mellitus between 2017 and 2022. The patients were divided into two groups as those associated with and not associated with COVID-19 and compared. RESULTS: Thirty-nine diabetic patients were included in the study, with 15 (38.5%) of them being COVID-19 associated mucormycosis (CAM) group. CAM patients showed higher orbital involvement and cavernous sinus involvement (p = 0.002 and p = 0.013, respectively). The mortality rate in the non-COVID-19 associated mucormycosis (non-CAM) group was statistically higher in patients with intracranial and cavernous sinus involvement (p = 0.015 and p = 0.033, respectively). The difference between the overall survival of the CAM patients and non-CAM patients was not statistically significant (p = 0.741). CONCLUSIONS: With COVID-19, progressive mucormycosis accompanied by orbital and intracranial involvement is observed more frequently. However, on the contrary, the mortality rate in COVID-19-associated mucormycosis is considerably lower than expected. The fact that temporary immune suppression can be ameliorated with adequate supportive treatment and liposomal amphotericin-B which can be given to patients in high doses may explain this situation. It has been attained hints that the essential factor in the treatment of COVID-19-associated ROCM is the control of the underlying disease and to be cautious in the decision of early aggressive surgery.

Obsructive sleep apnea syndrome: is it a risk factor for ocular surface disease and ocular comorbidities?

PURPOSE: To investigate the accompanying ocular findings in patients with obstructive sleep apnea syndrome (OSAS) and evaluate the susceptibility to ophthalmological diseases. MATERIALS AND METHODS: In this cross-sectional study, qualifying study subjects were patients who had been diagnosed with severe OSAS (apnea/hypopnea index (AHI > 30/h), n = 31), and control subjects (n = 30) who had an AHI index of < 5 (as normal). General ophthalmological examination, eyelid laxity measurements, corneal topography, visual field, retinal nerve fiber layer parameters, dry eye tests were performed on the patients. RESULTS: It was observed that the two groups had similar characteristics in terms of gender, age, presence of hypertension, diabetes, and body mass index. According to eyelid laxity measurements, the incidence of loose eyelids was higher in the OSAS patient group. Choroidal thickness was thinner in the study group than in the control group. Schirmer test and tear break-up time were significantly lower in the study group than in the control group. The percentage of meibomian gland loss in meibography and the ocular surface disease index score for symptoms was significantly higher in the study group than in the control group. CONCLUSION: In this study, we found significant changes in ocular surface parameters, eyelid laxity, choroidal thickness, and visual field indices in OSAS patients. Dry eye syndrome might be related eyelid laxity and inflammation in OSAS patients. Early diagnosis and follow-up of ocular diseases in OSAS, which affect the quality of life and visual prognosis in advanced ages, are important.

Tarsorrhaphy with Sutureless Amnion Transplantation: Practical Management of Ocular Surface Pathologies.

Objectives: The objective of the study was to evaluate the technique of tarsorrhaphy combined with sutureless amniotic membrane transplantation in the treatment of resistant ocular surface pathologies. Methods: In this study, the post-operative results of patients who underwent tarsorrhaphy combined with sutureless amniotic membrane between May 2016 and July 2021 were evaluated. In this technique, we have placed the amniotic membrane on the ocular surface, and then simple tarsorrhaphy has been performed. We used this technique in our six patients during COVID-19 pandemic period at the bedside. The outcomes of corneal epithelial healing, visual acuity, pain score, patient tolerance, and adverse events were evaluated. Results: Fourteen patients (eight females and six males) were included in the study. The mean age of the patients was 65.7 years (range 9-96 years). The mean follow-up period was 9 months (range 6-12 months). In all cases, epithelial defect healed completely and it was seen that this new technique facilitated resolution of pain and inflammation and promoted epithelialization in our 14 cases with resistant ocular surface pathologies. Post-operative pain score was significantly lower than pre-operative pain score (p<0.05). Conclusion: Our results demonstrate that tarsorrhaphy with sutureless amniotic membrane accelerates the ocular surface healing process and increases the efficiency of amniotic membrane. This method has an important advantage that it can be performed at bedside. Patients and ophthalmologists need such an innovative treatment which is effortless, effective, and practical especially for the pandemic period.

