Medical Hypothesis, Discovery & Innovation (MEHDI) Journals
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Multimodal Imaging of Acute Central Retinal Artery Occlusion
Full text linkThe aim of this study was to describe fluorescein angiography (FA), ocular coherence tomography (OCT) and ocular coherence tomography angiography (OCTA) in the diagnosis of acute central retinal artery occlusion (CRAO). This is an observational case series study performed at Sohag Ophthalmic Investigation Center. Fifteen patients presented by a sudden marked unilateral diminution of vision were included. Corrected Distance Visual acuity (CDVA), color fundus photos, FA, OCT and OCTA, imaging obtained in the first week of presentation and imaging of the other normal eye as a control were assessed. Central macular thickness (CMT), parafoveal inner retinal layers thickness and parafoveal outer retinal thickness in diseased and contralateral normal eyes were compared. Fifteen patients (mean age 52.67 years, 11-74 years old) including 66.7% male entered the study. CDVA ranged from no perception of light to 0.05 (20/400). Fundus examination showed a cherry red spot in 10 cases (66.7 %) and retinal whitening in 9 cases (60%), arteriolar narrowing in 7 (46.67%), optic disc edema in 4 (26.67%), optic disc pallor in 5 (33.3%) and cattle trucking in 5 (33.3%). Fluorescein angiography showed delayed arteriovenous transit time > 23 seconds in 8 cases (53.33 %) and normal FA in 4 cases (26.67 %). OCT revealed increased hyperreflective of the inner retinal layers in comparison to hyporeflective inner retinal layers in all cases (100%) and significant increase in CMT in 10 cases (66.67%). The mean ± standard deviation (SD) of CMT (CRAO) was 306.5 ± 27.9 (P < 0.001), the parafoveal inner retinal thickness (CRAO) 345 ± 51.8 µm (P < 0.001) and the parafoveal outer retinal thickness (CRAO) 120.9 ± 13.6 µm (P < 0.001). OCTA was performed and clear images obtained in 11 cases (73.33%). Disruption of superficial and deep capillary plexus was found in all cases. We concluded that the OCT is the most confirmative imaging method in the diagnosis of acute CRAO even in the absence of fundus signs. OCTA confirms the diagnosis, but it cannot be performed in some cases. Epub: October 1, 2019
Office-based Air-Fluid Exchange for Diabetic Post-Operative Vitreous Cavity Hemorrhage
Full text linkPost-operative vitreous cavity hemorrhage (POVCH) is observed in 6-75% of eyes undergoing pars plana vitrectomy (PPV) for proliferative diabetic retinopathy (PDR). We describe our technique for office-based Air fluid exchange (AFX) in the treatment of POVCH. Sixteen eyes (15 patients) with PDR and POVCH undergoing office-based AFX between January 2006 and November 2016 were retrospectively identified. The pre- and post- procedure visual acuity (VA) and complications were compared between eyes with and without traction retinal detachment (TRD). Medicare charges for office-based AFX versus PPV were also analyzed. Mean age at the time of AFX was 55.31 (± 8.02) years. Nine eyes (56.25%) had TRD prior to PPV and 11 eyes (68.75%) were pseudophakic. The improvements in mean (± standard deviation [SD]) logMAR VA at the last postoperative visit (3 - 8 months) were 1.38 (± 0.99), 0.82 (± 0.91) and 2.09 (± 0.53) in all eyes, TRD eyes and non-TRD eyes, respectively. Complications included cataract progression, hypotony, and recurrence of TRD and ghost cell glaucoma. The total cost of outpatient AFX was $1,409.59 less than that of PPV. Office-based AFX is a cost-effective alternative treatment for non-clearing diabetic POVCH with an acceptable risk profile
Early Miscarriage Occurring Six Days After Intravitreal Ranibizumab Injection
Full text linkThe aim of this case report was to describe a miscarriage which occurred 6 days after an intravitreal Ranibizumab (IVR) injection. A 24-year-old female patient with type 1 diabetes diagnosed with diabetic macular edema in her left eye planned for 3 injections of IVR at one-month intervals. She had been receiving insulin injections 3 times a day and her Hemoglobin A1C (HbA1c) was in the approximate range of 6–7%. An ophthalmologic examination revealed that the patient’s Snellen corrected distance visual acuity (CDVA) was 10/10 in her right eye and 3/10 in her left eye. The patient was unaware of her pregnancy at the time of initial injection. Two days after the first injection, she found out that she was 5 weeks pregnant. This was the first pregnancy for the patient and there were no risk factors for miscarriage rather than diabetes. Six days after the injection, she was admitted to the hospital due to severe abdominal pain and vaginal bleeding. Miscarriage was diagnosed and she underwent curettage procedure. We concluded that pregnancy tests should be administered prior to intravitreal injection for female patients of reproductive age, and patient testimony should not be the sole reason to dismiss the possibility of pregnancy.
