Publications by authors named "Emin Özmert"

69 Publications

The Correlation of Inflammation and Microvascular Changes with Diabetic Retinal Neurodegeneration.

Curr Eye Res 2021 Apr 12:1-8. Epub 2021 Apr 12.

Department of Ophthalmology, Ankara University Faculty of Medicine, Ankara, Turkey.

: To evaluate the effect of aqueous flare intensity as a measurement of inflammation and microvascular changes on retinal neurodegeneration in diabetic eyes.: In cross-sectional study diabetic patients were assigned into 2 groups according to the presence of retinopathy: patients with nonproliferative diabetic retinopathy (group 1) and diabetic patients without clinically overt retinopathy (group 2). As a control group (group 3), age-matched healthy controls were included in the study. All subjects underwent visual acuity measurement, slit-lamp examination, ophthalmoscopy, spectral-domain optic coherence tomography (SD-OCT), optic coherence tomography angiography (OCTA), and laser flare-cell meter (LFCM).: The study enrolled 99 eyes of 99 patients in group 1; 99 eyes of 99 patients in group 2, and 50 eyes of 50 age-matched healthy controls in group 3. The eyes in group 1 had higher flare intensity, decreased ganglion cell layer (GCL) thickness, enlarged foveal avascular zone (FAZ) area, and enlarged capillary non-flow area compared to those in group 2 ( < .005). In group 1, decreased GCL thickness was statistically significantly correlated with increased aqueous flare intensity, enlarged FAZ area, and enlarged capillary non-flow area ( < .005).: The results demonstrated a correlation of the retinal neurodegeneration with the aqueous flare levels and macular ischemia indices in the early stages of diabetic retinopathy. This finding supports the role of inflammation in the pathogenesis of diabetic retinal neuropathy.
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http://dx.doi.org/10.1080/02713683.2021.1908567DOI Listing
April 2021

Evaluation of the effect of subtenon autologous platelet-rich plasma injections on visual functions in patients with retinitis pigmentosa.

Regen Med 2021 02 23;16(2):131-143. Epub 2021 Mar 23.

Department of Ophthalmology, Ankara University, School of Medicine, Ankara 06620, Turkey.

The photoreceptors in retinitis pigmentosa (RP) remain in dormant status for a while with a decrease in the growth factors in their microenvironment before apoptosis. Growth factors reduce retinal degeneration and apoptosis in animal models. The data of 188 eyes of 94 patients who were injected with autologous platelet-rich plasma (PRP) into the subtenon space three-times every 2 weeks were evaluated retrospectively. Statistically significant improvements in visual acuity, visual field and fixation stability were detected after treatment. When the treatment response of the patients' better-seeing eye compared with the response of the other eye, there was no statistically significant difference. The PRP treatment has a favorable effect on visual functions in patients with RP. This approach is promising as it is safe and easy.
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http://dx.doi.org/10.2217/rme-2020-0075DOI Listing
February 2021

A comparative study on the choroidal vascularity index and the determination of cut-off values in the pachychoroid spectrum diseases.

Jpn J Ophthalmol 2021 Mar 6. Epub 2021 Mar 6.

Department of Ophthalmology, Ankara University School of Medicine, Mamak Street Vehbi Koç Eye Hospital, Dikimevi, Ankara, Turkey.

Purpose: To determine the cut-off levels for choroidal thickness and choroidal vascularity index (CVI) to differentiate among pachychoroid spectrum diseases.

Study Design: A retrospective comparative study METHODS: A total of 143 eyes were included. Of these 29 had uncomplicated pachychoroid (UCP), 29 had pachychoroid pigment epitheliopathy (PPE), 25 had pachychoroid neovasculopathy (PNV), 30 had central serous chorioretinopathy (CSC), and 30 had polypoidal choroidal vasculopathy (PCV). The choroidal areas were measured with ImageJ software. The CVI, the proportion of the luminal area to the total choroidal area, was assessed.

Results: The cut-off points of central choroidal thickness were determined as 360 µm for the PPE and PCV group pair (p < 0.001), 422 µm for the PNV and CSC group pair (p = 0.026), 271 µm for the PNV and PCV group pair (p < 0.001), and 341 µm for the CSC and PCV group pair (p < 0.001). The cut-off points of CVI were 72.7 for the PPE and PCV group pair (p < 0.001), 74.7 for the PNV and CSC group pair (p = 0.005), 72.6 for the PNV and PCV group pair (p = 0.001), and 73.6 for the CSC and PCV group pair (p < 0.001).

Conclusion: Pachychoroid spectrum may be composed of a combination of distinct choroidal diseases with different vascular and structural characteristics.
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http://dx.doi.org/10.1007/s10384-021-00829-5DOI Listing
March 2021

Natural course of acquired vitelliform lesions associated with pigment epithelial detachments in dry age related macular degeneration.

Eur J Ophthalmol 2021 Jan 28:1120672121990566. Epub 2021 Jan 28.

Department of Ophthalmology, Ankara University School of Medicine, Ankara, Turkey.

Purpose: To describe the natural history of acquired vitelliform lesions (AVLs) associated with different types of pigment epithelial detachments (PEDs) in dry age-related macular degeneration.

Methods: A retrospective review of clinical examination and multimodal imaging data of patients with AVLs associated with PED(s) was performed.

Results: This study included 25 eyes of 17 patients. The mean age of patients was 67.2 ± 9.7 (47-83) years. The mean follow-up time was 32.6 ± 16.2 (12-66) months, excluding four patients (five eyes) that were lost to follow-up. The mean logMAR BCVA was 0.21 ± 0.16 at baseline and 0.38 ± 0.28 at final visit ( = 0.016). At the end of the follow-up period, PEDs enlarged in eight eyes (40%) and were unchanged in two eyes (10%). Spontaneous resolution of the central PED(s) with AVLs was seen in four (20%) eyes. Rupture of the PED(s) occurred in four eyes (20%), with two developing central foveolar atrophy afterwards. Overall, central foveolar atrophy was seen ultimately in four eyes (20%).