[Two Case of Rhino-Orbito-Cerebral Mucormicosis Developed After COVID-19 Infection]. / COVID-19 Enfeksiyonu Sonrasi Gelisen Iki Rino-Orbito-Serebral Mukormikoz Olgusu.

Coronavirus 2019 (COVID-19) infection causes excessive cytokine response and a decrease in cellular immune response and this increases susceptibility to fungal co-infections. Mucormycosis is a rare, lifethreatening invasive fungal infection. In this report, two cases who developed rhino-orbito-cerebral mucormycosis shortly after having COVID-19 infection were presented. The first case was a 68-year old woman who admitted to our clinic with orbital cellulitis in her left eye and had a known diagnosis of asthma and rheumatoid arthritis. She was diagnosed with COVID-19 pneumonia 40 days ago, stayed in the intensive care unit for a long time, and received pulse steroid (1000 mg methylprednisolone), interleukin-1 (IL-1) inhibitor (anakinra) and broad-spectrum antibiotic treatments together with antiviral therapy during this period. The second case was a 63-year-old male patient with known diabetes mellitus, hypertension and retinitis pigmentosa, with a history of hospitalization in the intensive care unit due to COVID-19 pneumonia 20 days ago and received pulse steroid therapy during this period. He admitted to our clinic with the complaints of droopy right eyelid, swelling, nausea and vomiting. In both cases, paranasal sinus tomography findings were consistent with invasive sinusitis. Functional endoscopic sinus surgery was performed immediately in less than 16 hours from the first admission in both cases. Histopathological examination of the both cases revealed results consistent with mucormycosis. Mucorales spp. was isolated in sinus tissue culture of the second case taken during the operation. Both of the patients received liposomal amphotericin B. First case died on the 19th day of the treatment. Second case was discharged with full recovery after nine weeks of treatment. The suppression of cellular immunity during the COVID-19 infection, and the use of steroids and interleukin inhibitors in the treatment of severe cases may increase secondary invasive fungal infections. Therefore, clinicians should more frequently consider possible fungal infections in patients with COVID-19.

Factors Affecting Binocular Sensorial Function in Accommodative Esotropia.

OBJECTIVES: This study was an assessment of factors related to the development and maintenance of binocular sensory function after successful alignment of accommodative esotropia (AE). METHODS: A total of 107 patients aged <12 years with ≥6 months follow-up were included in the study. The variables of age at onset of deviation, duration of deviation before treatment, the amount of uncorrected distance and near deviation, hyperopia, anisometropia, and accommodative convergence to accommodation ratio (AC/A) were evaluated. RESULTS: The study patients had a mean age of 4.9±2.5 years and a mean length of follow-up of 34.3±28 months. Anisometropia was identified in 26.1% of the participants. Anisometropic patients had a greater degree of hyperopia (mean: 5.02±2.07 D) than the patients without (p>0.05). Amblyopia was seen in 25% of the patients with anisometropia, and in 19% of those without (p<0.05). The binocular visual function of the 2 groups was not significantly different (p>0.05). The age at onset of deviation and the duration of deviation did not affect the final outcome (p>0.05 for all). The degree of initial uncorrected distance deviation had a significant effect on the development of amblyopia, fusion, and contoured stereopsis (p<0.05 for all), while the degree of near deviation without correction had a significant effect only on contoured stereopsis. CONCLUSION: The degree of uncorrected distance and near deviation had a negative impact on binocular vision and stereopsis in AE. The presence of anisometropia, age at onset of deviation, duration of deviation before treatment, high hyperopia, and high AC/A did not pose a significant risk for impaired binocular function.

