Ranibizumab or Aflibercept Monotherapies in Treatment-Naive Eyes with Diabetic Macular Edema: A Head-to-Head Comparison in Real-Life Experience

Objectives

To compare the functional and anatomical outcomes of ranibizumab and aflibercept monotherapies given according to a pro re nata (PRN) protocol in treatment-naive eyes with diabetic macular edema (DME) in a real-life clinical setting.

Materials and Methods

The medical charts of treatment-naive patients with center-involved DME retrieved from our institutional database were reviewed in this retrospective cohort study. A total of 512 treatment-naive eyes with DME underwent either ranibizumab (Group I; 308 eyes) or aflibercept (Group II; 204 eyes) monotherapy and 462 patients were included. The primary outcome was visual gain over 12 months.

Results

The mean number of intravitreal injections within the first year was 4.34±1.83 and 4.39±2.12 in Group I and II, respectively (p=0.260). The mean best corrected visual acuity (BCVA) improvement at 12 months was +5.7 and +6.5 ETDRS letters in Group I and II, respectively (p=0.321). However, among eyes with a BCVA score less than 69 ETDRS letters (54% of the study population), visual gain was more prominent in Group II (+15.2 vs. +12.1 ETDRS letters; p<0.001). Statistically significant decreases in central foveal thickness were observed with both ranibizumab and aflibercept monotherapy (p<0.001), with no significant difference between the groups. (p=0.148).

Conclusions

No statistically significant difference was found in visual outcomes at 12-month follow-up between ranibizumab and aflibercept monotherapies using a PRN protocol, although there was a tendency toward slightly better functional and anatomic prognosis in the aflibercept arm.

Is Bone Grafting Unnecessary in the Treatment of Cystic Scaphoid Pseudoarthrosis?

PURPOSE OF THE STUDY

The basic aim of the treatment of cystic nonunion is to provide stable fi xation and mechanical compression to increase union, but there is no consensus on whether to perform bone grafting in the cystic area or not. The aim of this study was to compare the clinical and radiological results of patients with cystic scaphoid non-union who received open grafting, and internal fi xation and those treated with percutaneous fi xation without grafting. MATERIAL AND METHODS A retrospective evaluation was made of patients included those determined radiologically with Slade and Dodds grade IV scaphoid cystic non-union. Two different surgical procedures were performed. Percutaneous screw fi xation was carried out on the patients in group 1. Open curettage-grafting and screw fi xation were performed on the patients in group 2. Group 1 was comprised of 16 patients treated with percutaneous screw fi xation, and group 2 was comprised of 17 patients who had open curettage-grafting and screw fi xation. RESULTS In the radiological evaluation at the fi nal follow-up examination, union was determined in 12 of the 16 (75%) patients in group 1 and 15 of the 17 (88%) patients in group 2. There was no statistically signifi cant difference between the two groups in terms of union, functional outcomes and complication rates. DISCUSSION In the current study, the union rate was higher in the patients who had open curettage-grafting and fi xation with a headless screw (88%) than in those with percutaneous screw without grafting (75%), but the difference was not determined to be statistically signifi cant. The union rate of the group that received grafting was similar to the rates reported in the literature. CONCLUSIONS We think that both of these techniques may be successfully used for cystic scaphoid nonunions but percutaneous technique should be preferred as it is minimally invasive. Nevertheless, there is a need for further prospective, randomised studies with larger series to have better comparisons.

KEY WORDS

scaphoid bone, nonunion, fracture fi xation, internal, bone grafting, bone screws.

Optic neuritis in CD59 deficiency: an extremely rare presentation

BACKGROUND

CD59 is the principal cell inhibitor of complement membrane attack on cells. Stroke, peripheral neuropathy, and recurrent central nervous system attacks have been reported in patients with inherited CD59 deficiency. In this paper, we report a patient with CD59 deficiency associated with two attacks of demyelinating peripheral neuropathy and the third attack as an isolated optic neuritis.

