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Banu Torun Acar, Ece Turan Vural, Suphi AcarHaydarpasa Numune Education and Research Hospital, Ophthalmology Clinic, Istanbul, TurkeyPurpose: To compare the effect of three different suturing techniques on astigmatism after deep anterior lamellar keratoplasty (DALK) in patients with keratoconus.Methods: In this retrospective study, 54 eyes of 54 patients with advanced keratoconus underwent DALK with three suturing techniques: single running, interrupted running, and combined interrupted and running. Postkeratoplasty astigmatism was evaluated during examinations 1, 3, and 6 months postoperatively and 2 months after completing suture removal.Results: Twenty-four eyes had single running sutures, 16 eyes had interrupted sutures, and in 14 eyes the suturing technique used was combined interrupted and running sutures. Mean age was 25.6 ± 5.9 years, 27.3 ± 6.8 years, and 26.5 ± 5.7 years (P = 0.422), and postoperative astigmatism 1 month after surgery was 3.79 ± 1.19 D, 5.56 ± 1.78 D, and 4.21 ± 1.55 D in the three groups, respectively (P = 0.012). However, 2 months after completing the suture removal, final postoperative astigmatism was 3.43 ± 1.44 D, 3.87 ± 1.38 D, and 3.71 ± 1.46 D (P = 0.846). Final astigmatism less than 4 D was seen in 18 cases (75%) in the single running group, nine cases (56.2%) in the interrupted running group, and nine cases (64.2%) in the combined interrupted and running group (P = 0.08).Conclusion: Postkeratoplasty astigmatism is comparable with three different suturing techniques used in patients with keratoconus after completing suture removal in DALK. Due to earlier suture removal in DALK, the type of suturing technique used is not considerably important.Keywords: astigmatism, deep anterior lamellar keratoplasty, suturing technique

Purpose: Blepharoptosis with coexisting strabismus can be observed in adults, and both these conditions affect cosmetic appearance and have psychosocial effects. Both also commonly require surgery, which is typically performed using a sequential approach. This study aimed to evaluate the efficacy of simultaneous Müller's muscle-conjunctival resection with or without tarsectomy and strabismus surgery in adult patients with ptosis and coexisting strabismus., Methods: Patients with ptosis and coexisting strabismus who underwent simultaneous Müller's muscle-conjunctival resection with or without tarsectomy and horizontal strabismus surgery were retrospectively evaluated. Analysis included measurement of the angle of deviation in prism diopters, margin reflex distance, eyelid height asymmetry, and complications following surgery. Success of Müller's muscle-conjunctival resection with or without tarsectomy was defined as a margin reflex distance of ≥3.5 and ≤5 mm with a difference between the two upper eyelids of <1 mm. Strabismus success was defined as alignment with ±10 prism diopters of orthotropia., Results: The patients comprised three women and five men with a mean age of 37.12 years (range, 22-62 years). The strabismus stage of the surgery was performed first in all patients. Upper eyelid symmetry outcomes were assessed as perfect (<0.5 mm) in four patients and good (≥0.5 mm, <1 mm) in four patients. Success of Müller's muscle-conjunctival resection with or without tarsectomy was achieved in six of eight patients (75%), and strabismus success was achieved in all patients. No revision eyelid or strabismus surgery was required following simultaneous surgery in any of the patients., Conclusion: Müller's muscle-conjunctival resection with or without tarsectomy combined with strabismus surgery may be an alternative approach for use in patients with ptosis and coexisting strabismus.

Objectives: The aim of the study was to determine the prevalence of positive corneoscleral donor rim cultures and to report keratitis and endophthalmitis after keratoplasty., Methods: Eye bank records and medical records of patients who underwent keratoplasty between September 1, 2015, and December 31, 2019, were retrospectively reviewed. Patients who had routine donor-rim culture taken during surgery and followed up for at least 1 year in the post-operative period were included in the study., Results: A total of 826 keratoplasty procedures were performed. A total of 120 (14.5%) cases had a positive donor corneoscleral rim culture. Positive bacterial cultures were obtained from 108 (13.7%) of the donors. Bacterial keratitis was observed in one patient (0.83% of recipients) who had a positive bacterial culture. Positive fungal cultures were obtained from 12 (1.45%) donors, of whom one (8.33% of recipients) developed fungal keratitis. Endophthalmitis was observed in one patient whose culture result was negative. Both bacterial and fungal culture results were similar in penetrating and lamellar surgical procedures., Conclusion: Although the donor corneoscleral rims have a high positive culture result, the rate of bacterial keratitis and endophthalmitis is low, the risk of infection is high in patients with a fungal positive donor rim. Closer follow-up of patients with fungal positive donor corneo-scleral rim result and initiation of aggressive antifungal treatment when infection occurs will be beneficial., Competing Interests: Conflict of Interest: None declared., (Copyright: © 2023 by Beyoglu Eye Training and Research Hospital.)