Novel Use of Double-Layer Amniotic Membrane Technique in Tube Erosion in a Pediatric Patient.

This case report illustrates the successful use of the double-layer amniotic membrane technique in a child with glaucoma and aniridia. A 3.5-year-old girl with bilateral congenital glaucoma as well as aniridia, lens coloboma, nystagmus, and strabismus had been followed up since birth. Medical treatment did not result in the desired intraocular pressure improvement. An Ahmed glaucoma valve was implanted bilaterally. In a follow-up visit at 2 years of age, there were complaints of redness with watery discharge in the right eye. A biomicroscopic evaluation revealed tube erosion of the conjunctiva. The eroded area was dissected from the surrounding tissue and the area was closed using the new double-layer amnion membrane technique. After the surgery, the intraocular pressure was normal. Subsequent follow-up indicated that the erosion defect was closed and stabilized. The double-layer amniotic membrane technique can be used successfully in cases of conjunctival tube erosion. To the authors' knowledge, this is the first published pediatric case report of using the novel technique of amniotic membrane transplantation for tube erosion.

Effect of diluted povidone iodine in adenoviral keratoconjunctivitis on the rate of subepithelial corneal infiltrates.

AIM: To evaluate the clinical characteristics of adenoviral keratoconjunctivitis, the management modalities, as well as the incidence of subepithelial corneal infiltrates (SEI). METHODS: Patients with characteristic clinical symptoms and signs, who presented to our clinic within the first week of symptoms and received the diagnosis of adenoviral keratoconjunctivitis between January 2013 and April 2016, were included in the study. A total of 211 patients were included in the study. Patients were evaluated for the incidence of clinical signs, late complications, management preferences, and the effect of diluted povidone-iodine (d-PVP-I) 2%. RESULTS: Patients' mean age was 33.03±14.76y. We observed an increase in the number of cases according to the years. At presentation and/or early follow-up, the clinical signs were conjunctival hyperemia (100%), conjunctival follicules (79.1%), edema of the eyelids (39.3%), chemosis (16.1%), pseudomembrane formation (16.6%), and corneal epitheliopathy (29.9%). During late follow-up 13.3% patients developed conjunctival subepithelial fibrosis, and 39.8% developed SEI. A significant decrease in the incidence of SEI development was observed in patients who used d-PVP-I 2% (P=0.032; 33.3% vs 45.9%, respectively in patients who received d-PVP-I 2% and who did not). CONCLUSION: Adenoviral keratoconjunctivitis has a tremendous effect on patient's comfort and abilities in short-term. Additionally, almost half of the patients develop visual problems related to SEI. According to our clinical experience, using d-PVP-I 2% in the first days of adenoviral keratoconjunctivitis might be helpful in reducing the risk of SEI as a complication.

Ischemic optic neuropathy in robotic-assisted gynaecologic surgery: A case report.

The study was aimed to present a rare case of who developed non arteritic anterior ischemic optic neuropathy (NAION) following robotic-assisted gynaecologic surgery. A 58-year-old female patient presented with vision loss in right eye after non-complicated robotic-assisted total hysterectomy and bilateral salpingo-oopherectomy. We observed on fundoscopy optic disc edema and splinter hemorrhages at the optic disc edges. Fluorescein angiography showed hypofluorescence of the optic disc in the early phases due to filling delay followed by hyperfluorescence with leakage from disc capillaries in the late phases of the angiogram. From these findings, we diagnosed NAION in the right eye. When NAION was diagnosed, the patient received intravenous methylprednisolone. Topical brimonidin and coenzyme-Q were given. On 1-month follow-up, recovery of visual loss was observed. Here, we present a case of NAION that is an uncommon cause of perioperative visual loss after robotic-assisted gyneacologic surgery.

Comparison of the inhibitory effect of different doses of subconjunctival bevacizumab application in an experimental model of corneal neovascularization.