CASE

An 8-month-old girl whose sibling died at 12th month of age with recurrent weakness episodes responsive to intravenous immune globulin treatment, presented with weakness in legs and poor sucking. Weakness episodes with neurogenic electromyography suggested CD59 deficiency. Immunophenotypic analysis with flow cytometry showed CD59 deficiency. Sanger sequencing of CD59 gene revealed a homozygous c146delA (p.Asp49Valfs*32) mutation. First two attacks were treated with intravenous immunoglobulin therapy without any sequalae. Third attack was an isolated optic neuritis which could not be explained by any other entity. The patient had no response to intravenous immunoglobulin but benefited from pulse steroid therapy. Eculizumab was started every two weeks in order to prevent possible advanced attacks and to reduce their severity.

CONCLUSION

Although it is a rarely reported disease, better recognition of CD59 deficiency by pediatric neurologists is necessary because it is curable. In addition to different presentations reported, optic neuritis may also be a manifestation of CD59 deficiency.

Lipemia Retinalis Diagnosed Incidentally After Laser Photocoagulation Treatment for Retinopathy of Prematurity

A preterm infant who underwent bilateral laser photocoagulation for the treatment of stage 3 retinopathy of prematurity (ROP) is presented because she was incidentally diagnosed with grade 3 lipemia retinalis by dilated fundoscopy at post-laser 2 weeks. Meticulous ophthalmologic examination is imperative in premature newborns for not only ROP screening but also detecting any concomitant ocular abnormalities, which can be sight-threatening or even life-threatening.

Non-infectious Intraocular Inflammation Following Intravitreal Anti-Vascular Endothelial Growth Factor Injection

Objectives

To evaluate the functional and anatomical results of patients with non-infectious intraocular inflammation (IOI) following intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection for the treatment of neovascular age-related macular degeneration (nAMD).

Materials and Methods

The medical records of patients receiving anti-VEGF treatment for nAMD between January 2015 and March 2019 were retrospectively analyzed. Preoperative and postoperative routine ophthalmological examinations, central macular thickness, duration of inflammation, and follow-up time of the patients with non-infectious IOI following anti-VEGF injection were recorded.

Results

Non-infectious IOI was determined in 13 eyes (11 eyes with aflibercept, 2 eyes with ranibizumab) of 1,966 patients who received a total of 12,652 anti-VEGF (4,796 aflibercept and 7,856 ranibizumab) injections. IOI was detected after a mean of 7 injections (2-12 injections). All eyes had both anterior chamber reaction (Tyndall +1/+3) and vitritis (grade 1-3). None of the patients had pain, hypopyon, or fibrin reaction. Visual acuity progressed to baseline levels within 28.3 days. Vitritis continued with a mean of 40 days. All patients recovered with topical steroid therapy. In 11 eyes, injection of the same anti-VEGF agent was continued. No recurrence of IOI was observed in any patients.

Conclusion

Non-infectious IOI following intravitreal anti-VEGF injection typically occurs without pain, conjunctival injection, hypopyon, or fibrin and responds well to topical steroid therapy. Visual acuity returns to baseline levels within weeks according to the severity of inflammation.

Demarcation Laser Photocoagulation for Subclinical Retinal Detachment: Can Progression to Retinal Detachment Be Prevented?

Objectives:

To describe results of demarcation laser photocoagulation in preventing progression of subclinical retinal detachment (SCRD).

Materials and Methods:

Twenty-one eyes of 20 patients with SCRD were included. All patients underwent a complete ophthalmological examination, spectral-domain optical coherence tomography, and color fundus photography. Ages at initial diagnosis ranged between 18 and 75 years (mean: 57.3±16.2 years). Patients followed for at least 6 months were included in the study. Periodic retinal examinations were performed over follow-up periods of 6-55 months using Goldmann three-mirror contact lens and sometimes semilunar mirror lens with scleral indentation.