Conclusion: It seems that high PED size may be a risk factor for PED rupture during follow-up. 1/3 of the eyes ended up with unfavorable anatomical outcome.
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http://dx.doi.org/10.1177/1120672121990566DOI Listing
January 2021

Comparison of Morphological Features of Type 1 CNV in AMD and Pachychoroid Neovasculopathy: An OCTA Study.

Ophthalmic Surg Lasers Imaging Retina 2020 11;51(11):640-647

BACKGROUND AND OBJECTİVE: The purpose of this study is to compare the morphological features of type 1 choroidal neovascularization (CNV) in eyes with age-related macular degeneration (AMD) and pachychoroid neovasculopathy (PNV) using optical coherence tomography angiography (OCTA). PATİENTS AND METHODS: Nineteen eyes of 17 patients with PNV and 30 eyes of 30 patients with AMD were evaluated. The size and area of CNV and morphological patterns during a 6-month period were analyzed using optical coherence tomography angiography. RESULTS: The presence of a feeder vessel was more common in AMD than in PNV. Indistinct pattern was more common in PNV than AMD. Pruned vascular tree pattern was rare in PNV eyes during follow-up. The mean size and flow of selected CNV area was significantly smaller in PNV group. CONCLUSİON: This study demonstrated that type 1 CNVs in the PNV group is characterized by a smaller area. Morphologic pattern differences between them might be explained by different etiopathogenesis under these circumstances. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:640-647.].
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http://dx.doi.org/10.3928/23258160-20201104-06DOI Listing
November 2020

Pseudophakic macular edema involving epiretinal proliferation associated with macular hole.

Indian J Ophthalmol 2020 Nov;68(11):2599-2601

Department of Ophthalmology, Ankara University School of Medicine, Ankara, Turkey.

This case report describes an unusual course of an impending macular hole (MH) throughout a 72-month follow-up period. A 53-year-old female presented with impending MH associated with epiretinal proliferation (EP) which showed unusual progress including full thickness MH, spontaneous closure, reopening as lamellar MH, and full anatomical closure with EP tissue. After cataract surgery, cystoid spaces occurred involving both EP tissue and neuroretina. Due to full recovery following a single dose of aflibercept, the source of the cystoid spaces was thought to be associated with postoperative inflammation leading to pseudophakic macular edema involving not only but also EP tissue.
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http://dx.doi.org/10.4103/ijo.IJO_602_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7774124PMC
November 2020

Treatment of resistant chronic central serous chorioretinopathy via platelet-rich plasma with electromagnetic stimulation.

Regen Med 2020 08 27;15(8):2001-2014. Epub 2020 Oct 27.

Ankara University Faculty of Medicine Department of Ophthalmology, Ankara, Turkey.

To evaluate whether subtenon injection of platelet-rich plasma (PRP) with retinal electromagnetic stimulation (rEMS) is effective in therapy-resistant chronic central serous chorioretinopathy (CSCR). Prospective, sequential. The study included 22 eyes with resistant chronic CSCR. Cases receiving micropulse laser or additional photodynamic therapy, subtenon PRP, and subtenon PRP + rEMS were classified as times 1, 2 and 3, respectively. At time 3, the mean best-corrected visual acuity was 85.7 and 97.0 letters before and after the procedures, respectively (p = 0.01). Submacular thickness improved by 17, 27 and 51% at times 1, 2 and 3 respectively. For treating resistant CSCR, subtenon PRP + rEMS should be considered as an effective and safe option. ClinicalTrials.gov ID: NCT04224831.
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http://dx.doi.org/10.2217/rme-2020-0056DOI Listing
August 2020

Inherited eye diseases in Turkey: Current approaches and future directions.

Am J Med Genet C Semin Med Genet 2020 09 30;184(3):773-781. Epub 2020 Aug 30.

Department of Ophthalmology, Gazi University Faculty of Medicine, Ankara, Turkey.

The aim of this review is to reveal Turkey's current status of medical practice in inherited eye diseases and the necessary steps to improve healthcare services and research activities in this area. Since consanguinity rate is high, disease burden is estimated to be high in Turkey. Universal health insurance system, easily accessible medical specialists, increasing genetic test, and counseling opportunities are the key advantages of Turkey's healthcare system. However, specialized clinics for inherited eye diseases, low-vision rehabilitation services, training of ophthalmologists about the recent developments in ocular genetics, and multidisciplinary translational research are the main headlines needed to be focused for better health services and successful research in Turkey.
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http://dx.doi.org/10.1002/ajmg.c.31829DOI Listing
September 2020

Management of retinitis pigmentosa by Wharton's jelly-derived mesenchymal stem cells: prospective analysis of 1-year results.

Stem Cell Res Ther 2020 08 12;11(1):353. Epub 2020 Aug 12.

Bioretina Eye Clinic, Ankara University Technopolis, Neorama Ofis 55-56 Yaşam Cad. No 13/A Beştepe, Yenimahalle, Ankara, Turkey.

Purpose: The aim of the study was to investigate annual structural and functional results, and their correlation with inheritance pattern of retinitis pigmentosa (RP) patients who were treated with Wharton's jelly-derived mesenchymal stem cells (WJ-MSCs).

Material And Methods: This prospective, sequential, open-label phase-3 clinical study was conducted at Ankara University Faculty of Medicine, Department of Ophthalmology, between April 2019 and May 2020. The study included 34 eyes from 32 retinitis pigmentosa patients of various genotypes who were enrolled in the stem cells clinical trial. The patients were followed for 12 months after the WJ-MSCs transplantation into subtenon space and evaluated with consecutive examinations. Genetic mutations were investigated using a retinitis pigmentosa panel sequencing method consisting of 90 genes. All patients underwent a complete routine ophthalmic examination with best corrected visual acuity, optical coherence tomography angiography, visual field, and full-field electroretinography. Quantitative data obtained from baseline (T0), 6th month (T1), and 12th month (T2) examinations were compared.