Objective: The objective of this study was to evaluate the efficacy of intravitreal dexamethasone implant in non-infectious uveitic macular edema., Methods: Between April 2013 and February 2017, 27 eyes of 21 patients were included in the study at Haydarpasa Numune Training and Research Hospital. The files of patients who underwent intravitreal dexamethasone implantation for non-infectious uveitic macular edema and followed up at least 6 months were retrospectively reviewed. The patients were evaluated in terms of best-corrected visual acuity (BCVA) and central macular thickness (CMT) before and at the 1 st , 3 rd , and 6 th months after injection and the need for re-injection., Results: Twenty-seven eyes of 21 patients were included in the study. The mean age of the patients was 39.2±11.7 years. The mean monitoring time was 24.15±10.08 months. In patients who received single-dose intravitreal dexamethasone implant, the decrease in CMT measurements and improvement in BCVA measurements at 1, 3, and 6 months after injection compared to baseline was found to be statistically significant (p=0.001 for each). Recurrence was detected in 33.3% (n=9) of the cases during follow-up; in cases with recurrence, second implants were repeated after an average of 9.67±3.12 months. The third dexamethasone implantation was applied due to the second relapse of four cases from nine relapsing cases. Third implants were performed at an average of 12.50±4.79 months. During the follow-up period, the most common complications in our patients were cataract (37%) and increased intraocular pressure (40.7%)., Conclusion: Intravitreal dexamethasone implantation is an effective and reliable treatment option in non-infectious uveitic macular edema. There was no difference between the first dose and re-implantations in terms of efficacy and safety., Competing Interests: No conflict of interest was declared by the authors., (© Copyright 2022 by Istanbul Provincial Directorate of Health.)

Purpose: To examine the efficacy of ptosis correction with a Müller muscle-conjunctival resection with or without tarsectomy (MMCR±T), combined with bandage contact lens (BCL) use, in corneal graft patients., Methods: Seven patients with corneal grafts who underwent MMCR±T for treatment of ptosis were evaluated retrospectively. A BCL was applied to the grafts at the end of the surgery. The collected data included preoperative and postoperative visual acuity, marginal reflex distance 1 (MRD-1), presence of Hering's dependency by the phenylephrine test, symmetry outcomes, and complications after MMCR±T., Results: The average duration between the penetrating keratoplasty and MMCR±T was 14 months, with a follow-up time of 10.4 months after MMCR±T. Hering's dependency was observed in four (57.2%) patients before MMCR±T, and MRD-1 was increased in all patients based on preoperative phenylephrine tests. The mean preoperative MRD-1 was -0.14 ± 0.55 mm, and the mean postoperative MRD-1 was 2.35 ± 0.89 mm (p < 0.0001). Symmetry outcomes of perfect (<0.5 mm), good (0.5-1 mm), and fair (≥1 mm) were noted after MMCR±T in three, three, and one patients, respectively. During the follow-up, no obvious corneal epitheliopathy, keratitis, or corneal graft rejection/failure were noted in any cases. BCL use was well tolerated by all patients., Conclusions: Most patients achieved good surgical outcomes with the application of the BCL to protect the graft and with the use of the phenylephrine test and Hering's dependency to predict the final eyelid position and symmetry. MMCR±T combined with BCL may therefore represent an alternative approach for correction of ptosis in patients with corneal graft.

