Publications by authors named "Sibel Demirel"

55 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

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

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

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

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

Culture-Proven Endogenous Endophthalmitis in a Patient with Onychomycosis.

Ocul Immunol Inflamm 2020 22;28(2):178-181. Epub 2019 Feb 22.

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

: To report a case of endogenous endophthalmitis in an immunocompetent patient with onychomycosis.: Retrospective case report.: A 40-year-old man with onychomycosis presented with subretinal abscess in the left eye. Systemic and intravitreal injections did not prevent further progression of the infection. The patient underwent pars plana vitrectomy. One month after surgery, the intraocular inflammation gradually subsided. However, his visual acuity stayed at counting fingers as a result of macular scarring.: The aim of this case presentation is to emphasize that endogenous fungal endophthalmitis can be seen in an immunocompetent patient. The use of systemic steroids in the past was the main reason for the progression of the disease in this case. In these situations, when the clinical findings suggest a fungal etiology, it should keep in mind that endogenous candida endophthalmitis can be a result of fungal infections from distant sites such as the toenails and systemic steroids should not be started before definite diagnosis.
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http://dx.doi.org/10.1080/09273948.2019.1568503DOI Listing
January 2021

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

The Recovery of Microvascular Status Evaluated by Optical Coherence Tomography Angiography in Patients after Successful Macular Hole Surgery.

Ophthalmic Res 2018 29;59(1):53-57. Epub 2017 Nov 29.

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

Purpose: The aim of this study was to evaluate the optical coherence tomography angiography (OCTA) features of patients who underwent successful macular hole (MH) surgery.

Methods: Nineteen patients who underwent surgery in a single eye due to MH and 13 healthy subjects as a control group were included in the study. Vascular densities, flow indexes, and the foveal avascular zone (FAZ) area in superficial and deep retinal capillary plexuses were evaluated by OCTA in the right eyes of the control group, and both the surgical and healthy fellow eyes of the patients.

Results: The mean vascular densities of the superficial and deep capillary plexuses were significantly lower in the surgical eyes than in the control group (44.1 vs. 49.6%, p = 0.002, and 47.3 vs. 59.1%, p = 0.009, respectively). The mean superficial and deep capillary flow indexes were significantly lower in the surgical eyes than in the control group (0.85 vs. 1.35, p = 0.003, and 0.57 vs. 1.45, p = 0.001, respectively), while the mean superficial and deep FAZ area were significantly greater in the surgical eyes in comparison to the control group (0.55 vs. 0.32, p < 0.001, and 0.64 vs. 0.37, p = 0.001, respectively). There was no difference between the flow indexes of both layers of the healthy fellow eyes and the control group.

Conclusions: These preliminary results may be an explanation for unsatisfactory visual gain after surgery, despite the successful anatomical closure of the MH.
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http://dx.doi.org/10.1159/000484092DOI Listing
March 2018

The Diagnostic Role of Multimodal Imaging Techniques in Isolated Foveal Hypoplasia.

Turk J Ophthalmol 2017 Oct 27;47(5):306-308. Epub 2017 Oct 27.

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

To report a case of bilateral isolated foveal hypoplasia in which multimodal imaging was used to confirm the diagnosis. Fundus autofluorescence imaging, optical coherence tomography (OCT), and fundus fluorescein angiography were used to describe the typical findings of a patient with isolated foveal hypoplasia. Spectral domain OCT showed absence of foveal depression and persistent inner retinal layers in the fovea. Fundus autofluorescence did not reveal foveal hypoautofluorescence in the presumed foveal area. Clinical diagnosis of foveal hypoplasia may be difficult due to the subtle nature of fundus findings. Fundus autofluorescence imaging may help to diagnose these patients. Foveal hypoplasia should be considered in the differential diagnosis of absence of foveal hypoautofluorescence.
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http://dx.doi.org/10.4274/tjo.43799DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5661184PMC
October 2017

Optical Coherence Tomography Angiography Findings in Type-2 Macular Telangiectasia.

Turk J Ophthalmol 2017 10 27;47(5):279-284. Epub 2017 Oct 27.

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

Objectives: To evaluate the vascular changes of idiopathic macular telangiectasia type 2 (MacTel 2) patients with optical coherence tomography angiography (OCTA) and correlate these changes with the findings of spectral domain optical coherence tomography (SD-OCT).

Materials And Methods: Simultaneous SD-OCT and OCTA images of 10 eyes of 6 patients who were diagnosed as MacTel 2 in Ankara University Faculty of Medicine, Department of Ophthalmology were obtained and graded according to the OCTA grading system for MacTel 2.