Results: According to timepoints at T0, T1, and T2: The mean outer retinal thickness was 100.3 μm, 119.1 μm, and 118.0 μm, respectively (p = 0.01; T0 < T1, T2). The mean horizontal ellipsoid zone width were 2.65 mm, 2.70 mm, and 2.69 mm respectively (p = 0.01; T0 < T1, T2). The mean best corrected visual acuity (BCVA) were 70.5 letters, 80.6 letters, and 79.9 letters, respectively (p = 0.01; T0 < T1, T2). The mean fundus perimetry deviation index (FPDI) was 8.0%, 11.4%, and 11.6%, respectively (p = 0.01; T0 < T1, T2). The mean full-field flicker ERG parameters at T0, T1, and T2: amplitudes were 2.4 mV, 5.0 mV, and 4.6 mV, respectively (p = 0.01; T0 < T1, T2). Implicit time were 43.3 ms, 37.9 ms, and 38.6 ms, respectively (p = 0.01; T0 > T1, T2). According to inheritance pattern, BCVA, FPDI, ERG amplitude, and implicit time data improved significantly in autosomal dominant (AD) and in autosomal recessive (AR) RP at 1 year follow-up (pAD = 0.01, pAR = 0.01; pAD = pAR > pX-linked). No ocular or systemic adverse events related to the surgical methods and/or WJ-MSCs were observed during the 1 year follow-up period.

Conclusion: Subtenon transplantation of WJ-MSCs was found to be effective and safe in the treatment of RP during the first year, similar to the sixth month's results. In autosomal dominant and autosomal recessive inheritance of RP, regardless of the genetic mutations, subtenon administration of WJ-MSCs can be considered an effective and safe option without any adverse effect for slowing or stopping the disease progression.

Trial Registration: ClinicalTrials.gov, NCT04224207 . Registered 8 January 2020.
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http://dx.doi.org/10.1186/s13287-020-01870-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7425139PMC
August 2020

Multimodal Imaging Characteristics and Functional Test Findings in a Case of Acute Macular Neuroretinopathy Accompanied by Behçet Disease.

Ocul Immunol Inflamm 2020 Jun 8:1-7. Epub 2020 Jun 8.

Department of Ophthalmology, Ankara University School of Medicine, Ankara, Turkey.

Purpose: To report a case of acute macular neuroretinopathy (AMN) in Behçet Disease.

Case: A 23-year-old male presented with a complaint for central scotoma in his right eye. He had been diagnosed with Behçet Disease 3 years ago. Best-corrected visual acuity (BCVA) was 20/20. Anterior chamber and fundus examinations were unremarkable. Optical coherence tomography revealed a paracentral area of outer nuclear layer thinning. Infrared reflectance showed a well-defined, circular, hyporeflective area. Optical coherence tomography angiography revealed an area of capillary dropout in deep retinal capillary plexus corresponding to that hyporeflective lesion. Microperimetry test showed decreased macular sensitivity on the lesion area and the loss of the macular integrity. In multifocal electroretinogram, diminished amplitudes of the central cone responses were detected nasal to fixation.

Conclusion: Behçet disease is a cause of occlusive retinal vasculitis. Accompanied retinal microvascular disease may be a possible risk factor of AMN suggesting ischemic etiopathogenesis for AMN.
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http://dx.doi.org/10.1080/09273948.2020.1751857DOI Listing
June 2020

The Use of Optical Coherence Tomography Angiography in the Diagnosis of Inflammatory Type 1 Choroidal Neovascularization Secondary to Tuberculosis: A Case Report.

Ocul Immunol Inflamm 2020 May 27:1-7. Epub 2020 May 27.

Department of Ophthalmology, Ankara University Faculty of Medicine, Ankara, Turkey.

: To report a case of choroidal neovascularization (CNV), which was not obvious with dye angiography but was detected with optical coherence tomography angiography (OCTA).: A 50-year-old female presented with decreased vision in her right eye. Funduscopic examination revealed a swollen hyperemic disc, peripapillary exudation, and choroidal infiltration.: Optical coherence tomography revealed intraretinal cysts, subretinal fluid in the macular region, and subretinal hyperreflective material in the papillomacular area. Fluorescein angiography revealed early hypofluorescence in the areas of choroidal infiltrations, and indocyanine green angiography (ICGA) also showed hypocyanescence corresponding to these infiltrations and revealed a faint hypocyanescence in the papillomacular region, further corresponding to the subretinal hyperreflective material on OCT scan. Two weeks after the initiation of systemic therapy with the diagnosis of tuberculosis, OCTA scans detected Type 1 CNV in the peripapillary area.: OCTA may be superior to ICGA in the detection of CNV secondary to inflammatory situations.
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http://dx.doi.org/10.1080/09273948.2020.1754862DOI Listing
May 2020

A comparative study of the choroidal vascularity indexes in the fellow eyes of patients with pachychoroid neovasculopathy and central serous chorioretinopathy by binarization method.

Graefes Arch Clin Exp Ophthalmol 2020 Aug 15;258(8):1649-1654. Epub 2020 May 15.

Department of Ophthalmology, Ankara University School of Medicine, Vehbi Koç Eye Hospital, Mamak Street, Dikimevi, Ankara, Turkey.

Purpose: To evaluate the choroidal vascularity index (CVI) in the fellow eyes of patients with pachychoroid neovasculopathy (PCN) and central serous chorioretinopathy (CSC).

Methods: Fifty-eight asymptomatic fellow eyes from 58 patients diagnosed with PCN or CSC and 26 eyes from 26 healthy participants were included. The total choroidal area (CA), luminal area (LA), and stromal area (SA) were measured with ImageJ software and Niblack threshold method. The CVI, which was the proportion of the LA to the CA, was assessed.

Results: The CA, LA, and SA were widest in the fellow eyes of the CSC group. The differences between the fellow eyes of the CSC group and the control group and the differences between the fellow eyes of the PCN group and the CSC group were significant (p < 0.001). The CVI of the fellow eyes of the CSC group was significantly higher than the control group (74.93 ± 3.58 vs. 73.38 ± 3.09, p = 0.023).

Conclusion: The differences in the CA, LA, and SA in particular pachychoroid diseases were evident in the asymptomatic fellow eyes. Pachychoroid diseases are characterized by thick choroid or vessels as a common feature, but they may have different structural choroidal features, which might result in different consequences.
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http://dx.doi.org/10.1007/s00417-020-04740-6DOI Listing
August 2020

Management of Retinitis Pigmentosa via Platelet-Rich Plasma or Combination with Electromagnetic Stimulation: Retrospective Analysis of 1-Year Results.