AIM: To evaluate the inhibitory effect of subconjunctival bevacizumab as single- and multiple-dose application, and compare their effects on corneal neovascularization in a rat model. METHODS: Thirty adult Sprague-Dawley rats were used in this experimental study. The central cornea of the rats was cauterized chemically. The rats were randomly enrolled into three groups. All groups received subconjunctival injections. In Group 1 (control group, n=10), 0.05 mL 0.9% NaCl solution was injected on the first day. In Group 2 (single-dose group, n=10), 0.05 mL bevacizumab (1.25 mg) was injected on the first day. In Group 3 (multiple-dose group, n=10), four doses of 0.05 mL bevacizumab (1.25 mg) were injected on the first, third, fifth and seventh day. Slit-lamp examination of all rats was performed at the third and ninth day. Digital images of the corneas were taken and analyzed using image analysis software to calculate corneal neovascularization area. All rats were sacrificed on the tenth day. In corneal sections, the number of blood vessels, state of inflammation and collagen formation was evaluated histopathologically. RESULTS: In Group 3, corneal edema grades were significantly lower than Group 1 and Group 2 (P=0.02, and P=0.035, respectively). The mean percentage of neovascularized corneal area in Group 3 was significantly lower than Group 2 (P=0.005). On histopathological examination, Group 2 and Group 3 showed significantly less number of blood vessels than Group 1 (P=0.005, and P=0.001, respectively). Additionally, Group 3 showed significantly less number of blood vessels compared to Group 2 (P=0.019). Inflammation and edema grades were significantly lower in Group 3 compared to Group 1 (P=0.001). CONCLUSION: Subconjunctival bevacizumab injection is effective in inhibition of newly formed corneal neovascularization. The multiple-dose bevacizumab treatment seems to be more effective compared to single-dose treatment.

Choroidal thickness measurements with optical coherence tomography in branch retinal vein occlusion.

AIM: To evaluate central macular thickness (CMT) and mean choroidal thickness (MCT) in eyes with branch retinal vein occlusion (BRVO), before and after ranibizumab treatment using spectral domain-optical coherence tomography (SD-OCT). METHODS: Forty-two patients with unilateral BRVO and macular edema were included in this study. There were 25 men and 17 women. Using SD-OCT, choroidal thickness was measured at 500 µm intervals up to 1500 µm temporal and nasal to the fovea. MCT was calculated based on the average of the 7 locations. All the eyes with BRVO were treated with intravitreal ranibizumab (0.5 mg/0.05 mL). Comparisons between the BRVO and fellow eyes were analyzed using Mann-Whitney U test. Pre-injection and post-injection measurements were analyzed using Wilcoxon test and repeated measure analysis. RESULTS: At baseline, there was a significant difference between the BRVO and fellow eyes in MCT [BRVO eyes 245 (165-330) µm, fellow eyes 229 (157-327) µm] and CMT [BRVO eyes 463 (266-899) µm, fellow eyes 235 (148-378) µm (P=0.041, 0.0001, respectively)]. Following treatment, CMT [295 (141-558) µm] and MCT [229 (157-329) µm] decreased significantly compared to the baseline measurements (P=0.001, 0.006, respectively). Also BCVA (logMAR) improved significantly (P=0.0001) in the BRVO eyes following treatment. After treatment CMT [BRVO eyes 295 (141-558) µm, fellow eyes 234 (157-351) µm] and MCT [BRVO eyes 229 (157-329) µm, fellow eyes 233 (162-286) µm] values did not reveal any significant difference in BRVO eyes and fellow eyes (P=0.051, 0.824, respectively). CONCLUSION: In eyes with BRVO, CMT and MCT values are greater than the fellow eyes, and decrease significantly following ranibizumab injection.

Hyperbaric oxygen therapy in combination with systemic treatment of sickle cell disease presenting as central retinal artery occlusion: a case report.

