Nonsurgical treatment for upper eyelid retraction in patients with inactive Graves' orbitopathy

PURPOSE

To evaluate the effectiveness of incobotulinumtoxinA (Xeomin^®) in treating upper eyelid retraction in patients with Graves orbitopathy (GO) initially scheduled for surgery via two different application sites.

METHODS

This is a comparative, prospective study, conducted at the Department of Ophthalmology, Medical School, University Hospital Centre Zagreb, EUGOGO site (EUropean Group On Graves' Orbitopathy) in Croatia from January 2020 till January of 2021 in accordance with national health headquarter recommendations. All patients were classified as inactive with marked eyelid retraction and randomly divided into groups according to application sites. Group A underwent transconjunctival application (18 eyes) and group B transcutaneous application (20 eyes) of incobotulinumtoxinA. The primary end point of this study was lowering the eyelid, to alleviate anterior eye segment symptoms and achieve acceptable aesthetic appearance until surgery becomes available.

RESULTS

There were no nonresponders and we found no statistically significant difference in the degree of lowering the eyelid between the two application sites. Following rules for avoiding spread of SARS-CoV-19, none of the patients included in this study were infected. Moreover, participants reported diminishing of anterior eye segment irritation and improved aesthetics.

CONCLUSION

Treatment of inactive GO patients with incobotulinumtoxinA for upper eyelid retraction is efficient and safe and can be used as an adjuvant treatment while patients wait for surgery, by alleviating symptoms and improving the level of aesthetic satisfaction without causing a threat to anterior eye segment and visual function. The study showed that effect of treatment was the same, whether we applied the toxin transconjunctivaly or transcutaneously.

LENS CARE COMPLIANCE RATES AND PERCEPTIONS AMONG RIGID GAS PERMEABLE CONTACT LENS WEARERS - A PILOT STUDY

The aim was to estimate compliance rate among rigid gas permeable lens wearers (RGPLW) in lens system care, identify procedures in lens care process with poorest compliance levels, and assess concordance between participant reported practices and their subjectively perceived compliance. The study included outpatient RGPLW managed at Zagreb University Hospital Center in Zagreb, Croatia. They filled out a questionnaire that included demographic data, duration of lens wear, self-evaluation compliance grade, and 14 lens care procedures and wearing habits indicative of compliance. There were 50 patients (mean age 34.6 years, 68% female). Full compliance was found in a single patient. The mean number of non-compliant procedures was 5.48, with 32% of participants non-compliant in more than 50% of the compliance criteria. Critical procedures of the lens care process were infrequent lens case exchange (74%), using tap water for lens (70%), and improper case cleaning (68%). The mean lens case replacement time was 9.8 months (SD 6.76), with only 26% of patients replacing lens case at least once in 3 months. Excessive daily lens wear was associated with greater total number of non-compliant procedures (p<0.0008). RGPLW were aware of their inappropriate lens care only when achieved non-compliance in almost 50% of the procedures. In conclusion, lens wearers were not aware of their extremely low compliance rate in several aspects of lens and lens case maintenance. Study results indicated the key procedures the practitioners should focus on when evaluating subjective and objective compliance and reinforcing care and hygiene education of RGPLW.

The Global Retinoblastoma Outcome Study: a prospective, cluster-based analysis of 4064 patients from 149 countries

Background

Retinoblastoma is the most common intraocular cancer worldwide. There is some evidence to suggest that major differences exist in treatment outcomes for children with retinoblastoma from different regions, but these differences have not been assessed on a global scale. We aimed to report 3-year outcomes for children with retinoblastoma globally and to investigate factors associated with survival.

Methods

We did a prospective cluster-based analysis of treatment-naive patients with retinoblastoma who were diagnosed between Jan 1, 2017, and Dec 31, 2017, then treated and followed up for 3 years. Patients were recruited from 260 specialised treatment centres worldwide. Data were obtained from participating centres on primary and additional treatments, duration of follow-up, metastasis, eye globe salvage, and survival outcome. We analysed time to death and time to enucleation with Cox regression models.