Results: Ten eyes of 6 patients were included. Four (66%) patients were female and 2 (34%) were male. The disease was grade 0 in 2 eyes, grade 1 in 2 eyes, grade 2 in 3 eyes, grade 3 in 1 eye, grade 4 in 1 eye, and grade 5 in 1 eye. The most common findings in grade 1, 2, and 3 non-proliferative disease were thinning of the outer retinal layers, presence of intraretinal hyporeflective layers and inner limiting membrane draping. In cases with subretinal choroidal neovascularisation (CNV) in OCTA, CNV or CNV scar was present in the B-scan SD-OCT images. In a case in which OCT was within normal limits, vascular changes consistent with grade 1 disease were observed in OCTA. On the contrary, 2 patients with significant foveal atrophy and macular hole in B-scan showed changes of early disease in OCTA. In some of the eyes, OCTA revealed an intact superficial vascular layer despite visible changes in the deep layer and the presence of neovascularisation.

Conclusion: OCTA yields findings which are important for understanding the pathogenesis of the disease and providing better follow-up. Contrary to fundus fluorescein angiography, changes in the deep arterial plexus in the early disease and CNV can be clearly observed with OCTA. To achieve the best results in clinical practice, en face flow maps should be evaluated together with B-scan SD-OCT images.
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http://dx.doi.org/10.4274/tjo.68335DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5661178PMC
October 2017

The use of optical coherence tomography angiography in pachychoroid spectrum diseases: a concurrent comparison with dye angiography.

Graefes Arch Clin Exp Ophthalmol 2017 Dec 11;255(12):2317-2324. Epub 2017 Sep 11.

Department of Ophthalmology, Ankara University Faculty of Medicine, Vehbi Koç Göz Hastanesi, Mamak Caddesi, Dikimevi, Ankara, Turkey.

Purpose: The study objective was to compare dye angiography and optical coherence tomography angiography (OCTA) in detecting choroidal neovascuarization (CNV) in patients presenting with pachychoroid features and flat irregular pigment epithelial detachment (PED).

Methods: Nineteen eyes of 17 patients, presenting with flat PED and pachychoroid features, and without age-related macular degeneration or any other degenerative change, were analyzed. Fuorescein angiography (FA)/Indocyanine green angiography (ICGA) and OCTA were performed during the same visit. Subfoveal choroidal thickness was measured by enhanced depth imaging using spectral domain optical coherence tomography.

Results: The mean age of the patients was 59.1 years. Mean subfoveal choroidal thickness was 388 μm. FA revealed non-patognomic features including RPE alterations, window defects, leaking points and leakage from an undetermined source. ICGA revealed choroidal vascular plaque in eight eyes (42%) and suspicious plaque in five eyes (26%). Nonneovascular features, such as hyperpermeability or dilated choroidal vessels, were observed in six eyes (32%). OCTA showed choroidal neovascularization in 14 (74%). For all of the eyes, which ICGA was positive for presence of CNV, OCTA also showed CNV, and in one case it also revealed polypoidal characteristics of the neovascular network. OCTA was also able to detect CNV in all of the eyes with suspicious plaque, and in one eye without CNV appearance using ICGA.

Conclusions: OCTA demonstrated greater sensitivity in detecting type 1 CNV than conventional dye angiography in cases with pachychoroid spectrum disease.
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http://dx.doi.org/10.1007/s00417-017-3793-8DOI Listing
December 2017

Evaluation of Ganglion Cell-Inner Plexiform Layer Thickness after Vitreoretinal Surgery with Internal Limiting Membrane Peeling in Cases with Idiopathic Macular Hole.

Turk J Ophthalmol 2017 Jun 1;47(3):138-143. Epub 2017 Jun 1.

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

Objectives: To evaluate macular retinal ganglion cell-inner plexiform layer (GCIPL) thickness after vitrectomy with internal limiting membrane (ILM) peeling for idiopathic macular holes using spectral domain optical coherence tomography (SD-OCT).

Materials And Methods: Eighteen eyes of 18 patients with unilateral idiopathic macular hole who underwent vitrectomy with ILM peeling were retrospectively analyzed. Healthy fellow eyes of the patients and 18 eyes of 18 age-matched healthy individuals constituted the control group. The patients were evaluated at 1 day, 1 week, 1 month, and 3 months after surgery. The best corrected visual acuity (BCVA) measurements, biomicroscopic examination findings and SD-OCT measurements were recorded. Ganglion cell-inner plexiform layer thickness was evaluated with ganglion cell analysis software of Cirrus HD-OCT before surgery and at 1 month and 3 months after surgery and compared with control groups. Presence of dissociated optic nerve fiber layer (DONFL) was evaluated with C-scan mode.