Systemic Immunosuppression for Limbal Allograft and Allogenic Limbal Epithelial Cell Transplantation
Full text linkBilateral limbal stem cell deficiency (LSCD) treatment requires the need to obtain allogenic limbal tissue for transplantation. Outcomes of different surgical techniques depend on multiple factors, including the underlying etiology, ocular surface, eyelid status and used surgical intervention. Some of the management options for bilateral LSCD include cadaveric, living related or living non-related conjunctival limbal allograft (CLAL), keratolimbal allograft (KLAL), allogenic cultured limbal epithelial transplantation (CLET) and allogenic simple limbal epithelial transplantation (SLET). Systemic immunosuppressive therapy plays a pivotal role in survival of transplanted tissue. The present review focuses on different systemic immunosuppression protocols for limbal allograft and allogenic limbal epithelial cell transplantation, with specific emphasis on different surgical techniques and their outcomes. We included all reports with details of different systemic immunosuppression protocols for limbal allograft and allogenic limbal epithelial cell transplantation. Oral cyclosporine A at different doses is the most commonly used immunosuppressive agent in limbal allograft and allogenic limbal epithelial cell transplantation. However, different studies using oral mycophenolate mofetil and tacrolimus also reported good results. In conclusion, systemic immunosuppression protocols for limbal allograft and allogenic limbal epithelial cell transplantation are not standardized. Further studies regarding different surgical techniques should assess outcomes and adverse effects of such protocols
Diagnosis and Management of Pseudoguttata: A Literature Review
Full text linkCorneal pseudoguttata (PG), also known as pseudoguttae or secondary guttata, is a transient, reversible endothelial edema commonly associated with anterior segment pathology. While considered rare, PG presents on slit-lamp examination more commonly than originally thought. We have clinically observed PG after refractive surgeries, in association with infectious keratitis, and following medication use. PG presents as dark lesions on slit-lamp exam with specular illumination, similar to primary corneal guttata. PG is distinct from guttata because PG resolves over time and does not involve Descemet’s membrane. Other ocular findings that may be confused with guttata include endothelial blebs (EB) and endothelial denudation (ED). EB are possibly a type of PG that present after contact lens use or hypoxia. ED is a distinct entity that is characterized by loss of endothelial cells without involvement of Descemet’s membrane. Confocal microscopy may be useful in differentiating these four endothelial lesions, with differences in border definition and the presence of hyperreflective areas two main distinctions. PG presents as a hyporeflective, elevated shape without clear borders on confocal microscopy. PG, EB, and ED can resolve with time without the need for surgical intervention, unlike corneal guttata. Treatment of the underlying condition will lead to resolution of both PG and EB
Graft Detachment After Descemet's Stripping Automated Endothelial Keratoplasty in Bullous Keratopathy and Fuchs Dystrophy
Full text linkDescemet’s stripping automated endothelial keratoplasty (DSAEK) is a surgical technique for corneal transplantation in case of corneal decompensation. One of the main complications is graft detachment (GD) recoverable with Air Re-bubbling (ARB). The aim of this retrospective, interventional case series was to identify factors related to this complication in eyes operated for bullous keratopathy (BK) and Fuchs dystrophy (FD). We considered one-hundred patients who underwent DSAEK for BK or FD between January 2016 and October 2017 at Department of Ophthalmology, Policlinico Universitario of Bari, Italy. Studied parameters included physiological and pathological anamnesis of both donors and recipients and properties of donor’s lenticules and of the recipient’s corneas. Data was analyzed using One-way ANOVA with Tukey post hoc test and Chi-square test with Odds Ratio (OR) calculation. We grouped patients according to diagnosis. GD occurred in 9 eyes affected by BK and 19 by FD (p=0.003, OR = 0.25, 95% CI, 0.098-0.62). It was recovered with ARB. In BK, ARB correlated to complicated cataract extraction (p=0.04, OR = 7.83, 95% CI, 1.28 – 47.98) and aphakia (p=0.026, OR = 54.38, 95% CI, 2.51 - 11.76). In FD, ARB was associated to donor’s death for neoplasia (p=0.06, OR= 4.04, 95% CI, 1.06 – 15.37). No other differences were found. In conclusion, we could hypothesize that in FD patients, donor’s cancer therapy may play a role on altered corneal fibroblast metabolism, activating a synergetic effect between chemotherapy and genetic alteration of FD, which may lead to an altered adhesion of donor’s lenticule on recipient's stroma. In BK patients, complicated cataract extraction and aphakic status of recipients’ eye may contribute to altered adhesion of donor’s lenticule post-DSAEK
Preliminary Outcomes of Temporary Collagen Punctal Plugs for Patients with Dry Eye and Glaucoma