Findings

The cohort included 4064 children from 149 countries. The median age at diagnosis was 23·2 months (IQR 11·0–36·5). Extraocular tumour spread (cT4 of the cTNMH classification) at diagnosis was reported in five (0·8%) of 636 children from high-income countries, 55 (5·4%) of 1027 children from upper-middle-income countries, 342 (19·7%) of 1738 children from lower-middle-income countries, and 196 (42·9%) of 457 children from low-income countries. Enucleation surgery was available for all children and intravenous chemotherapy was available for 4014 (98·8%) of 4064 children. The 3-year survival rate was 99·5% (95% CI 98·8–100·0) for children from high-income countries, 91·2% (89·5–93·0) for children from upper-middle-income countries, 80·3% (78·3–82·3) for children from lower-middle-income countries, and 57·3% (52·1-63·0) for children from low-income countries. On analysis, independent factors for worse survival were residence in low-income countries compared to high-income countries (hazard ratio 16·67; 95% CI 4·76–50·00), cT4 advanced tumour compared to cT1 (8·98; 4·44–18·18), and older age at diagnosis in children up to 3 years (1·38 per year; 1·23–1·56). For children aged 3–7 years, the mortality risk decreased slightly (p=0·0104 for the change in slope).

Interpretation

This study, estimated to include approximately half of all new retinoblastoma cases worldwide in 2017, shows profound inequity in survival of children depending on the national income level of their country of residence. In high-income countries, death from retinoblastoma is rare, whereas in low-income countries estimated 3-year survival is just over 50%. Although essential treatments are available in nearly all countries, early diagnosis and treatment in low-income countries are key to improving survival outcomes.

Funding

Queen Elizabeth Diamond Jubilee Trust.

Religiousness, Anxiety and Depression in Patients with Glaucoma, Age-Related Macular Degeneration and Diabetic Retinopathy

BACKGROUND

Many chronic medical conditions such as glaucoma, senile macular degeneration and diabetic retinopathy are further complicated by emotional and psychological disorders. Religiousness represents a part of a social culture and has a significant role in the prevention of mental difficulties of the patients, especially those belonging to older population. The aim of this study was to investigate the connection between religiousness, anxiety, and depression in patients with glaucoma, age-related macular degeneration and diabetic retinopathy and to test their connection related to different diagnosis.

SUBJECTS AND METHODS

This cross-sectional study included 163 patients divided into three groups (glaucoma group, senile macular degeneration group and diabetic retinopathy group). Respondents voluntarily agreed to participate in the study and with assistance they fully completed the Scale of Religiousness, Hospital Anxiety and Depression Scale, General Health Questionnaire and demographic information (age, gender, education, employment and marital status).

RESULTS

The results showed noticeable religiosity of the respondents (M=18.31, SD=5.28), but also the presence of anxiety (M=7.55, SD=3.73), especially in patients with glaucoma, as well as impaired mental health in AMD patients (M=19.56, SD=4.14). No differences were found in the severity of anxiety, depression, general health and religiosity between groups, but the presence of depression in subjects with age-related macular degeneration significantly affects the level of religiosity (p=0.032).

CONCLUSION

These results unequivocally point to the need for further research and raising awareness of all health professionals about the importance of a holistic approach to the patient regardless of his diagnosis in order to identify the possible effective ways to deal with chronic disease considering all levels of patient's needs.

Fear of Blindness in Patients Undergoing Cataract Surgery

BACKGROUND

Fear is a negative emotion induced by the threat of danger, pain and harm. Cataract surgery is one of the most performed surgeries in the world. The aim of this study was to investigate and analyze the predominant fears in patients undergoing cataract surgery.

