A comparative study of knotless versus knotted transscleral suture-fixated intraocular lens implantation.

PURPOSE: To compare functional outcomes and complication rates of two scleral fixated intraocular lens implantation (SFIOL) techniques. METHODS: In this retrospective study, there were 30 eyes of 30 patients who underwent SFIOL implantation for dislocation of the IOL or crystalline lens. Group 1 (n = 17) comprised patients who received scleral-fixated polymethylmethacrylate (PMMA) IOL implantation through a self-sealing sclerocorneal tunnel with the suture burial technique, and group 2 (n = 13) comprised patients who received scleral-fixated foldable acrylic IOL implantation with a cartridge using a self-sealing clear corneal incision (CCI) with knotless Z-suture technique between 2014 and 2019. Surgical outcomes concerning safety, efficiency, visual function, induced astigmatism with vector analysis, and complications were compared. RESULTS: The indications were dislocated crystalline lens (n = 5/30), dislocated IOL (n = 17/30), and dropped nucleus (n = 8/30). The mean follow-up time was 50.65 ± 14.02 months in group 1 and 15.69 ± 3.71 months in group 2 (P < 0.001). The postoperative visual acuity improvement was statistically significant in both groups (P < 0.001). Surgically induced astigmatism was significantly higher in group 1 (2.68 ± 1.04 D) compared with group 2 (1.6 ± 1.0 D) at month 12 (P = 0.001). Postoperative complications included suture exposure (n = 1 in group 1) and cystoid macular edema (n = 1 in group 1; n = 1 in group 2). CONCLUSION: Both SFIOL techniques are safe and effective in the absence of adequate capsular support. However, the knotless Z-suture technique appears to be superior to the suture burial technique with regard to suture exposure-related complications. In addition, self-sealing CCI appears to be superior to self-sealing sclerocorneal tunnel with regard to surgically induced astigmatism.

Foveal Displacement following Temporal Inverted Internal Limiting Membrane Technique for Full Thickness Macular Holes: 12 Months Results.

Purpose: To compare conventional 360° internal limiting membrane (ILM) peeling and temporal inverted ILM flap technique with regard to postoperative foveal displacement.Methods: Patients who underwent 23 G vitrectomy with either 360° ILM peeling (Group 1) or temporal inverted ILM technique (Group 2) for idiopathic macular hole with a minimum follow up of 12 months were included. The metamorphopsia rates and distances between fovea and 3 retinal landmarks: the first retinal vascular bifurcation or crossover located superonasal and inferonasal to the fovea and ciliary vessel at the temporal margin of the disc, were compared on MultiColor SLO and near-infrared reflectance images. In addition, papillofoveal distance was measured on B-scan optical coherence tomography (OCT).Results: A total of 57 eyes were recruited (Group 1, n = 25; Group 2, n = 32). The visual acuity at month-1 was significantly higher in Group 2 than Group 1 (p = .007). A significant postoperative foveal displacement towards the disc was observed in Group 1 and Group 2 (p < .001 and p = .002 respectively). Shortening of the papillofoveal distance was greater in Group 1 than Group 2 at all postoperative visits (p < .05 for all). Furthermore, significant changes in papillofoveal distance continued until 6 months in Group 1 (p < .05 for all), whereas no significant changes occurred in Group 2 after month-1 (p > .05 for all). The complaints of metamorphopsia was significantly higher in Group 1 (n = 18/25) compared with Group 2 (n = 10/32) (p = .002).Conclusion: Temporal inverted ILM flap appear to be superior to 360° ILM peeling with regard to faster visual rehabilitation, lower rates of subjective metamorphopsia and less foveal displacement.

DNA repair proteins may differentiate papillary thyroid cancer from chronic lymphocytic thyroiditis and nodular colloidal goiter.