Results:

Twelve patients (60%) were female, eight (40%) were male. The mean follow-up period was 24.3±15.2 months (6-55 months). Three (14.3%) eyes were pseudophakic. One patient was affected bilaterally, with both eyes each containing two separate areas of involvement. The SCRD was in the upper quadrant of 18 eyes (85.7%) and the lower quadrant in 3 eyes (14.3%), and was located in the temporal region 10 eyes (47.6%), the nasal quadrant in 4 eyes (19.1%), and in the upper quadrant (temporal-nasal) in 7 eyes (33.3%). Six eyes (28.6%) were found to have myopia greater than -3.0 diopters. Progression to clinical retinal detachment was observed in 4/21 SCRD eyes (19%). All eyes showing progression to clinical retinal detachment had >-3.0 diopter myopia and multiple retinal tears located in the upper quadrant.

Conclusion:

Demarcation laser photocoagulation should be kept in mind as a first-line treatment for eyes with SCRD. Laser photocoagulation is vital in preventing progression to rhegmatogenous retinal detachment in most patients. After this treatment, these patients should be followed closely.

Rarebit Perimetry in the Evaluation of Visual Field Defects in Idiopathic Intracranial Hypertension

Purpose.

Rarebit perimetry (RBP) is a new perimetric technique that has been reported as a sensitive test for the evaluation of the neural structure of the visual system. The aim of this study was to compare RBP with standard automated perimetry in detecting the visual field defects of patients with idiopathic intracranial hypertension (IIH).

Methods.

Twenty-five patients with IIH and 16 healthy controls were considered. Visual fields were analyzed with Marco automated static perimeter with threshold and central 30–2 programs (MP 30–2) and rarebit perimetry. A visual field was classified into 3 zones for both tests as central, paracentral, and peripheral zones. Mean sensitivity (MS) recorded by the MP 30–2 was compared with the mean hit rate (MHR) recorded by RBP for each zone.

Results.

MS recorded by MP 30–2 and MHR recorded by RBP for each zone were significantly lower in the IIH group than in healthy control eyes (p<0.001). Good correlation was present between the visual fields recorded by both tests. Although the sensitivity and specificity values for each zone were lower in the RBP group than the MP 30–2 group, RBP was found to be efficient to differentiate between the visual fields of normal and IIH-Affected eyes. The average RBP test duration was significantly shorter than the MP 30–2 test duration (p<0.001).

Conclusions.

RBP is a rapid, comfortable, and widely accessible perimetric test giving reliable results in detecting visual field defects in IIH.

Myxosporean parasites of Ceratomyxa merlangi and Myxidium gadi in whiting Merlangius merlangus: a comparative epizootiological analysis based on samples from two localities off southern and northern coasts of the Black Sea

Totally 690 and 423 whiting Merlangius merlangus samples were collected from two localities off Southern (Sinop) and Northern coasts (Balaklava Bay) of the Black Sea, respectively, and examined for myxosporeans in the period from May 2011 to March 2014. Ceratomyxa merlangi and Myxidium gadi were the only myxosporean parasites identified in the content of gall bladder and their infection indices of prevalence (%) and intensity were calculated for length classes and sex of fish as well as for the seasons at both sampling localities. Overall infection prevalence of C. merlangi was 22.6% in Sinop and 27.9% in Balaklava samples while those values of M. gadi were 18.4% and 28.6% in Sinop and Balaklava samples, respectively. Both parasite species were also found to be co-existed in whiting samples. This is the first comprehensive epizootiological study yielded comparable data on C. merlangi and M. gadi infections in whiting in the southern and northern coasts of the Black Sea.

Seasonality and host-parasite interrelationship of Hysterothylacium aduncum (Nematoda) in whiting Merlangius merlangus off the southern and northern coasts of the Black Sea

In the present study, we investigated the comparative infection levels, ecology and host-parasite interrelationship of a nematode Hysterothylacium aduncum (Rudolphi, 1802) in whiting, Merlangius merlangus (L., 1758) in southern (Sinop) and northern (Balaklava Bay) coasts of the Black Sea for the first time. Fish were collected throughout a period from May 2011 to March 2014 from local fishermen. A total of 690 fish specimens near Sinop and 423 fish near Balaklava Bay were examined for parasites. Hysterothylacium aduncum was the only nematode species identified in the digestive tract of the Black Sea whiting Merlangius merlangus. Prevalence of infection, mean intensity and mean abundance values were determined according to season, length classes and sex of fish at both localities. These infection indices were always higher in Sinop samples than those of Balaklava Bay samples.