SUBJECTS AND METHODS

In this cross-sectional study 152 patients were examined. Self-designed questionnaires to examine emotions of the fear, anxiety, nervousness frequency gratitude was used and insecurity immediately before cataract surgery. We also examined what the greatest fear during the cataract surgery was. The fear of blindness was compared with other life fears such as cancer, memory loss, AIDS, stroke and heart attack. The presence of fear was compared in patients having had previous cataract surgery with those undergoing their first cataract surgery. Including criteria were adults with senile cataract. Excluding criteria was ocular co-morbidity, psychiatric disorders, inability to read, deafness and surgery under general anesthesia. Completed questionnaires were analyzed. Pearson's chi-squared test was used.

RESULTS

Fear was the most frequent emotion before cataract surgery, present in 60.5% patients. Fear of blindness was the greatest fear during cataract surgery in 55.3% of patients. There was no statistically significant difference in fear in patients having undergone their first cataract surgery and patients before their second cataract surgery (p<0.05).

CONCLUSION

Fear is the predominant emotion before cataract surgery which is in correlation to the leading life fear - fear of blindness. Good preoperative preparation and a trusting doctor-patient relationship are important for reducing the fear of the procedure.

Travel burden and clinical presentation of retinoblastoma: analysis of 1024 patients from 43 African countries and 518 patients from 40 European countries

BACKGROUND

The travel distance from home to a treatment centre, which may impact the stage at diagnosis, has not been investigated for retinoblastoma, the most common childhood eye cancer. We aimed to investigate the travel burden and its impact on clinical presentation in a large sample of patients with retinoblastoma from Africa and Europe.

METHODS

A cross-sectional analysis including 518 treatment-naïve patients with retinoblastoma residing in 40 European countries and 1024 treatment-naïve patients with retinoblastoma residing in 43 African countries.

RESULTS

Capture rate was 42.2% of expected patients from Africa and 108.8% from Europe. African patients were older (95% CI -12.4 to -5.4, p<0.001), had fewer cases of familial retinoblastoma (95% CI 2.0 to 5.3, p<0.001) and presented with more advanced disease (95% CI 6.0 to 9.8, p<0.001); 43.4% and 15.4% of Africans had extraocular retinoblastoma and distant metastasis at the time of diagnosis, respectively, compared to 2.9% and 1.0% of the Europeans. To reach a retinoblastoma centre, European patients travelled 421.8 km compared to Africans who travelled 185.7 km (p<0.001). On regression analysis, lower-national income level, African residence and older age (p<0.001), but not travel distance (p=0.19), were risk factors for advanced disease.

CONCLUSIONS

Fewer than half the expected number of patients with retinoblastoma presented to African referral centres in 2017, suggesting poor awareness or other barriers to access. Despite the relatively shorter distance travelled by African patients, they presented with later-stage disease. Health education about retinoblastoma is needed for carers and health workers in Africa in order to increase capture rate and promote early referral.

Complication and prognosis of juvenile idiopathic arthritis associated uveitis in the era of modern immunomodulatory treatment

JIA is the most common rheumatic disease of childhood and JIA-U is its most frequent and most devastating extraarticular manifestation. This form of uveitis is usually asymptomatic, chronic anterior uveitis, often accompained with complications. JIA-U is the main cause of vision loss and even blidness in childhood. Thus, screening for JIA-U in all JIA patients and early treatment is of prime importance. Over the last 15-20 years, ever since IMT has been used, studies generally show trends toward decrease of JIA-U onset, complications frequency, improvement of prognosis and remission achievement. Despite evident improvements, over 20% JIA-U patients still develop complications in long-term follow-up. Moreover, about 50% JIA-U patients continue to have active uveitis in adulthood. Therefore, JIA-U is still associated with high risk of late sequelae and visual acuity loss, functionally and structurally eye damage and quality of life impairment.

Comparison of temporal and stride characteristics in myotonic dystrophies type 1 and 2 during dual-task walking

OBJECTIVE

We analyzed temporal and stride characteristics in patients with myotonic dystrophy type 1 (DM1) and type 2 (DM2) while performing dual mental and motor tasks, and investigated correlations between gait parameters and cognitive impairments.