Malignant thyroid lesions are the most common malignancy of the endocrine glands with increasing rates in the last two decades. Papillary thyroid cancer is the most common thyroid malignancy. In our study, we aimed to quantitatively evaluate the levels of DNA repair proteins MSH2, MLH1, MGMT, which are representative blocks of patients diagnosed with papillary carcinoma, chronic thyroiditis, or colloidal goiter. Total or subtotal thyroidectomy material of 90 patients diagnosed with papillary carcinoma, nodular colloidal goiter, or chronic thyroiditis between 2009 and 2012 were retrospectively evaluated. Tissue samples obtained from paraffin blocks were stained with MGMT, MSH2, MLH1 proteins and their immunohistochemistry was evaluated. Prepared sections were examined qualitatively by an impartial pathologist and a clinician, taking into account the staining method under the trinocular light microscope. Although there was no statistically significant difference in MGMT, MSH2, MLH1, follicular cell positivity, staining intensity, and immunoreactivity values, papillary carcinoma cases showed a higher rate of follicular cell positivity, and this difference was more pronounced between papillary carcinoma and colloidal goiter. In the MSH2 follicular cell positivity evaluation, the difference between chronic thyroiditis and colloidal goiter was significant (p = 0.023). The difference between chronic thyroiditis and colloidal goiter was significant in the MSH2 staining intensity evaluation (p = 0.001). The difference between chronic thyroiditis and colloidal goiter was significant in MLH1 immunoreactivity evaluation (p = 0.012). Papillary carcinoma cases were demonstrated by nuclear staining only for MSH2 and MLH1 proteins as opposed to hyperplastic nodules. The higher levels of expression of DNA repair genes in malignant tumors compared to benign tumors are attributed to the functional activation of DNA repair genes. Further studies are needed for DNA repair proteins to be a potential test in the development and progression of thyroid cancer.

The predictive value of ectopic inner retinal layer staging scheme for idiopathic epiretinal membrane: surgical results at 12 months.

BACKGROUND/OBJECTIVES: To assess the effect of ectopic inner foveal layers (EIFL) based staging scheme, foveal avascular zone (FAZ) alterations and other microstructural optical coherence tomography (OCT) findings on visual function for patients undergoing idiopathic epiretinal membrane (iERM) surgery. SUBJECTS/METHODS: In this retrospective study, patients who underwent 27 G pars plana vitrectomy (PPV) for idiopathic ERM with a minimum follow-up of 12 months were included. Preoperative and postoperative OCT scans, FAZ area measurements on en face OCT angiography images and mean retinal sensitivity (MRS) using microperimetry were recorded in all cases. The correlation of FAZ area, EIFL and other OCT parameters with preoperative and postoperative best-corrected visual acuity (BCVA) was analysed. RESULTS: In all, 112 eyes of 112 patients were included. Visual acuity improvement was statistically significant in all four stages; however, differences between Stages 2, 3 and 4 ERMs remained significant (p < 0.05). The presence and thickness of the EIFL was associated with worse baseline (p = 0.013; p = 0.005, respectively) and final (p < 0.001 for both) BCVA. The presence of cystoid macular oedema was associated with worse BCVA at baseline (p = 0.027) and postoperative month-6 (p = 0.04). The mean FAZ area was significantly reduced in all stages of ERM compared with the fellow eyes (p < 0.05 for all). Postoperative retinal sensitivity improvement was statistically significant in Stage 1 and Stage 2. CONCLUSION: The presence of EIFL is an independent predictor of worse postoperative BCVA. Accordingly, despite significant BCVA improvements in all stages of ERM, visual acuity gain remains limited in eyes with Stage 3 and Stage 4 ERM.

Subretinal Coapplication of Tissue Plasminogen Activator and Bevacizumab with Concurrent Pneumatic Displacement for Submacular Hemorrhages Secondary to Neovascular Age-Related Macular Degeneration.