Effects of conventional vs high-dose rocuronium on the QTc interval during anesthesia induction and intubation in patients undergoing coronary artery surgery: a randomized, double-blind, parallel trial

Myocardial ischemia, as well as the induction agents used in anesthesia, may cause corrected QT interval (QTc) prolongation. The objective of this randomized, double-blind trial was to determine the effects of high- vs conventional-dose bolus rocuronium on QTc duration and the incidence of dysrhythmias following anesthesia induction and intubation. Fifty patients about to undergo coronary artery surgery were randomly allocated to receive conventional-dose (0.6 mg/kg, group C, n=25) or high-dose (1.2 mg/kg, group H, n=25) rocuronium after induction with etomidate and fentanyl. QTc, heart rate, and mean arterial pressure were recorded before induction (T0), after induction (T1), after rocuronium (just before laryngoscopy; T2), 2 min after intubation (T3), and 5 min after intubation (T4). The occurrence of dysrhythmias was recorded. In both groups, QTc was significantly longer at T3 than at baseline [475 vs 429 ms in group C (P=0.001), and 459 vs 434 ms in group H (P=0.005)]. The incidence of dysrhythmias in group C (28%) and in group H (24%) was similar. The QTc after high-dose rocuronium was not significantly longer than after conventional-dose rocuronium in patients about to undergo coronary artery surgery who were induced with etomidate and fentanyl. In both groups, compared with baseline, QTc was most prolonged at 2 min after intubation, suggesting that QTc prolongation may be due to the nociceptive stimulus of intubation.

Clinical significance of p95HER2 overexpression, PTEN loss and PI3K expression in p185HER2-positive metastatic breast cancer patients treated with trastuzumab-based therapies

Background:

Overexpression of p185HER2 is an established poor prognostic factor in breast cancer, portending an aggressive course and potential for early metastasis. On the other hand, monoclonal antibody trastuzumab is widely used in the clinic to target this overexpressed oncogene. Unfortunately, ∼30–40% of all patients overexpressing HER2 respond to trastuzumab, warranting further research regarding the structure and additional modulation of the receptor. In this study, we aimed to investigate the response to trastuzumab in terms of the potential roles of several oncogenic pathways (phosphatase and tensin homologue (PTEN) and phosphatidylinositol 3-kinase (PI3K)) and a truncated receptor protein, p95HER2, retrospectively.

Materials and methods:

Paraffin-embedded primary tumour tissues of 100 HER2-positive metastatic breast cancer patients who received trastuzumab with combination cytotoxic chemotherapy were analysed with immunohistochemical method for p95HER2, p85 (PI3K) and PTEN. Relationship between variables were tested via χ², Fischer's exact test and Mann–Whitney U tests, wherever appropriate. Progression-free survival (PFS) and overall survival (OS) periods were calculated with Kaplan–Meier method and survival curves of subgroups were compared with log-rank test.

Results:

Percentage of patients was found to be 33%, 57% and 42% positive for p95 expression, PTEN and PI3K, respectively. p95-expressing tumours had statistically lower response rates for trastuzumab than tumours not expressing p95 (P=0.001). On the contrary, PTEN-expressing tumours had statistically higher response rates for trastuzumab than tumours not expressing PTEN (P=0.012). PI3K expression had no significant effect on trastuzumab response. Median PFS for p95-expressing and not expressing tumours were 8 months (95% CI, 2.5–13.4 months) and 22 months (95% CI, 9.9–34 months), respectively (P=0.0001). Median PFS for PTEN-expressing and not expressing tumours were 15.3 months (95% CI, 12.6–34 months) and 12.1 months (95% CI, 7.9–16.2 months), respectively (P=0.04). Median OS for p95-expressing and not expressing tumours were 24 months (95% CI, 8.3–40.4 months) and 29.1 months (95% CI, 8.6–43.2 months), respectively (P=0.045). Median OS for PTEN-expressing and not expressing tumours were 25.1 months (95% CI, 7.5–40.1 months) and 26.8 months (95% CI, 8.1–42 months), respectively, which was not statistically significant (P=0.5). Level of PI3K expression had no effect on PFS and OS in our patient population. Presence of visceral metastases HR=2.38 ((95% CI, 1.2–4.5), P=0.009), p95 expression HR=2.1 ((95% CI, 1.1–3.7), P=0.03) and response to trastuzumab HR=2.2 ((95% CI, 1.18–4.47), P=0.014) are identified as factors independently affecting PFS. Response to trastuzumab HR=1.7 ((95% CI, 1.14–3.47), P=0.013) was identified as the single parameter influencing survival by Cox regression analysis.