Adv Ther 2020 05 18;37(5):2390-2412. Epub 2020 Apr 18.

Department of Ophthalmology, Faculty of Medicine, Ankara University, Ankara, Turkey.

Purpose: To investigate whether the natural progression rate of retinitis pigmentosa can be decreased by subtenon autologous platelet-rich plasma application alone or combination with retinal electromagnetic stimulation.

Methods: The study includes retrospective analysis of 60 patients with retinitis pigmentosa. Patients constitute three groups with similar demographic characteristics: the combined management group (group 1) consists of 20 patients with retinitis pigmentosa (40 eyes) who received combined retinal electromagnetic stimulation and subtenon platelet-rich plasma; the subtenon platelet-rich plasma-only group (group 2) consisted of 20 patients with retinitis pigmentosa (40 eyes); the natural course (control) group (group 3) consists of 20 patients with retinitis pigmentosa (40 eyes) who did not receive any treatment. Horizontal and vertical ellipsoid zone width, fundus perimetry deviation index, and best corrected visual acuity changes were compared within and between groups after a 1-year follow-up period.

Results: Detected horizontal ellipsoid zone percentage changes were + 1% in group 1, - 2.85% in group 2, and - 9.36% in group 3 (Δp 1 > 2 > 3). Detected vertical ellipsoid zone percentage changes were + 0.34% in group 1, - 3.05% in group 2, and - 9.09% in group 3 (Δp 1 > 2 > 3). Detected fundus perimetry deviation index percentage changes were + 0.05% in group 1, - 2.68% in group 2, and - 8.78% in group 3 (Δp 1 > 2 > 3).

Conclusion: Platelet-rich plasma is a good source of growth factors, but its half-life is 4-6 months. Subtenon autologous platelet-rich plasma might more effectively slow down photoreceptor loss when repeated as booster injections and combined with retinal electromagnetic stimulation.

Trial Registration: ClinicalTrials.gov identifier, NCT04252534.
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http://dx.doi.org/10.1007/s12325-020-01308-yDOI Listing
May 2020

Role of Inflammation in Retinal Microcirculation in Diabetic Eyes: Correlation between Aqueous Flare and Microvascular Findings.

Ophthalmologica 2020 11;243(5):391-398. Epub 2020 Mar 11.

Department of Ophthalmology, Ankara University School of Medicine, Ankara, Turkey.

Purpose: To investigate the correlation between aqueous flare and macular microvascular status assessed by optic coherence tomography angiography (OCTA) in diabetes mellitus.

Methods: A cross-sectional study was conducted on 52 diabetic patients with nonproliferative retinopathy, 44 diabetic patients without retinopathy, and 20 nondiabetic age-matched controls. Spectral domain OCT, OCTA, and laser flare-cell meter were performed.

Results: Compared to eyes without retinopathy, eyes with retinopathy had higher flare intensity (p = 0.024), enlarged capillary nonperfusion area (p < 0.001), and enlarged foveal avascular zone (p < 0.001). There was a significant correlation between flare intensity and capillary nonperfusion areas (p < 0.001, r = 0.511) and superficial capillary density (p = 0.005, r = -0.388) in diabetic eyes with retinopathy.

Conclusion: The results demonstrated a positive correlation between aqueous flare levels, an indicator of intraocular inflammation, and microvascular damage demonstrated by OCTA in the early stages of diabetic retinopathy (DR). This finding supports the role of inflammation in the pathogenesis of DR.
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http://dx.doi.org/10.1159/000507089DOI Listing
March 2020

ADVERSE EVENTS OF THE ARGUS II RETINAL PROSTHESIS: Incidence, Causes, and Best Practices for Managing and Preventing Conjunctival Erosion.

Retina 2020 Feb;40(2):303-311

Department of Ophthalmology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

Purpose: To analyze and provide an overview of the incidence, management, and prevention of conjunctival erosion in Argus II clinical trial subjects and postapproval patients.

Methods: This retrospective analysis followed the results of 274 patients treated with the Argus II Retinal Prosthesis System between June 2007 and November 2017, including 30 subjects from the US and European clinical trials, and 244 patients in the postapproval phase. Results were gathered for incidence of a serious adverse event, incidence of conjunctival erosion, occurrence sites, rates of erosion, and erosion timing.

Results: Overall, 60% of subjects in the clinical trial subjects versus 83% of patients in the postapproval phase did not experience device- or surgery-related serious adverse events. In the postapproval phase, conjunctival erosion had an incidence rate of 6.2% over 5 years and 11 months. In 55% of conjunctival erosion cases, erosion occurred in the inferotemporal quadrant, 25% in the superotemporal quadrant, and 20% in both. Sixty percent of the erosion events occurred in the first 15 months after implantation, and 85% within the first 2.5 years.

Conclusion: Reducing occurrence of conjunctival erosion in patients with the Argus II Retinal Prosthesis requires identification and minimization of risk factors before and during implantation. Implementing inverted sutures at the implant tabs, use of graft material at these locations as well as Mersilene rather than nylon sutures, and accurate Tenon's and conjunctiva closure are recommended for consideration in all patients.
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http://dx.doi.org/10.1097/IAE.0000000000002394DOI Listing
February 2020

Management of retinitis pigmentosa by Wharton's jelly derived mesenchymal stem cells: preliminary clinical results.

Stem Cell Res Ther 2020 01 13;11(1):25. Epub 2020 Jan 13.

Ankara University Technopolis, Neorama Ofis 55-56 Yaşam Cad, No 13/A Beştepe /Yenimahalle, Ankara, Turkey.

Purpose: The aim of this study is to determine if umbilical cord Wharton's jelly derived mesenchymal stem cells implanted in sub-tenon space have beneficial effects on visual functions in retinitis pigmentosa patients by reactivating the degenerated photoreceptors in dormant phase.

Material And Methods: This prospective, open-label, phase-3 clinical trial was conducted between April of 2019 and October of 2019 at Ankara University Faculty of Medicine, Department of Ophthalmology. 32 RP patients (34 eyes) were included in the study. The patients were followed for 6 months after the Wharton's jelly derived mesenchymal stem cell administration, and evaluated with consecutive examinations. All patients underwent a complete routine ophthalmic examination, and best corrected visual acuity, optical coherens tomography angiography, visual field, multifocal and full-field electroretinography were performed. The quantitative results were obtained from a comparison of the pre-injection and final examination (6th month) values.