Purpose: To evaluate the accommodative response to different accommodative stimulus and to determine the changes in ocular higher-order aberrations with accommodation in keratoconus patients fitted with mini scleral lenses., Material and Methods: The study included 15 keratoconus patients wearing mini scleral lenses (Misa Scleral Lens-Microlens, Arnhem, the Netherlands) and 15 keratoconus patients wearing rigid gas permeable lenses. Hartmannn Shack aberrometer (IRX-3; Imagine Eyes, Orsay, France) was used for the evaluation of accommodation. Accommodative responses to the accommodative stimulus ranging from 0.5 to 5.0 diopters (D) with intervals of 0.5 D were recorded. Spherical, coma, trefoil aberration, and root mean square (RMS) of total higher-order aberrations (HOAs, third to sixth orders) at baseline, at 2.5 D stimulus, and at 5 D stimulus were also recorded., Results: Although accommodative response to accommodative stimulus of 0.5 to 2.5 D (with 0.5 D intervals) was similar in both groups, accommodative response to accommodative stimulus of 3.0 to 5.0 D was significantly lower in keratoconus group wearing mini scleral lenses. The coma, spherical, trefoil aberrations, and the RMS of total HOAs at baseline, at 2.5 D stimulus, and at 5 D stimulus were not significantly different between the groups. However, changes in the coma and trefoil aberrations and RMS of total HOA with 2.5 D and 5.0 D stimulus were significant only in the RGP group., Conclusions: Accommodative response to increasing accommodative stimulus was found to be impaired in keratoconus patients wearing mini scleral lenses.

The purpose of this study is to report the intermediate-term surgical outcomes of patients with iridocorneal endothelial syndrome-related glaucoma. The medical records of four patients (five eyes) surgery (Ahmed glaucoma valve implantation surgery and EX-PRESS mini shunt) were retrospectively reviewed. Median follow-up after glaucoma surgery was 24 (15-36) months. The preoperative intraocular pressure was significantly reduced from a median of 33 (22.5-36) mmHg on a median of 4 (4-5) glaucoma medications to a median of 12 (10.5-14.5) mmHg on a median of 2 (0-2) medications at last follow-up after surgery (p = 0.043 for IOP and p = 0.042 for glaucoma medications). Median preoperative visual acuity [0.016 (0.008-0.1)] did not change significantly when compared to median visual acuity at last follow-up [0.016 (0.004-0.5)] (p = 0.59). Intraocular pressure control in patients with iridocorneal endothelial syndrome is challenging and may require multiple operations and revisions. Some modifications during glaucoma drainage implant surgery and use of EX-PRESS mini shunt in certain cases could offer an advantage in these patients.

Purpose: To evaluate the efficacy of intravitreal ranibizumab (IVR) combined with posterior sub-Tenon injection of triamcinolone acetonide (STTA) for treatment of diabetic macular edema (DME) with serous retinal detachment (SRD)., Methods: Eighty-five eyes of 65 patients with DME and SRD were enrolled in this retrospective study. Fifty-eight eyes were treated with IVR and STTA (combined group), whereas 27 eyes were treated with pro re nata (PRN) IVR (control group). The combined group patients received a single and the control group patients received mean 1.29 ± 0.46 injections and followed for 3 months. The primary outcome measures were change in central macular thickness (CMT) and best corrected visual acuity (BCVA). The secondary outcome measure was the complication rate., Results: In the combined group, mean initial CMT was 543.9 ± 133.5 μm. Macular thickness was significantly reduced both after 1 month (334 ± 88 μm; P < 0.001) and after 3 months (387.6 ± 131.9 μm; P < 0.001) of treatment. At the 3-month follow-up, BCVA improved in 37.2% of the eyes. Complications were drug reflux at the time of STTA injection, elevation of intraocular pressure, and migration of hard exudates to the fovea. The decrease in CMT was statistically significant in the combined group in the first month, but not in the third month compared with the control group. The improvement in BCVA was not statistically significant between the 2 groups both after the first and third months. SRD disappeared with a higher rate with the combined therapy in the first month., Conclusion: IVR and STTA seem to be effective in improving BCVA in DME with SRD.

Purpose: To evaluate the mean platelet volume (MPV) and the neutrophil/lymphocyte ratio (NLR) in patients with branch retinal vein occlusion (BRVO)., Methods: Thirty patients with branch retinal vein occlusion (BRVO group) and 27 age and sex matched subjects (control group) were included in the study. MPV and NLR parameters obtained from peripheral blood were recorded., Results: The mean age was 62.6 ± 12.3 years in BRVO and 63.5 ± 8.2 years in control group. The BRVO group consisted of 13 males and 17 females and the control group included 12 male and 15 female subjects. The mean MPV values were 8.64 ± 2.01 fL in BRVO group and 8.5 ± 1.26 fL in control group. NLR was 2.24 ± 0.79 and 1.89 ± 0.64 in BRVO and control groups respectively. The difference between two groups in terms of MPV and NLR was not statistically significant., Conclusion: MPV and NLR were found to be not affected in branch retinal vein occlusion patients.