METHOD

Dual-task walking was performed by 37 patients (20 DM1 and 17 DM2) and 48 healthy subjects divided into two groups, age- and gender-matched control group for DM1 (HC1) and age- and gender-matched control group for DM2 (HC2). The subjects performed a basic walking task, dual-motor task, dual-mental task, and combined motor and mental task.

RESULTS

DM1 and DM2 patients differed significantly in temporal and stride characteristics compared to HC. Main differences in DM1 were slower gait and shorter stride length, while both DM1 and DM2 patients had a higher degree of variation of the swing time during dual-task gait, a parameter that reflects posture and balance. Impact of the cognitive dual task on gait pattern changes was also observed. Visuospatial ability correlated with gait changes in DM1, while executive functions had stronger influence in DM2 (p<0.01). Both patient groups had leg muscle weakness.

CONCLUSION

Gait pattern was impaired in both patient groups concerning temporal and stride characteristics. Dual-task walking paradigm may discover mild initial gait changes and could provide early identification of fall risks and predict possible falls in DM patients.

Corticosteroid therapy in patients with non-arteritic anterior ischemic optic neuropathy

Non-arteritic anterior ischemic optic neuropathy is one of the most common conditions affecting the optic nerve in the elderly. It may lead to severe visual loss. Typical symptoms are painless impairment of visual function accompanied by relative afferent pupillary defect, edema of the optic disc and visual field defects. Aim is to present 38 patients with nonarteritic anterior ischemic optic neuropathy who were treated with corticosteroid therapy. This prospective study involved 38 patients, 20 men and 18 women aged 60-75 years who were treated with corticosteroid therapy. The study included patients with visual acuity in the affected eye from 0.1 to 0.8 according to Snellen. Every patient underwent clinical examination, the Octopus 900 perimetry in G program, laboratory testing, while the compressive optic neuropathy was rule out with MSCT of the brain and orbits. The most common forms of visual field defect are altitudinal defect and diffuse depression. Corticosteroid therapy led to recovery in 65% of patient, in 30% of patients did not change, while the deterioration occurred in 5% of patients.

Ocular surface disease in pseudoexfoliation syndrome

Aim of the study is to determine connection between pseudoexfoliation (PEX) syndrome and symptoms and signs of ocular surface disease. Tear film break-up time test, Schirmer II test and assessment of lid parallel conjunctival folds were performed in 40 PEX syndrome patients and 40 controls. All data was statistically analyzed. Results show statistically significant difference in every component between groups, most prominent in tear film break up time test. We have concluded that patients with PEX syndrome have higher predisposition of tear function disorders and that both components of dry eye syndrome are present in PEX syndrome.

Ocular related emergencies in Zagreb University Hospital Centre--ten month analysis

To determine number, demographic characteristics and presenting symptoms of patients admitted to Emergency ophthalmologic department of Zagreb University hospital centre. Prospective analysis of data of 743 patients admitted to Emergency ophthalmologic department of University hospital centre Zagreb during period of 10 month. Main presenting symptoms at admission were red eye, pain and foreign body sensation. 64% of all patients admitted to emergency unit were male. Almost 40% of them were between 20 and 40 years of age. In female population majority is between 50 and 60 years old (19.33%). The study shows that the most frequent reason for admission in emergency ophthalmic unit is red eye, pain and foreign body sensation. These symptoms were present most frequently in young male patients. Considering fact of their working ability, data can suggest that they don't comply with occupational safety measures. Further research in this direction is needed.