Results: The mean best corrected visual acuity was 70.5 letters prior to Wharton's jelly derived mesenchymal stem cell application and 80.6 letters at the 6th month (p = 0.01). The mean visual field median deviation value was 27.3 dB before the treatment and 24.7 dB at the 6th month (p = 0.01). The mean outer retinal thickness was 100.3 μm before the treatment and 119.1 μm at 6th month (p = 0.01). In the multifocal electroretinography results, P1 amplitudes improved in ring1 from 24.8 to 39.8 nv/deg2 (p = 0.01), in ring2 from 6.8 to 13.6 nv/deg2 (p = 0.01), and in ring3 from 3.1 to 5.7 nv/deg2 (p = 0.02). P1 implicit times improved in ring1 from 44.2 to 32.4 ms (p = 0.01), in ring2 from 45.2 to 33.2 ms (p = 0.02), and in ring3 from 41.9 to 32.4 ms (p = 0.01). The mean amplitude improved in 16 Tds from 2.4 to 5.0 nv/deg2 (p = 0.01) and in 32 Tds from 2.4 to 4.8 nv/deg2 (p = 0.01) in the full-field flicker electroretinography results. Full field flicker electroretinography mean implicit time also improved in 16 Tds from 43.3 to 37.9 ms (p = 0.01). No ocular or systemic adverse events related to the two types of surgical methods and/or Wharton's jelly derived mesenchymal stem cells itself were observed during the follow-up period.

Conclusion: RP is a genetic disorder that can result in blindness with outer retinal degeneration. Regardless of the type of genetic mutation, sub-tenon Wharton's jelly derived mesenchymal stem cell administration appears to be an effective and safe option. There are no serious adverse events or ophthalmic / systemic side effects for 6 months follow-up. Although the long-term adverse effects are still unknown, as an extraocular approach, subtenon implantation of the stem cells seems to be a reasonable way to avoid the devastating side effects of intravitreal/submacular injection. Further studies that include long-term follow-up are needed to determine the duration of efficacy and the frequency of application.

Trial Registration: SHGM56733164. Redistered 28 January 2019 https://shgm.saglik.gov.tr/organ-ve-doku-nakli-koordinatorlugu/56733164/203 E.507.
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http://dx.doi.org/10.1186/s13287-020-1549-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6958670PMC
January 2020

Evaluation of the choroidal features in pachychoroid spectrum diseases by optical coherence tomography and optical coherence tomography angiography.

Eur J Ophthalmol 2021 Jan 4;31(1):184-193. Epub 2019 Nov 4.

Vehbi Koç Eye Hospital and Department of Ophthalmology, Faculty of Medicine, Ankara University, Ankara, Turkey.

Purpose: To evaluate choroidal area, stroma/lumen ratio, choriocapillaris vessel density, and choriocapillaris flow area in eyes with central serous chorioretinopathy, uncomplicated pachychoroid, and pachychoroid pigment epitheliopathy using enhanced depth imaging-optical coherence tomography and optical coherence tomography angiography.

Materials And Methods: This retrospective study analyzed enhanced depth imaging-optical coherence tomography and optical coherence tomography angiography scans of 142 eyes of 92 patients with central serous chorioretinopathy, uncomplicated pachychoroid, and pachychoroid pigment epitheliopathy. The choroidal area and stroma/lumen ratio were measured by binarization of enhanced depth imaging-optical coherence tomography images. Choriocapillaris vessel density and choriocapillaris flow area were measured at the choriocapillaris level by manual segmentation of optical coherence tomography angiography scans.

Results: The mean stroma/lumen ratio results were 0.361, 0.345, and 0.354 in central serous chorioretinopathy, uncomplicated pachychoroid, and pachychoroid pigment epitheliopathy groups, respectively ( > 0.05). The mean whole image choriocapillaris vessel density in uncomplicated pachychoroid group was higher compared with central serous chorioretinopathy and pachychoroid pigment epitheliopathy groups ( < 0.0001). The mean foveal, parafoveal, and perifoveal choriocapillaris vessel densities were lower in central serous chorioretinopathy group than in uncomplicated pachychoroid group ( < 0.0001). The mean choriocapillaris flow area was lower in central serous chorioretinopathy group than in uncomplicated pachychoroid and pachychoroid pigment epitheliopathy groups ( < 0.0001 and  = 0.01, respectively).

Conclusion: Our findings suggest that both choroidal vessels and stroma are equally involved in central serous chorioretinopathy, uncomplicated pachychoroid, and pachychoroid pigment epitheliopathy. The choriocapillaris segment seems to be more affected in central serous chorioretinopathy compared to uncomplicated pachychoroid and pachychoroid pigment epitheliopathy. However, the reduced optical coherence tomography angiography signal in central serous chorioretinopathy group could be due to shadowing artifact or choriocapillaris hypoperfusion and further studies with higher quality imaging tools are needed.
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http://dx.doi.org/10.1177/1120672119887095DOI Listing
January 2021

A Case of Best Disease Accompanied by Pachychoroid Neovasculopathy

Turk J Ophthalmol 2019 09;49(4):226-229

Ankara University Faculty of Medicine, Department of Ophthalmology, Ankara, Turkey

The aim of this case presentation is to describe ocular findings of a 22-year-old patient with Best vitelliform macular dystrophy accompanied by pachychoroid neovasculopathy. Color fundus photography, fundus autofluorescence (FAF), optical coherence tomography (OCT), and optical coherence tomography angiography (OCTA) images were reviewed. Funduscopic examination showed bilateral yellowish vitelliform-like submacular deposits. FAF revealed these deposits as hyperautofluorescent spots. OCT showed flat irregular pigment epithelial detachments corresponding to these submacular deposits. OCT showed choroidal thickening and dilatation of the large outer oval choroidal vessels. Fundus fluorescein angiography could not be performed because the patient was pregnant. En face OCTA images of the choriocapillaris illustrated the choroidal neovascular network. In this case report, we describe for the first time the coexistence of Best vitelliform macular dystrophy and pachychoroid neovasculopathy with OCTA images enabling visualization of the neovascular network in a patient with contraindication for fluorescein angiography.
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http://dx.doi.org/10.4274/tjo.galenos.2019.38073DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6761379PMC
September 2019