Aim: To determine the impact of rigid gas permeable (RGP) and silicone-hydrogel keratoconus lenses on the quality of life (QoL) in keratoconus (KCN) patients using the self-reported results from the Contact Lens Impact on Quality of Life (CLIQ) Questionnaire., Methods: From January 2013 to April 2013, 27 consecutive KCN patients who wore RGP contact lenses (conflexair100 UV KE Zeiss-Wöhlk) or soft silicone-hydrogel contact lenses (SHCLs) for KCN (KeraSoft IC- Bausch&Lomb or Hydrocone Toris K-Swiss lens) completed the CLIQ questionnaire., Results: The mean age of 27 patients was 29.6±8.0y. Fifteen patients were RGP user. The groups were comparable with respect to the mean patient age, sex, and mean K values (P=0.1, P=0.8 and P=0.1, respectively). The mean CLIQperson measure was 42.8±5.5 in RGP group and 39.6±5.5 in SHCLs for KCN group (P=0.06). CLIQperson measure was positively correlated with steep K value (r=0.301, P=0.04). When eyes were stratified by visual acuity with contact lenses, the mean CLIQperson measure was 42.01±5.6 in eyes with a visual acuity of 20/20-20/25 (n=44) and 38.4±5.26 in eyes with a visual acuity of 20/32 or less (n=10; P=0.097)., Conclusion: RGP lenses and SHCLs for KCN have similar impact on QoL.

Purpose: To evaluate the diagnostic ability of Fourier-domain optical coherence tomography (FD-OCT) measurements in both normal individuals and patients with different stages of glaucoma., Patients and Methods: A total of 113 patients diagnosed with glaucoma and classified into different stages of glaucoma according to Glaucoma Staging System 2 and 30 healthy individuals were included in this study. In all patients, parameters of both the retinal ganglion cell complex (GCC) and the peripapillary retinal nerve fiber layer were measured by FD-OCT (RTVue-100). Comparisons were made from measurements in patients with different stages of glaucoma., Results: Both GCC and retinal nerve fiber layer thickness values of patients with glaucoma were statistically significantly lower compared with those of healthy individuals. As the stage of glaucoma progressed, the mean GCC and retinal nerve fiber layer thickness values decreased., Conclusions: GCC and retinal nerve fiber layer thickness measurements performed by FD-OCT showed high diagnostic ability in detecting glaucoma. Mean thickness values can be determined for each glaucoma stage.

Objectives: The aim of this study was to investigate the prognosis of visual acuity (VA) in the patients with keratoconus, who underwent deep anterior lamellar keratoplasty (DALK) with a successful big bubble or lamellar dissection., Methods: Sixty-eight eyes of 60 patients with keratoconus, who underwent DALK using the big-bubble technique, were enrolled in this retrospective comparative study. The VA and refractive errors were assessed before the operation and, thereafter, at months 1, 3, 6, and 12 after the operation (1) in the patients who achieved a big-bubble formation, and in those who required layer-by-layer lamellar dissection (2) to reach the Descemet membrane., Results: Successful big bubble was achieved in 50 eyes (73.5 %) (group 1), and lamellar dissection was performed in 18 eyes (26.5 %) (group 2). The mean follow-up period was 22.4±6.2 months in group 1 and 23.7±7.8 months in group 2 (P=0.562). Although best-corrected visual acuity (BCVA) values observed at months 1 and 3 were significantly higher in group 1 than in group 2 (P=0.016 and P=0.024, respectively), there was no statistically significant difference between the two groups for BCVA values observed at months 6 and 12 (P=0.412 and P=0.528, respectively)., Conclusions: Although the visual recovery was delayed in the early postoperative follow-up because of residual stroma in lamellar dissection, the final results were comparable between the achievement of big-bubble formation and lamellar dissection.