Objectives: To evaluate the functional and morphological outcomes of vitrectomy in combination with intravitreal 5% C3F8 tamponade and subretinal injections of tissue plasminogen activator (tPA) and anti-vascular endothelial growth factor (anti-VEGF) in patients with submacular hemorrhage (SMH) and to investigate the preoperative prognostic factors. Materials and Methods: This retrospective study included 30 patients (16 women, 14 men) diagnosed with SMH secondary to neovascular age-related macular degeneration (AMD). Preoperative SMH thickness and area, ellipsoid zone integrity, and postoperative reduction in the amount of subfoveal blood on optical coherence tomography and fundus photographs were assessed. Furthermore, visual acuity (VA), hemorrhage duration, and the need for additional intravitreal anti-VEGF injections were recorded. Results: The patients' mean age was 73.33±8.23 years. Mean VA improved from logMAR 2.11±0.84 at baseline to logMAR 1.32±0.91, 0.94±0.66, 1.13±0.84, and 1.00±0.70 at postoperative month 1, 2, 3, and 6, respectively. A significant negative correlation was found between hemorrhage duration and postoperative VA at month 2 (p=0.005), month 3 (p=0.019), and month 6 (p=0.012). The mean preoperative SMH duration was significantly shorter in patients who achieved total resolution of the hemorrhage compared with the subtotal resolution group (p<0.001). The mean SMH area was smaller in the patients with continuous ellipsoid zone. Conclusion: Vitrectomy and submacular tPA and anti-VEGF injections with concurrent C3F8 tamponade appears to provide adequate displacement of the hemorrhage, resulting in significant VA improvement in patients with hemorrhagic neovascular AMD. Timing of the surgery appears to be the most important factor determining the final VA.

The Influence of Crescent-Shaped Selective Internal Limiting Membrane Staining on Vital Dye Toxicity in Temporal Inverted Flap Technique.

Purpose: To investigate the macular function and morphology after temporal inverted internal limiting membrane (ILM) flap technique with and without staining of the ILM flap in contact with the retinal pigment epithelium (RPE).Materials and Methods: This retrospective study included 30 patients with idiopathic macular hole (MH), who underwent 27 G vitrectomy and temporal inverted ILM flap technique with brillant blue G (BBG) assisted ILM staining. In Group 1 (n = 16), a large bubble of perfluorocarbon liquid (PFCL) measuring approximately 6-disc diameters was used to cover the hole and central part of the ILM flap whereas in Group 2 (n = 14), only a small drop of PFCL to merely cover the MH was used. Complete ophthalmic examination including microperimetry (MP), optical coherence tomography (OCT) was performed preoperatively, 6 months after surgery.Results: MH closure was achieved in all the eyes in both groups. The sizes of ellipsoid zone (EZ) and external limiting membrane (ELM) defect significantly decreased after surgery relative to the baseline width in both groups (p < .05 for all). The mean improvement in visual acuity (p = .896) and retinal sensitivity was similiar between groups (p = .409). Accordingly, the postoperative mean lengths of the EZ (p = .254) and ELM disruption (p = .406) on OCT scans were similiar between groups. However, 3 of the eyes in Group 2 developed cystoid macular edema between postoperative month-1 and month-6.Conclusion: The crescent-shaped selective staining of the ILM flap could prevent prolonged retinal toxicity of vital dyes in inverted ILM flap technique. Further studies involving larger number of patients with longer follow up are needed to determine the impact of this technique in the management of vital dye toxicity.

Evaluation of inner retinal dimples and internal limiting membrane flap configuration after temporal inverted ILM flap technique.

PURPOSE: To quantitatively evaluate structural changes associated with inner retinal dimples (IRDs) and qualitatively classify the internal limiting membrane (ILM) flap configuration after temporal inverted ILM flap technique using spectral domain optical coherence tomography (SD-OCT). METHODS: Twenty-three eyes of 23 patients with successfully closed idiopathic, large (>400 µm) macular hole were enrolled. Patients were treated with pars plana vitrectomy followed by temporal inverted ILM flap technique. A complete ophthalmologic examination including cross sectional and en face OCT in addition to multicolor blue reflectance imaging of confocal scanning laser ophthalmoscopy (cSLO) was performed preoperatively and at postoperative month-12. The location, number, depth, and width of the IRDs were analyzed using blue reflectance images of multicolor cSLO and en face OCT. The ILM flap is also classified as smooth, wrinkled, and folded with en face OCT. RESULTS: The mean number of IRDs visualized on en face OCT (n = 23.08 ± 22.05) was statistically significantly higher compared with multicolor cSLO blue reflectance module (5.91 ± 10.58; p < 0.001). The mean depth of IRDs measured on en face OCT was 8.08 ± 3.1 µm (3-14 µm) which referred to the nerve fiber layer. The final visual acuity was associated with neither ILM flap configuration (p = 0.408), nor number of the IRDs on en face OCT (p = 0.112). CONCLUSION: En face OCT is a novel imaging modality that offers improved visualization and accuracy in identifying the features of the IRDs and the ILM flap. Additionally, it provides clear visualization of the vitreoretinal interface to distinguish whether ILM was peeled or not in the initial surgery.