Retinal Prostheses and Artificial Vision

Turk J Ophthalmol 2019 09;49(4):213-219

Bio-Retina Eye Clinic, Ankara, Turkey

In outer retinal degenerative diseases such as retinitis pigmentosa, choroideremia, and geographic atrophy, 30% of the ganglion cell layer in the macula remains intact. With subretinal and epiretinal prostheses, these inner retinal cells are stimulated with controlled electrical current by either a microphotodiode placed in the subretinal area or a microelectrode array tacked to the epiretinal region. As the patient learns to interpret the resulting phosphene patterns created in the brain through special rehabilitation exercises, their orientation, mobility, and quality of life increase. Implants that stimulate the lateral geniculate nucleus or visual cortex are currently being studied for diseases in which the ganglion cells and optic nerve are completely destroyed.
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http://dx.doi.org/10.4274/tjo.galenos.2019.44270DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6761377PMC
September 2019

Management of Deep Retinal Capillary Ischemia by Electromagnetic Stimulation and Platelet-Rich Plasma: Preliminary Clinical Results.

Adv Ther 2019 09 5;36(9):2273-2286. Epub 2019 Aug 5.

Ankara University Technopolis, Ankara, Turkey.

Introduction: To investigate the efficacy of retinal electromagnetic stimulation and sub-tenon autologous platelet-rich plasma in the treatment of deep retinal capillary ischemia.

Methods: The study included 28 eyes of 17 patients aged 15-76 years (mean 37.9 years) who had deep retinal capillary ischemia. Patients who had acute-onset paracentral scotoma in the last 1 month were included in the study between January 2018 and January 2019. The diagnosis of deep retinal capillary ischemia was based on clinical history and typical findings of optical coherence tomography angiography. The eyes were divided into three groups: group 1 (n = 7 eyes) received electromagnetic stimulation alone; group 2 (n = 7 eyes) received electromagnetic stimulation and sub-tenon autologous platelet-rich plasma injection; group 3 had no intervention and served as a control group (n = 14 eyes). The patients underwent ten sessions of electromagnetic stimulation in groups 1 and 2. Sub-tenon autologous platelet-rich plasma injection was performed immediately after the first, fifth, and tenth sessions of electromagnetic stimulation in group 2. The deep retinal capillary density and best corrected visual acuity changes were investigated before and after treatment at the first month.

Results: The mean deep retinal capillary density was 52.0% before electromagnetic stimulation and 56.1% after ten sessions of application in group 1; this improvement was statistically significant (p = 0.01). In the combined treatment group (group 2), the mean deep retinal capillary density was 46.9% before the treatment and 56.5% after the treatment; this increase was also statistically significant (p = 0.01). Statistically significant best corrected visual acuity improvement (p = 0.01) could be achieved only in group 2. The combined treatment was significantly superior (p < 0.01) to treatment with only electromagnetic stimulation regarding best corrected visual acuity and deep retinal capillary density. In the control group (group 3), there was no statistically significant change (p = 0.09) in the mean deep retinal capillary density and best corrected visual acuity.

Conclusion: Treatment of the underlying cause is a priority in the treatment of deep retinal capillary ischemia. However, in the acute period, local ischemia treatment is necessary to prevent permanent retinal damage and scotomas. In mild cases, only electromagnetic stimulation, which is non-invasive and easy to use, might have a beneficial effect on deep retinal capillary density. In more severe cases, sub-tenon fresh autologous platelet-rich plasma injection together with electromagnetic stimulation may be more effective in the treatment of local ischemia of the retina in order to augment the response.

Funding: The Rapid Service Fees were funded by the Ankara University Tecnopolis Institute.

Clinical Trial Registration: titck.gov.tr identifier, 2018-136.
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http://dx.doi.org/10.1007/s12325-019-01040-2DOI Listing
September 2019

Comparison of United States and International Ophthalmic Drug Pricing.

Ophthalmology 2019 10 27;126(10):1358-1365. Epub 2019 May 27.

Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Medical Center, New York, New York. Electronic address:

Purpose: To compare United States and international drug pricing for commonly prescribed intravitreal and topical ophthalmic medications.

Design: Cross-sectional observational study.

Methods: For 25 commonly used ophthalmic medications (3 intravitreal, 22 topical), we obtained 2017 third quarter United States average wholesale price (AWP), drug acquisition cost, or consumer pricing through United States government health insurance plans (Veterans Affairs [VA], Medicaid, Medicare Part B, and Medicare Part D) and commercial drug plans (CVS Caremark and Navitus Health Solutions), online pricing without insurance through a large United States warehouse retailer (Costco), and international drug pricing through government-sponsored health plans in Italy, Spain, Turkey, Canada, and Japan.

Main Outcome Measures: Drug acquisition costs and consumer pricing of ophthalmic drugs through various payment systems. All prices were converted to United States dollars.

Results: For intravitreal medications in the United States, aflibercept and ranibizumab were priced similarly to each other and were more expensive than dexamethasone implants. Pricing of aflibercept and ranibizumab through government health insurance plans in Italy, Spain, Turkey, Canada, and Japan were less expensive by as much as 84.3% compared with the United States. For topical medications in the United States, pricing varied significantly both across different classes of medications and also between nonbranded and branded medications. Drug acquisition costs through the VA and Medicaid were inexpensive on average, but pricing through a hospital-employee drug insurance plan offered the smallest range (between $2.35 and $60.00). In all 5 non-United States countries studied, each topical medication with the exceptions of cyclosporine emulsion and difluprednate was less than $100, and 94.4% of topical medications in these countries had a nonbranded or branded option that was less than $50.

Conclusions: In the United States, for topical more than intravitreal medications, significant price variation exists across both different drug pricing systems and different medications. Price differentials between nonbranded and branded medications can be significant. Internationally, topical medications exhibited a more limited and lower price range compared with drug pricing in the United States.
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http://dx.doi.org/10.1016/j.ophtha.2019.04.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6756974PMC
October 2019

Vascular and structural alterations of the choroid evaluated by optical coherence tomography angiography and optical coherence tomography after half-fluence photodynamic therapy in chronic central serous chorioretinopathy.