Automated static perimetry: the influence of myopic anisometropia on evaluation of visual field

The aim of study was to establish which level of myopic refractive error influences visual field defects in automated static perimetry, if these defects are typical, and if optimal correction normalized the visual field. The study included 100 patients (200 eyes) divided into three groups according to the severity of the myopic refractive error: group A (till -3.25 Dsph), group B (-3.50 Dsph to -5.25 Dsph) and group C (-5.50 Dsph to -8.00 Dsph). The control group included 20 emmetropes (40 eyes). This study confirms that optimal corrected and uncorrected myopia up to -3.25 Dsph does not produce quantitative visual field defects, when tested by static automated perimetry. Even in optimally corrected myopics, with myopia higher than -5.50 Dsph, visual field defects on gray scale can be found. Defects are in the intermediary zone with more prominent defects in the upper quadrants. Visual field indices (MD, MS, LV RF) were completely normalized.

Side effects assessment in glicolyc acid peelings in patients with acne type I

Chemical peeling implies the application of a chemical agent to the skin, which causes controlled destruction of a part or the entire epidermis, with or without the dermis, leading to exfoliation and removal of superficial lesions, followed by regeneration of new epidermal and dermal tissues. The present study was directed toward safety concerns associated with superficial chemical peeling with glycolic acid (GA) in different concentrations at patients with acne tip I. A sample of 90 patients of either sex, aged between 17 to 21 years, were included in the study and submitted to superficial chemical peeling for acne vulgaris. The study lasted eight weeks and peeling sessions were carried out in each patient. Tolerance to the procedure and any undesirable effects noted during these sessions were recorded. For data statistical analysis and interpretation of results, software program "SPSS version 13" was used. Results were expressed through the descriptive statistics, as simple frequencies and percentages, while for establishing of statistically significant differences, in use was Friedman's test of significance. Almost all the patients tolerated the procedure well. Of totally 90 patients, only six, at the end of therapy experienced hard erythema, only ten, at the end of therapy experienced hard desquamation and only eleven, at the end of therapy experienced hard sensation of pulling of facial skin. Chemical peeling with glycolic acid is a well tolerated and safe treatment modality in acne type I.

Validation of Serbian version of the disease-specific myasthenia gravis questionnaire

AIM

The aim of this study was to validate translated and cross-cultural adapted Italian version of myasthenia gravis-specific questionnaire (MGQ) in Serbian MG patients.

MATERIALS AND METHODS

The questionnaire was validated in 140 consecutive MG patients from Belgrade. In each patient association between the total MGQ score and form and severity of the disease was determined. Also, correlation between regional domain scores of MGQ and main clinical findings according to Besinger's clinical score was analyzed.

RESULTS

Patients' participation in the assessment was satisfactory with excellent internal consistency and reproducibility. Total MGQ score, as well as domain scores, correlated with highly significant inverse relationship with the disease severity and clinical status of patients at the moment of completing the questionnaire. Furthermore, the bulbar domain of the questionnaire appeared more specific and sensitive than clinical history and examination.

CONCLUSION

We concluded that the Serbian version of the MGQ may be useful as a measure of clinical outcome in patients with MG.

Intravenous immunoglobulin therapy in two patients with myasthenia gravis and pemphigus vulgaris

Various forms of pemphigus have been reported to occur with myasthenia gravis (MG), with and without thymoma. We described two cases of pemphigus vulgaris associated with MG without thymoma. Case 1. A 44 year-old woman presented with 3 years history of pemphigus vulgaris. Three years later, she developed myasthenic symptoms with elevated level of anti-acetylcholine receptor (AChR) antibodies - 5.2 nmol/L. She was thymectomised and we revealed only hyperplastic thymus. Case 2. A 64-year-old woman had a general fatigue and intermittent double vision. She was diagnosed as MG three years later. Two months before she diagnosed as MG, she had pruritic erythematous, erosive and bullous lesions on her body and extremities. Oral prednisolon, pyridostigmine bromide and azathioprine or cyclophosphamide didn't adequately control MG and pemphigus in our patients, so they received intravenous immunoglobulins of 0.4 g/kg for 5 consecutive days. After that therapy, our patients markedly improved.