Results: Of the 18 patients, 9 were male and 9 were female with a mean age of 65.6±5.6 (55-77) years. Preoperative BCVA was 0.75±0.19 logMAR, while it was 0.44±0.17 logMAR and 0.36±0.15 logMAR at postoperative 1 and 3 months, respectively (p<0.001). Postoperative mean GCIPL thickness was 66.33±17.28 µm. There was a correlation between mean GCIPL thickness and BCVA at postoperative 3 months (p<0.01). When compared with the control group, GCIPL thickness was significantly thinner in all quadrants of all patients at postoperative 3 months. Dissociated optic nerve fiber layer appearance was observed on C-scan in 13 of 18 eyes postoperatively. There was no correlation between the presence of DONFL and BCVA (p>0.05).

Conclusion: Internal limiting membrane peeling during macular hole surgery may cause functional and/or structural changes that may be associated with visual acuity. Significant GCIPL thinning and DONLF appearance may occur postoperatively.
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http://dx.doi.org/10.4274/tjo.34545DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5468526PMC
June 2017

REPEATABILITY OF AUTOMATED VESSEL DENSITY AND SUPERFICIAL AND DEEP FOVEAL AVASCULAR ZONE AREA MEASUREMENTS USING OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY: Diurnal Findings.

Retina 2018 Jun;38(6):1238-1245

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

Purpose: To evaluate the repeatability of vessel density and superficial and deep foveal avascular zone measurements using optical coherence tomography angiography, and to specify a diurnal change range.

Methods: Forty-six eyes of 25 healthy individuals were included. Optical coherence tomography angiography measurements were planned for three consecutive sessions, with 3 hours in between them. AngioVue software of the RTVue XR Avanti was used. Superficial and deep retinal layer vessel density values, including the whole retina, fovea, and each parafoveal zone, were obtained from the software. The intraclass correlation, coefficient of variation, and coefficient of repeatability were calculated for each parameter.

Results: The whole image intraclass correlation value was 0.81 for the superficial and 0.86 for the deep layer among the three consecutive sessions. The smallest real difference (coefficient of repeatability) value of whole image measurements was 7.72% for the superficial and 9.84% for the deep retinal layer. Foveal avascular zone area intraclass correlation value was 0.97 for the superficial and 0.83 for the deep retinal layer.

Conclusion: The optical coherence tomography angiography analysis provides quantitative data about the retinal microvasculature, which could be used to distinguish between normal and pathology. Changes in superficial vessel density >8% and deep vessel density >10% may be considered as real clinical change rather than variation.
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http://dx.doi.org/10.1097/IAE.0000000000001671DOI Listing
June 2018

Endoscope-Assisted and Controlled Argus II Epiretinal Prosthesis Implantation in Late-Stage Retinitis Pigmentosa: A Report of 2 Cases.

Case Rep Ophthalmol 2016 Sep-Dec;7(3):315-324. Epub 2016 Dec 28.

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

Several different approaches for restoring sight in subjects who are blind due to outer retinal degeneration are currently under investigation, including stem cell therapy, gene therapy, and visual prostheses. Although many different types of visual prostheses have shown promise, to date, the Argus II Epiretinal Prosthesis System, developed in a clinical setting over the course of 10 years, is the world's first and only retinal prosthesis that has been approved by the United States Food and Drug Administration (FDA) and has been given the CE-Mark for sale within the European Economic Area (EEA). The incidence of serious adverse events from Argus II implantation decreased over time after minor changes in the implant design and improvements in the surgical steps used for the procedure had been made. In order to further decrease the scleral incision-related complications and enhance the assessment of the tack position and the contact between the array and the inner macular surface, we used an ophthalmic endoscope during the regular course of Argus II implantation surgery in 2 patients with late-stage retinitis pigmentosa in an attempt to improve the anatomical and functional outcomes.
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http://dx.doi.org/10.1159/000453606DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5260530PMC
December 2016

Low-Fluence Photodynamic Therapy versus Subthreshold Micropulse Yellow Wavelength Laser in the Treatment of Chronic Central Serous Chorioretinopathy.

J Ophthalmol 2016 15;2016:3513794. Epub 2016 Aug 15.