INTRODUCTION: We describe hyperbaric oxygen therapy for the treatment of central retinal artery occlusion in a young adult with sickle cell disease. CASE PRESENTATION: A 25-year-old Turkish man with a history of sickle cell disease developed sudden painless loss of vision in the left eye and was hospitalized for diagnosis and treatment. Central retinal artery occlusion was diagnosed with retinal whitening, cherry red spot, and delayed arteriovenous transit on fluorescein angiography. He underwent exchange transfusion and hyperbaric oxygen therapy. In the following three months, his visual acuity improved to 20/30. CONCLUSIONS: In this present case with sickle cell disease, the visual acuity improved with hyperbaric oxygen therapy in addition to systemic therapy. The result of our case suggests that hyperbaric oxygen therapy may be beneficial in the treatment of central retinal artery occlusion.

Interexaminer reproducibility of optical coherence tomography for measuring the tear film meniscus.

PURPOSE: New optical coherence tomography (OCT) devices with anterior segment module are able to measure the tear meniscus height (TMH) and tear meniscus area (TMA). Since the borders of the area and the height are to be marked by an examiner, the measurements are prone to be subjective. Herein, we aimed to evaluate the interexaminer reproducibility of the tear meniscus measurements with OCT. MATERIALS AND METHODS: In this prospective cross-sectional study, both eyes of 300 consecutive patients with and without dry eye were studied. Following routine ophthalmologic examination, tear-film OCT images were obtained. Two examiners, who were unaware of the other examiner's results, measured the TMH (i.e. the line connecting the intersection of the meniscus with the cornea/sclera and eyelid) and cross-sectional TMA. The reliability and correlation of the two examiners' results were assessed. RESULTS: Four right and six left eyes were excluded from the final analysis, so a total of 590 eyes were evaluated. The mean difference of the two examiners' measurements of both eyes was -0.001 ± 0.027 mm(2) in TMA, and -21.29 ± 39.95 µm in TMH. An agreement between the two examiners was found regarding TMA and TMH measurements for right and left, as well as both eyes (Cronbach's alpha > 0.900, for all). Also, the correlation between both variables was high (inter item correlation matrix > 0.840, for all). CONCLUSIONS: We showed a strong statistical agreement for both TMA and TMH measurements. According to our results, we believe that FD-OCT device is dependable in measuring the TMA and TMH values, given that its results are reproducible.

Assessment of tear meniscus with optical coherence tomography in thyroid-associated ophtalmopathy.

PURPOSE: To evaluate the tear-film meniscus with optical coherence tomography (OCT) in patients with Graves' disease (GD). MATERIALS AND METHODS: Patients with GD without clinical features of thyroid-associated ophthalmopathy (TAO) (Group 1, n=35), patients with signs of TAO (Group 2, n=31) and healthy participants (Group 3, n=31) were enrolled. Palpebral fissure width, Schirmer test, tear break-up time (TBUT) test and tear-film meniscus height and area obtained with Fourier-domain-OCT were analyzed. RESULTS: TBUT test scores were 8 s (2-25) in Group 1, 8 s (2-15) in Group 2 (p=0.380); and 10 s (5-17) in Group 3 (p=0.000 Group 1 versus 3, and 0.000 for Group 2 versus 3). Tear-film meniscus height did not significantly differ between Groups 1 and 2 (257.5 µm (86-962) and 258 µm (99-1340), respectively, p=0.980). In Group 3, tear-film meniscus height was 316 µm (122-720) (p=0.005 Group 1 versus 3 and 0.004 for Group 2 versus 3). Tear-film meniscus area did not significantly differ between Groups 1 and 2 (0.025 mm(2) (0.004-0.250) and 0.024 mm(2) (0.003-0.316), respectively, p=0.850). In Group 3, tear-film meniscus area was 0.048 mm(2) (0.006-0.75) (p=0.000 Group 1 versus 3 and 0.000 for Group 2 versus 3). CONCLUSION: Tear function is significantly disturbed in GD. OCT is an effective way to assess the tearing function also in patients with GD.