Conventional internal limiting membrane peeling versus temporal inverted internal limiting membrane flap for large macular holes.

PURPOSE: To compare the functional, anatomical, and morphological results of conventional internal limiting membrane peeling versus temporal inverted internal limiting membrane flap technique for the treatment of macular holes larger than 400 µm. DESIGN: Retrospective, comparative case series. METHODS: A total of 33 patients were included, of whom 18 were treated with internal limiting membrane peeling (Group 1) and 15 were treated with temporal inverted internal limiting membrane flap technique (Group 2). Complete ophthalmic examination, such as microperimetry and optical coherence tomography, was performed preoperatively and at 12 months after surgery. RESULTS: The closure rates accomplished in Groups 1 and 2 were 72.2% and 100%, respectively (p = 0.036). The mean improvement in best-corrected visual acuity was logMAR 0.49 ± 0.17 in Group 1 and logMAR 0.91 ± 0.15 in Group 2 (p = 0.037). U-shaped closure was achieved in one eye in Group 1 and 12 eyes in Group 2 (p < 0.001). Complete restoration of external limiting membrane and ellipsoid zone rates were significantly higher in Group 2 (p = 0.027 and p = 0.001, respectively). CONCLUSION: The single-layered temporal inverted internal limiting membrane flap technique improves not only anatomical and morphological but also functional outcomes of surgery for large macular holes. Furthermore, this technique seems to minimize the risk of iatrogenic trauma to the nasal part of the fovea and the corresponding papillomacular bundle fibers.

Combined Femtosecond Laser-Assisted Cataract Surgery and 27-Gauge Transconjunctival Sutureless Vitrectomy.

PURPOSE: To report the outcomes of combined surgery using femtosecond laser-assisted cataract surgery (FLACS) and sutureless 27-gauge pars plana vitrectomy with intravitreal tamponade. METHODS: This retrospective clinical study involved 23 eyes of 23 patients on whom combined vitreoretinal surgery was performed. Patients were initially given the femtosecond laser treatment that was performed after selection of capsulotomy and lens fragmentation patterns. The capsulotomy diameter was chosen as 4.9 mm in all patients. After the femtosecond laser, the sutureless phacovitrectomy procedure was performed. At the end of surgery, perfluoropropane or sterile air tamponade was applied. RESULTS: The mean age of patients was 66.43 ± 7.61 (range, 54-83) years. Fifteen patients were females (65.2%). The mean follow-up was 16.09 ± 4.71 (range, 9-25) months. The most common surgical indication was epiretinal membrane (65.3%). The mean preoperative best-corrected visual acuity (BCVA) was 0.71 ± 0.44 (range, 1.7-0.3) logMAR, and the mean postoperative BCVA at 6 months was 0.16 ± 0.14 (range, 0.4-0) logMAR (p < 0.001). The mean target sphere refractive error was -0.24 ± 0.16 (range, -0.50-0.11) D, and the mean postoperative spherical equivalent refractive error was -0.14 ± 0.39 (range, -1.00-0.50) D at 6 months (p=0.196). All intraocular lenses (IOLs) remained well centered in the capsular bag during surgery and follow-up. There was no iris capture, posterior synechiae, capsular opacification, or pseudophakic cystoid macular edema. The only complication related to femtosecond laser was two cases of subconjunctival haemorrhage related with suction. CONCLUSIONS: FLACS is a safe and effective technique providing the advantage of repeatable, precise capsulorhexis shape and size to achieve a well-centered and stable IOL postoperatively. These advantages can certainly improve the results of vitrectomy, especially in gas-filled eyes. FLACS and 27-gauge sutureless combined surgery may be a future trend in appropriate cases.