Full text linkThe aim of this study was using a temporary collagen punctal plug as a pre-test before decision of permanent punctal closure or long-term plug use for patients with dry eye disease (DED) and primary open-angle glaucoma (POAG). This case-control study was conducted at a single office in Honolulu, Hawaii from January 2017 to August 2018. In the case group, a temporary collagen plug was used in 33 eyes of 33 patients with DED and POAG who were receiving glaucoma medications with good control. On the other hand in the control group, 33 eyes of 33 patients with DED and POAG who were receiving glaucoma medications with good control were included, but punctal plug was not used. In the case group, one of the lower lid puncta was selected for the study and a canalicular rod shape plug was inserted as a therapeutic trial to predict the efficacy of long-term punctal plug placement or punctal closure. The mean changes of intraocular pressure (IOP) and improvement in symptoms/signs of DED were compared between the two study groups. Results revealed a statistically significant IOP reduction in the case group compared to the control group. Furthermore, DED improved significantly more in the case group compared to the control group (P< 0.001). We concluded that temporary punctal plug in patients with DED and POAG can significantly improve DED and lower IOP. Therefore, we could consider permanent punctal closure or long-term plug for patients with DED and POAG who responded well to temporary punctal plug without epiphora or other complications
Ocular Surface Evaluation After the Substitution of Benzalkonium Chloride Preserved Prostaglandin Eye Drops by a Preservative-free Prostaglandin Analogue
Full text linkTo evaluate ocular surface changes after withdrawal of Benzalkonium chloride (BAK) in patients with glaucoma in monotherapy with BAK-preserved prostaglandin. This was a prospective observational study. All patients underwent complete ophthalmologic examination and evaluation of ocular surface. A questionnaire was filled regarding symptoms of dry eye (Ocular Surface Disease Index [OSDI]) at the beginning of study. The treatment was switched to preservative-free tafluprost for 6 weeks and after this period, all patients were re-evaluated. All patients reported improvement of symptoms. The green lissamine test showed a significant improvement of the ocular surface, with most patients classified as light dry eye (P < 0.001). A significant improvement in the score (P < 0.001) was also found, with an average of 17.95 ± 5.35 points, which classifies the patients' symptoms in the normal to light zone. Benzalkonium chloride withdrawal reduced the signs and symptoms of dry eye in patients with primary open angle glaucoma (POAG)
A Case of Artificial Snow Foam induced Corneal Endotheliitis Followed up by Scheimpflug Densitometry
Full text linkThe aim was to present a rare case of artificial snow foam induced corneal endotheliitis followed up by Scheimpflug Densitometry. A 15-year-old male complained of redness, tearing and reduced vision in the left eye after artificial snow foam entered his left eye 4 days before the presentation. Slit lamp examination of the same eye showed ciliary injection with corneal edema with no epithelial defect and endothelial lesion measuring 3 × 4 millimeters (mm) with large keratic precipitates (KP). Examining the left eye by the Scheimpflug densitometry of the Sirius device (CSO, Florence, Italy) showed plaque on the back of the cornea. Aqueous tab Polymerase chain reaction analysis (PCR) results for the affected eye had negative results for viral infection. Improvement of ocular symptoms occurred after treatment with topical steroid therapy. Scheimpflug densitometry showed disappearance of the saw-tooth protrusions on the back of the cornea with decreased reflectivity. Corneal endotheliitis can be triggered by chemical ocular trauma. The Scheimpflug densitometry examination may be a useful noninvasive method for reaching a clinical diagnosis of corneal endotheliitis and monitoring treatment effectiveness
Role of Schwann Cells in Preservation of Retinal Tissue Through Reduction of Oxidative Stress
No full textThe aim of this study was to evaluate the effect of subretinal injection of Schwann cells on preservation of retina by decreasing oxidative stress in Dystrophic Royal College of Surgeons (RCS) rats. Schwann cells were harvested from the sciatic nerve of postnatal day 5, RCS rats. Twenty-five RCS rats randomly assigned to cell and sham groups. Schwann cells injected in the sub-retinal space in one eye of the cell group and carrier medium was injected in one eye of the sham group. The proof for the appropriate site of injection of Schwann cells confirmed by the green fluorescent protein (GFP) positive cells. Electroretinogram (ERG) and enucleation for histopathology and enzymatic evaluation were performed 1, 2 and 3 months post-injection. The enzymatic evaluation included catalase, superoxide dismutase (SOD) and glutathione peroxidase 1 (GPx1) by enzyme-linked immunosorbent assay (ELISA) method. Three months after injection, histopathology assessments showed a complete absence of the outer nuclear layer (ONL), photoreceptors and obvious reduction of retinal pigment epithelium (RPE) in the sham group. Cell group showed marked preservation of RPE, choroidal congestion and mild presence of ONL. The green fluorescent protein positive Schwann cells remained in one integrated layer during the study under RPE. The enzymatic evaluation showed that in cell group expression of SOD and GPx1 until month 2 and catalase until month 1 were significantly more than the sham group. At the end of month 3, the amplitude of ERG waves significantly preserved in cell group in comparison to baseline waves and the sham group. We concluded that Schwan cells are able to preserve retinal in RCS rats by reducing oxidative stress. Epub: October 1, 2019