Graefes Arch Clin Exp Ophthalmol 2019 May 7;257(5):905-912. Epub 2019 Jan 7.

Department of Ophthalmology, Ankara University Faculty of Medicine Ankara, Mamak Street, Dikimevi, Ankara, Turkey.

Purpose: To concurrently evaluate the effect of half-fluence photodynamic therapy (hf PDT) on choriocapillaris (CC) perfusion and choroidal structure in chronic central serous chorioretinopathy (CSC).

Methods: This prospective study included 48 eyes of 41 patients with chronic CSC. Enhanced depth imaging optical coherence tomography and optical coherence tomography angiography (OCTA) images were analyzed. Choroidal area (CA), luminal area (LA), and stromal area (SA) were computed using Image J software.

Results: One month after hf-PDT, total CA decreased to 1.312 mm from 1.490 mm (p < 0.001), LA decreased to 0.981 mm from 1.097 mm (p < 0.001), and SA decreased to 0.331 mm from 0.393 mm (p < 0.001). In OCTA, the CC flow in the eyes with CSC (17.75 mm) was statistically significantly lower than the fellow eyes (18.93 mm) at the baseline visit (p < 0.001). After hf-PDT, the flow in the choriocapillaris statistically significantly increased to 18.81 mm at the first month (p = 0.02).

Conclusions: OCTA proves that after hf-PDT a significant increase in CC perfusion occurred at first month. The decrease of the luminal areas in enhanced depth imaging optical coherence tomography is mainly due to a decrease in large-caliber vessels, which indicates that hf-PDT has an effect on larger choroidal vessels and spares CC flow.
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http://dx.doi.org/10.1007/s00417-018-04226-6DOI Listing
May 2019

Multimodal Imaging in Pachychoroid Neovasculopathy: A Case Report.

Turk J Ophthalmol 2018 Oct 31;48(5):262-266. Epub 2018 Oct 31.

Ankara University Faculty of Medicine, Department of Ophthalmology, Ankara, Turkey.

Pachychoroid neovasculopathy (PNV) is a form of type 1 neovascularization characterized by dilated choroidal vessels in areas of increased choroidal thickness. In this article, we describe a patient diagnosed with PNV. A 50-year-old male with a 2-month history of blurred vision was referred to our clinic. His best corrected visual acuity was 20/100 in both eyes. Retinal pigment epithelium alterations, which were more prominent in fundus autofluorescence, were detected in both eyes on dilated fundus examination. Characteristic findings of PNV were detected in fundus fluorescein angiography, indocyanine green angiography, spectral domain optical coherence tomography, and optical coherence tomography angiography.
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http://dx.doi.org/10.4274/tjo.89166DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6216529PMC
October 2018

Short-term Efficacy of Micropulse Yellow Laser in Non-center-involving Diabetic Macular Edema: Preliminary Results.

Turk J Ophthalmol 2018 Oct 31;48(5):245-249. Epub 2018 Oct 31.

Ankara University Faculty of Medicine, Department of Ophthalmology, Ankara, Turkey.

Objectives: The aim of this study was to evaluate the efficacy of micropulse yellow laser (MPL) on best corrected visual acuity (BCVA) and retinal thickness in patients with non-center-involving diabetic macular edema (DME).

Materials And Methods: We retrospectively reviewed 9 eyes of 8 patients with non-center-involving DME who underwent MPL treatment between January 2015 and December 2016. BCVA (logMAR) and retinal thickness were evaluated before and 3 months after treatment. Maximum retinal thickness was determined manually from simultaneous spectral-domain optical coherence tomography images and recorded. The change in the measurements from before to after treatment was analyzed statistically.

Results: Of the 8 patients, 3 were female and 5 were male. The mean age was 52.8 years. Two of the 9 eyes had received previous intravitreal anti-vascular endothelial growth factor injection(s). Median BCVA was improved 3 months after treatment, although the difference was not statistically significant (0.34 logMAR before and 0.29 logMAR after treatment). BCVA was improved in 4 eyes while it showed no change in the remaining 5 eyes. The mean retinal thickness was 470.6 μm at baseline and 416 μm at 3 months after MPL treatment (p=0.01). Retinal thickness decreased in all eyes after treatment.

Conclusion: In this study, parafoveal retinal thickness showed significant decrease after MPL treatment in patients with DME. The limited increase in BCVA may be due to the inclusion of a low number of patients and only those with non-center-involving macular edema. MPL may be used as an alternative to conventional argon laser in non-center-involving DME.
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http://dx.doi.org/10.4274/tjo.04657DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6216533PMC
October 2018

Role of a mydriasis-free, full-field flicker ERG device in the detection of diabetic retinopathy.

Doc Ophthalmol 2018 12 17;137(3):131-141. Epub 2018 Oct 17.

Department of Ophthalmology, Faculty of Medicine, Vehbi Koç Eye Hospital, Ankara University, Mamak Street, Dikimevi, Ankara, Turkey.

Purpose: To determine if the RETeval system can be used for the screening of diabetic retinopathy (DR) to provide early diagnosis.

Methods: The subjects were 42 diabetic patients selectively recruited by examination of their medical records to have varying severities of DR. The severity of DR was classified into four groups according to the International Clinical Diabetic Retinopathy Disease Severity Scale. Full-field electroretinograms (ERG) without mydriasis were obtained by the DR assessment protocol of the RETeval system. Macular retinal nerve fiber layer (RNFL) thickness was measured by optical coherence tomography. We compared the DR assessment protocol results and the macular RNFL thickness among four groups. Moreover, an analysis was conducted on whether there was any correlation among the DR assessment protocol results, duration of diabetes mellitus, and RNFL thickness individually for each group of patients.

Results: The mean ages and mean duration of diabetes mellitus of the four groups were similar. The DR assessment protocol results in the moderate-severe nonproliferative DR, and proliferative DR groups were significantly higher than those in the other groups (p < 0.001). The mean macular RNFL thickness was similar in all groups. No significant correlation was found between the DR assessment protocol results and duration of DM and the RNFL thickness.