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

Purpose. To compare the efficacy and safety of subthreshold micropulse yellow wavelength laser (SMYL) and low-fluence photodynamic therapy (PDT) in the treatment of chronic central serous chorioretinopathy (CSC). Methods. Thirty-three eyes of 30 patients with chronic CSC received either PDT (18 eyes) or SMYL (15 eyes) therapy. Best corrected visual acuity (BCVA), subretinal fluid (SRF) height, and central macular thickness (CMT) were evaluated at the baseline visit and one, three, six, nine, and 12 months after the therapy. Results. After 12 months, mean BCVA improved from 67.3 ± 14.2 to 71.5 ± 21.4 ETDRS letters in SMYL group and from 60.7 ± 16.3 to 64.4 ± 24.9 ETDRS letters in PDT group (p = 0.285 and p = 0.440, resp.). Mean CMT decreased from 242.8 ± 80 μm to 156.9 ± 60 μm in the PDT group and from 287.3 ± 126 μm to 138.0 ± 40 μm in the SMYL group (p = 0.098 and p = 0.003, resp.). SRF resolved completely in 72.2% and 80.0% of the eyes in the PDT and SMYL groups, respectively. Mean SRF height decreased from 117.2 ± 58 μm to 31.3 ± 56 μm in the PDT group and from 130.0 ± 104 μm to 12.5 ± 21 μm in the SMYL group (p = 0.031 and p = 0.014, resp.). Conclusions. Subthreshold micropulse yellow wavelength laser seems to be effective in the treatment of chronic CSC without any side effect and results in the resorption of SRF without causing visible retinal scarring.
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http://dx.doi.org/10.1155/2016/3513794DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5002482PMC
September 2016

Is There Any Difference between Ranibizumab and Aflibercept Injections in Terms of Inflammation Measured with Anterior Chamber Flare Levels in Age-Related Macular Degeneration Patients: A Comparative Study.

Ophthalmic Res 2016 31;56(1):35-40. Epub 2016 Mar 31.

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

Purpose: To evaluate the inflammatory reaction to intravitreal aflibercept (IVA) or ranibizumab (IVR) in patients with age-related macular degeneration (AMD).

Methods: A total of 60 eyes of 60 neovascular AMD patients and 30 eyes of 30 age-matched healthy people as a control group were included in this observational, prospective, comparative study. The AMD patients received 1:1 either IVA or IVR. Anterior chamber flare was measured with the Kowa FM-600 laser flare meter (Kowa Company, Ltd., Tokyo, Japan) at days 0, 1, and 30. The mean flare value and standard deviation are expressed as photon counts per millisecond.

Results: There were 51 (56.7%) men and 39 (43.3%) women, with a mean age of 72.7 ± 7.5 years. Mean aqueous flare values at baseline, day 1 and day 30 were 7.08 ± 2.44, 7.23 ± 2.56, and 6.99 ± 2.29, respectively, for the IVR group, 6.87 ± 3.18, 6.86 ± 3.19, and 6.53 ± 2.79, respectively, for the IVA group, and 6.4 ± 3.29, 6.41 ± 3.06, and 6.42 ± 3.05, respectively, for the control group. There was no statistically significant difference in terms of baseline flare values for these three groups (p = 0.666). At the 1-day follow-up, a slight but not significant increase in flare was observed in the ranibizumab group. However, there was no significant change in aqueous flare values in either the ranibizumab- or the aflibercept-injected patients (p = 0.768 and p = 0.387, respectively) or between the groups (p = 0.635). No significant clinical inflammatory reactions were noted before or after intravitreal injections of either ranibizumab or aflibercept.

Conclusion: No significant short-term intraocular inflammation was noted in the eyes receiving aflibercept or ranibizumab for the treatment of neovascular AMD. Although aflibercept has more immunogenic properties than ranibizumab, such as having an extra Fc portion and being a larger molecule, it is likely that its more potent anti-inflammatory effects prevent it from inducing inflammation.
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http://dx.doi.org/10.1159/000444497DOI Listing
January 2017

Updates on the Clinical Trials in Diabetic Macular Edema.

Middle East Afr J Ophthalmol 2016 Jan-Mar;23(1):3-12

University of Nebraska Medical Center, Stanley M. Truhlsen Eye Institute, Omaha, Nebraska, USA.

In this era of evidence-based medicine, significant progress has been made in the field of pharmacotherapeutics for the management of diabetic macular edema (DME). A. number of landmark clinical trials have provided strong evidence of the safety and efficacy of agents such as anti-vascular endothelial growth factors for the treatment of DME. Decades of clinical research, ranging from the early treatment of diabetic retinopathy study to the present-day randomized clinical trials (RCTs) testing novel agents, have shifted the goal of therapy from preventing vision loss to ensuring a maximum visual gain. Systematic study designs have provided robust data with an attempt to optimize the treatment regimens including the choice of the agent and timing of therapy. However, due to a number of challenges in the management of DME with approved agents, further studies are needed. For the purpose of this review, an extensive database search in English language was performed to identify prospective, RCTs testing pharmacological agents for DME. In order to acquaint the reader with the most relevant data from these clinical trials, this review focuses on pharmacological agents that are currently approved or have widespread applications in the management of DME. An update on clinical trials presently underway for DME has also been provided.
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http://dx.doi.org/10.4103/0974-9233.172293DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4759901PMC
August 2016