Objective: Because patients with keratoconus tend to wear contact lens for a long period of time, they are more prone to ocular surface changes induced by the lenses. This study aimed to compare immunohistochemical changes induced by two different types of contact lenses in patients with keratoconus., Methods: Twenty-four contact lens-naive keratoconus patients (30 eyes) were included in this prospective study. Group 1 comprised 14 eyes (12 patients) wearing piggyback lenses, and group 2 comprised 16 eyes (12 patients) wearing ClearKone hybrid lenses. The patients were analyzed for bulbar conjunctival impression cytology, tear interleukin-6 (IL-6) and IL-8 levels, and confocal microscopic changes of the cornea before and 6 months after wearing contact lenses., Results: Six months after wearing contact lenses, the groups demonstrated similar epithelial metaplasia rates, tear IL-6 and IL-8 levels, and similar confocal microscopy findings (P>0.05 for all intergroup comparisons). Among the parameters tested in this study, only IL-6 and IL-8 levels and posterior keratocyte density on confocal microscopy showed an increase after 6 months when compared with baseline values but at a similar degree in the two groups., Conclusions: This small sample was not able to demonstrate a difference between the two types of lenses with regard to the variables examined, and further larger trials would be required to determine if differences truly exist or not. However, clinicians may still consider patient comfort and vision in selecting the lens type in patients with keratoconus.

Aim: To compare the corneal endothelial cell density (ECD) of clear grafts after penetrating keratoplasty (PK) and deep anterior lamellar keratoplasty (DALK)., Methods: The study included 44 and 54 patients treated with PK and DALK, respectively, between March 2006 and April 2010. Corneal ECD was examined using specular microscopy at postoperative 1, 3, 6, 12, and 18 months, and the values were compared., Results: Corneal ECD reduction in the PK group was 7.4%, 15.2%, 23.5%, and 28.9% at 3, 6, 12 and 18 months respectively after surgery, compared with 4.2 % in the first month (P<0.01). These figures were 3.0%, 6.7%, 7.2%, and 7.7% at 3, 6, 12 and 18 months respectively, compared with 2.2 % in the first month in the DALK group (P>0.05)., Conclusion: Compared with DALK, PK significantly reduced ECD of the clear grafts. These results suggest that survival of endothelial cells in grafts is better after DALK than after PK.

Purpose: To describe the inferior flap design as a modification in external dacryocystorhinostomy (DCR) and to evaluate the effectiveness on surgical outcome., Methods: This prospective study enrolled 33 consecutive patients with acquired nasolacrimal duct obstruction who underwent external DCR with this modified flap design from February 2007 to April 2008. Success was defined as amelioration of epiphora and anatomic patency. Operative outcomes and success of the procedure were evaluated., Results: The mean age was 45 years (range, 12-65 years). The mean follow-up time was 15.6 months (range, 10-23 months). None of the patients had signs or symptoms of epiphora at the end of the follow-up period., Conclusions: The inferior flap design simplifies the surgical procedure and produces success rates comparable with those found in conventional DCR. Further studies with larger numbers of patients are necessary.

Aim: The aim of the study is to describe the demographic and clinical features of Behçet disease (BD) in paediatric patients., Methods: The study included 62 patients who presented to the Department of Ophthalmology at Ankara Education and Research Hospital, Ankara, Turkey and diagnosed as having BD. These patients were placed into three age groups based on the age at the time of BD presentation: group 1, birth to 10 years old; group 2, 11-15 years old; group 3, 16-20 years old. Among these three age groups, the objective was to identify the ocular and extraocular clinical findings and complications of BD, and to uncover the role of gender, if exists, in the aetiology of the disease., Results: The findings indicated that gender played no significant role in the aetiology of BD. In group 1, a family history of BD was more prevalent, and the most common ocular finding was bilateral anterior uveitis. The most frequent form of ocular involvement in groups 2 and 3 was bilateral panuveitis with retinal vasculitis and retinitis. The majority of disease complications were glaucoma, maculopathy and cataract formation., Conclusion: Patient age appeared to define the type of ocular involvement in BD. While anterior uveitis was the most frequent ocular finding in BD patients younger than 10 years, panuveitis was the most frequent in patients older than 10 years. As a family history of BD was more frequent among patients younger than 10 years, family screening for BD is considered critical for early and accurate diagnosis of BD, as well as for the control of its complications.