Conclusions: Our results suggest that the RETeval full-field ERG system can be used as an adjunctive tool for the mass screening of DR, while macular RNFL thickness would not be useful.
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http://dx.doi.org/10.1007/s10633-018-9656-8DOI Listing
December 2018

SPONTANEOUS CLOSURE OF MACULAR HOLE IN A PATIENT WITH MACULAR TELANGIECTASIA TYPE 2.

Retin Cases Brief Rep 2018 Aug 9. Epub 2018 Aug 9.

Department of Ophthalmology, Ankara University Faculty of Medicine, Ankara, Turkey.

Purpose: To present a case of macular hole associated with macular telangiectasia Type 2 (Mac-Tel 2) which underwent spontaneous closure.

Methods: A 58-year-old woman is admitted with complaints of blurred and distorted vision. Optical coherence tomography, fundus autofluorescence, and optical coherence tomography angiography were performed for diagnosis and follow-up.

Results: Optical coherence tomography revealed hyporeflective cavitations in both eyes, and full-thickness macular hole covered with internal limiting membrane drape in the left eye. Fundus autofluorescence showed loss of hypoautofluorescence in temporal parafoveal area in the right eye, and centrally in the left one. Vascular irregularities were detected in optical coherence tomography angiography images. The patient was diagnosed as Mac-Tel 2. During the follow-up, the macular hole underwent a process of spontaneous closure, starting as bridging at the level of external limiting membrane and outer nuclear layer followed by further repairment and organization of the outer plexiform layer, accompanied with visual gain.

Conclusion: Spontaneous closure of macular hole in patients with Mac-Tel 2 is a rare entity. We hypothesize that extension or proliferation of Muller cells, which leads to reconstruction of normal foveal structure, is the main mechanism for this phenomenon.
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http://dx.doi.org/10.1097/ICB.0000000000000812DOI Listing
August 2018

Optical coherence tomography angiography in pachychoroid spectrum diseases.

Graefes Arch Clin Exp Ophthalmol 2018 08 1;256(8):1559-1560. Epub 2018 Jun 1.

Department of Ophthalmology, Ankara University Faculty of Medicine, Mamak Street, Dikimevi, Ankara, Turkey.

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http://dx.doi.org/10.1007/s00417-018-4019-4DOI Listing
August 2018

Effects of subtenon-injected autologous platelet-rich plasma on visual functions in eyes with retinitis pigmentosa: preliminary clinical results.

Graefes Arch Clin Exp Ophthalmol 2018 May 15;256(5):893-908. Epub 2018 Mar 15.

Faculty of Medicine, Department of Ophthalmology, Ankara University, Ankara, Turkey.

Purpose: One of the main reasons for apoptosis and dormant cell phases in degenerative retinal diseases such as retinitis pigmentosa (RP) is growth factor withdrawal in the cellular microenvironment. Growth factors and neurotrophins can significantly slow down retinal degeneration and cell death in animal models. One possible source of autologous growth factors is platelet-rich plasma. The purpose of this study was to determine if subtenon injections of autologous platelet-rich plasma (aPRP) can have beneficial effects on visual function in RP patients by reactivating dormant photoreceptors.

Material And Methods: This prospective open-label clinical trial, conducted between September 2016 and February 2017, involved 71 eyes belonging to 48 RP patients with various degrees of narrowed visual field. Forty-nine eyes belonging to 37 patients were injected with aPRP. A comparison group was made up of 11 patients who had symmetrical bilateral narrowed visual field (VF) of both eyes. Among these 11 patients, one eye was injected with aPRP, while the other eye was injected with autologous platelet-poor plasma (aPPP) to serve as a control. The total duration of the study was 9 weeks: the aPRP or aPPP subtenon injections were applied three times, with 3-week intervals between injections, and the patients were followed for three more weeks after the third injection. Visual acuity (VA) tests were conducted on all patients, and VF, microperimetry (MP), and multifocal electroretinography (mfERG) tests were conducted on suitable patients to evaluate the visual function changes before and after the aPRP or aPPP injections.

Results: The best-corrected visual acuity values in the ETDRS chart improved by 11.6 letters (from 70 to 81.6 letters) in 19 of 48 eyes following aPRP application; this result, however, was not statistically significant (p = 0.056). Following aPRP injections in 48 eyes, the mean deviation of the VF values improved from - 25.3 to - 23.1 dB (p = 0.0001). Results regarding the mfERG P1 amplitudes improved in ring 1 from 24.4 to 38.5 nv/deg (p = 0.0001), in ring 2 from 6.7 to 9.3 nv/deg (p = 0.0301), and in ring 3 from 3.5 to 4.5 nv/deg (p = 0.0329). The mfERG P1 implicit times improved in ring 1 from 40.0 to 34.4 ms (p = 0.01), in ring 2 from 42.5 to 33.2 ms (p = 0.01), and in ring 3 from 42.1 to 37.9 ms (p = 0.04). The mfERG N1 amplitudes improved in ring 1 from 0.18 to 0.25 nv/deg (p = 0.011) and in ring 2 from 0.05 to 0.08 nv/deg (p = 0.014). The mfERG N1 implicit time also improved in ring 1 from 18.9 to 16.2 ms (p = 0.040) and in ring 2 from 20.9 to 15.5 ms (p = 0.002). No improvement was seen in the 11 control eyes into which aPPP was injected. In the 23 RP patients with macular involvement, the MP average threshold values improved with aPRP injections from 15.0 to 16.4 dB (p = 0.0001). No ocular or systemic adverse events related to the injections or aPRP were observed during the follow-up period.

Conclusion: Preliminary clinical results are encouraging in terms of statistically significant improvements in VF, mfERG values, and MP. The subtenon injection of aPRP seems to be a therapeutic option for treatment and might lead to positive results in the vision of RP patients. Long-term results regarding adverse events are unknown. There have not been any serious adverse events and any ophthalmic or systemic side effects for 1 year follow-up. Further studies with long-term follow-up are needed to determine the duration of efficacy and the frequency of application.
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http://dx.doi.org/10.1007/s00417-018-3953-5DOI Listing
May 2018