Ocular Syphilis Unmasked Following Bilateral Intravitreal Dexamethasone Implant (Ozurdex) Injection.

Intraocular corticosteroids are used in ophthalmologic conditions such as macular edema secondary to vascular occlusions, diabetes, and uveitis. Infectious ocular diseases must be ruled out before intravitreal corticosteroid implantation. Here, the authors report a case that has been referred to their clinic for surgical treatment due to dense vitreous hemorrhage in the right eye after bilateral intravitreal dexamethasone implantation. As an intraoperative finding, diffuse changes in the color-like paleness of the retina as well as intraretinal white-colored deposits were observed. Serology tests were performed, and syphilis serology was positive. Intravenous penicillin provides resolution of inflammation. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e77-e80.].

Comparison of the Effect of Intravitreal Dexamethasone Implant in Vitrectomized and Nonvitrectomized Eyes for the Treatment of Diabetic Macular Edema.

PURPOSE: To compare the effectiveness of sustained-release dexamethasone (DEX) intravitreal implant in nonvitrectomized eyes and vitrectomized eyes with diabetic macular edema (DME). METHODS: A retrospective review of the medical records of 40 eyes of 30 consecutive patients with diabetic macular edema who underwent intravitreal DEX implant injection. Patients were divided into 2 subgroups: 31 eyes that were nonvitrectomized (group 1) and 9 eyes that had previously undergone standard pars plana vitrectomy (group 2). The main outcome measures were BCVA and foveal thickness (FT). RESULTS: A significant improvement was seen in BCVA in both group 1 and group 2 at the 1st, 2nd, and 6th months after treatment with DEX implant (p < 0.05). In group 1, a significant reduction in FT was observed at the 1st, 2nd, and 6th months (p < 0.05). In group 2, a significant reduction in FT was seen at the 1st and 2nd months (p < 0.05), but the reduction rate at the 6th month after the injection was not statistically significant (p = 0.06). CONCLUSION: DEX implant is effective for the treatment of diabetic macular edema, and the effectiveness of the drug is similar in vitrectomized and nonvitrectomized eyes.

VITREORETINAL SURGERY FOR PATIENTS WITH SEVERE EXUDATIVE AND PROLIFERATIVE MANIFESTATIONS OF RETINAL CAPILLARY HEMANGIOBLASTOMA BECAUSE OF VON HIPPEL-LINDAU DISEASE.

PURPOSE: The evaluation of long-term results of vitreoretinal surgery and retinal capillary hemangioblastoma (RCH) resection in patients with complicated retinal detachment (RD) secondary to RCHs. METHODS: Twelve eyes of 12 patients were operated on with vitreoretinal surgery, including occlusion of afferent and efferent feeder vessels with endodiathermy and endolaser photocoagulation, and subsequent resection of RCHs. The long-term anatomical and visual outcomes were retrospectively evaluated. RESULTS: Total exudative RD was detected in six eyes and subtotal exudative RD was found in the remaining six eyes. A tractional component was present in eight eyes, and four eyes had pure exudative RD. Laser treatment had been previously applied to four eyes but vitreoretinal surgery was the primary treatment in eight eyes. A total of 19 RCHs were resected. The quadrant location of RCHs was superior temporal in six, superior nasal in five, inferior nasal in five, and inferior temporal in three. The dimensions of the RCHs ranged between 1 and 4 disk diameters (DD) (1-DD in 1 eye, 1.5-DD in 3, 2-DD in 10, 2.5-DD in 3, 3-DD in 1, and 4-DD in 1). Preoperative mean logarithm of the minimum angle of resolution visual acuity was 1.9 ± 1.0 (3.0-0.7) (20/1,588 ± 20/200 [20/20,000-20/100]). Silicone oil and C3F8 was applied to four and eight eyes, respectively. The median postoperative follow-up was 30.5 (18-48) months. Single operation and final anatomical success was obtained in 9 and 11 eyes, respectively. Mean logarithm of the minimum angle of resolution visual acuity in the postoperative 18th month and at the final visit were 1.05 ± 0.8 (3.0-0.2) (20/224 ± 20/125 [20/20,000-20/32]) and 0.96 ± 0.8 (3.0-0.2) (20/182 ± 20/125 [20/20,000-20/32]), respectively. New RCHs occurred in eight eyes. Rubeosis iridis was not present in any of the eyes. CONCLUSION: Promising anatomical and visual outcomes were obtained after vitreoretinal surgery and resection of RCHs in eyes with complicated RD secondary to RCH. However, life-long follow-up is needed to recognize recurrent RD seen even in the early period or recurrences of RCHs seen in the long-term period.