CONCLUSION

The precise pathological mechanisms of the association between pemphigus and MG are not fully understood. The thymus has been suggested to be a possible common origin of autoimmune response in these disorders.

Precancerous morphologic and functional aberrations in the rat mammary glands carcinogenesis

The precancerous changes of mammary glands in 7,12-dimethylbenz(alpha)anthracene (DMBA) induced carcinogenesis in Wistar rats were examined. Carcinogen was inserted into the left fifth mammary gland of the anesthetised rats. After 35 days all the animals were sacrificed and mammary glands were extirpated. Macroscopic examination of mammary glands was performed and the tissue was processed for a pathohistological analysis. H&E, VanGieson's and Toluidine-blue methods were applied, as well as ABC immunohistochemical method with anti-cytokeratin antibodies.The identified precancerous changes resembled to aberrations of fibrocystic disease in women. The fibrosclerosis, lobular hyperplasia, cystic ductal dilatation and apocrine metaplasia of ductal epithelium were found. Micropapillomatoid hyperplasia was another frequent finding, but the presence of the real papilloma was not registered. The keratocysts with the squamous epithelial metaplasia were present in three of the animals. Dysplastic changes were found in the skin, above the treated glands. The difference in expression of cytokeratins, between normal and preneoplastic epithelium, makes cytokeratin useful for verification of early precancerous lesions. The epithelial ductus and ductulus cells of the mammary glands of animals belonging to the control group showed neither CK 19 nor CK 14 expression.

Coexistence of ochronosis and B 27 positive ankylosing spondylitis

We describe a 49-year-old man with coexistence of ochronosis and B27 positive ankylosing spondylitis. This is the first report documenting the simultaneous occurrence of ochronosis and B27 positive ankylosing spondylitis, with no positive familiar history for seronegative spondylarthropathies. The relations of these rheumatic diseases are discussed.

[Clinical and radiographic characteristics of patients with osteoarthritis of knees]

The study of 60 outpatients with clinical diagnosis of the osteoarthritis (OA) of the knees is performed. Measured parameters were: general demographic data, clinical data and standard radiographic x-ray of knees in standing position, graduated by Kellgren and Lawrence clasificiation from 0-4. The aim of this study was to establish clinical and radiographic features of OA of knees and to compare those characteristiscs in the two subgroups of patients according to radiographic stages: a group of an early disease (stages 0 or 1) and a group of late disease (stages from 2 to 4). The mean age was 60 years with range from 39 to 85 years. 85% of patients were female. Distribution of patients according to Kellgren and Lawrence radiographic stages was as follows: 13 patients (21,7%) in grade 0, 17 (28,3%) in grade 1, 10 (16,7%) in grade 2, 11 (18,3%) in grade 3, and nine patients (15%) in grade 4. Crepitus on movement was registered in aproximatelly 80% of all patients, with no difference between early and late disease. Instability of the knee was present in eleven patients (18%), with more than a half of them (56%) in a radiographic grade 4 of OA of knees. There were no difference between functional parameters comparing original group of patients and two sub-groupes. Crepitus on movement was not related to any specific radiographic stage of disease, but instability of knee was frequently registered in late disease.

Anterior ischaemic optic neuropathy in patient with rheumatoid arthritis--case report

This case report presents a patient with long-lasting rheumatoid arthritis (RA) of fourth clinical grade, having ocular complications. RA was diagnosed according to current modified ARA criteria from 1987. Upon admission to the Department of Ophthalmology clinical examination revealed anterior ischaemic optic neuropathy (AION), which is not characteristic manifestation of RA in the eye. The occurrence of AION in patients with RA has been explained in literature as a secondary manifestation of hypertension in these patients or, by the presence of other connective tissue disease apart from RA (for example, MCTD--mixed connective tissue disease). Both mentioned causes were excluded in our case, as well as any other condition that could lead to AION. Therefore, we had concluded that AION presented a late complication of RA.