Choroidal thickness changes in patients with pseudoexfoliation syndrome.

To evaluate the choroidal thickness using spectral-domain optical coherence tomography (OCT) in patients with pseudoexfoliation syndrome (PXS) and to compare them with healthy controls. This observational comparative study consisted of 35 PXS patients and 35 age- and sex-matched control cases. The control cases had neither systemic nor ocular disease. All 70 patients underwent a complete ophthalmic examination as well as choroidal thickness measurement using a high speed and high resolution SD-OCT device (Topcon 3D OCT-2000, Japan). There was no significant difference with respect to mean refractive error and intraocular pressure measurement between patients with PXS and controls (p = 0.237 and 0.433, respectively). The mean choroidal thickness was found as 206.6 ± 37.6 µm in the PXS group and 215.9 ± 47.3 µm in controls, respectively. The mean choroidal thickness was not significant between the PXS patients and the control cases (p = 0.362). Although PXS patients had lower mean choroidal thickness than controls, our results did not reach any statistical significance.

A rare disease in the differential diagnosis of acute pancreatitis: acute brucellosis.

Some infectious organisms may give rise to acute pancreatitis; brucellosis, however, extremely rarely leads to acute pancreatitis. A 40-year-old man was diagnosed with acute pancreatitis, the etiology of which was determined to be acute brucellosis. The patient was discharged without complications approximately 15 days after the initiation of trimethoprim-sulfamethoxazole and doxycycline treatment. Brucella infections may rarely be complicated by acute pancreatitis. Thus, brucellosis should be remembered in the etiology of acute pancreatitis in regions such as Turkey, where Brucella infections are endemic.

Posterior iris fixation of the iris-claw intraocular lens implantation through a scleral tunnel incision.

PURPOSE: To evaluate the technique, efficacy, and safety of posterior iris fixation of iris-claw intraocular lens (IOLs) implantation through a scleral tunnel incision for aphakia correction. DESIGN: Noncomparative, interventional case series. METHODS: A secondary posterior iris fixation of the Artisan iris-claw IOL (Ophthec BV, Groningen, The Netherlands) was implanted for aphakia correction in the authors' clinical practice. Uncorrected visual acuity, best spectacle-corrected visual acuity (BSCVA), astigmatism, manifest refraction, lens position, pigment dispersion, and intraocular pressure (IOP) were evaluated in 32 consecutive eyes of 32 patients. RESULTS: BSCVA was 20/40 or better in 28 eyes (87.50%) during the mean follow-up time (nine months). Mean postoperative spherical equivalent was -0.70 diopters (D; standard deviation [SD], 0.47 D) at six months after surgery. Mean prediction error was -0.13 D (SD, 0.28 D), and mean absolute prediction error was 0.26 D (SD, 0.15 D). Preoperative mean astigmatism was -1.08 D (SD, 0.55 D; range, 0.0 to -2.0 D). At six months after surgery, mean astigmatism was -2.1 D (SD, 0.81 D; range, -0.75 to -3.75 D). There was no significant postoperative IOP increase. Lens position, evaluated by Oculus Pentacam (Pentacam 70700: Oculus, Wetzlar, Germany) and ultrasound biomicroscopy [UBM] (Ophthalmic Technologies Inc, Toronto, Ontario, Canada), was parallel to the iris plane. CONCLUSIONS: Posterior iris fixation of the iris-claw IOL implantation through a scleral tunnel incision is a safe procedure and an effective option for aphakic eyes without capsule support.