Conclusions:

Presence of p95 predicted a poorer response to trastuzumab treatment, shorter PFS and OS in our HER2-positive metastatic breast cancer cohort. In addition, loss of PTEN predicted a poorer response to trastuzumab treatment and shorter PFS but not OS. We could not find an effect of PI3K expression on the above-mentioned parameters.

Efficacy of endodontic applications of ozone and low-temperature atmospheric pressure plasma on root canals infected with Enterococcus faecalis

This study aimed to compare the antimicrobial efficacy of low-temperature atmospheric pressure plasma (LTAPP) design and gaseous ozone delivery system with 2.5% NaOCl on Enterococcus faecalis in root canal walls and dentine tubules. The samples were divided into LTAPP (n = 12), ozone (n = 12), NaOCl (positive control, n = 12) and saline (negative control, n = 6) groups. Microbial samples were collected using paper points and dentin chips from root canals. Antimicrobial efficacy was assessed by counting the colony-forming units of Ent. faecalis before and after each irrigation protocol. Data were analysed using Kruskal-Wallis, Wilcoxon signed-rank, Friedman and Bonferroni t (Dunn's test)-tests (P = 0.05). The microbial sampling with paper points showed antibacterial efficacy of NaOCl, LTAPP, ozone and saline in descending order, respectively (P < 0.05). The microbial sampling with dentin chips demonstrated a superior efficacy of LTAPP compared with NaOCl in the middle third (P < 0.05), while both had similar effects in coronal and apical thirds (P > 0.05). NaOCl and LTAPP were better than ozone at the coronal and middle parts of the root canals (P < 0.05). These findings led us to suggest that LTAPP, which has no thermal and chemical effects, may be of great aid in endodontic treatment.

SIGNIFICANCE AND IMPACT OF THE STUDY

The present study handles different perspectives on chemomechanical preparation of root canals. Ozone and low-temperature atmospheric pressure plasma (LTAPP) were investigated to determine whether they could be an alternative for NaOCl. Up to now, chemical solutions (NaOCl, chlorhexidine digluconate, etc...) have been used to disinfect the root canals. When the reported effects of LTAPP on biological and chemical decontamination were taken into consideration, a question rose whether it has antimicrobial efficacy in root canals infected with E. faecalis. According to the findings of the present study, LTAPP may constitute a promising aid in endodontics in disinfection of root canals.

Efficacy of endodontic applications of ozone and low-temperature atmospheric pressure plasma on root canals infected with Enterococcus faecalis

This study aimed to compare the antimicrobial efficacy of low-temperature atmospheric pressure plasma (LTAPP) design and gaseous ozone delivery system with 2.5% NaOCl on Enterococcus faecalis in root canal walls and dentine tubules. The samples were divided into LTAPP (n = 12), ozone (n = 12), NaOCl (positive control, n = 12) and saline (negative control, n = 6) groups. Microbial samples were collected using paper points and dentin chips from root canals. Antimicrobial efficacy was assessed by counting the colony-forming units of Ent. faecalis before and after each irrigation protocol. Data were analysed using Kruskal-Wallis, Wilcoxon signed-rank, Friedman and Bonferroni t (Dunn's test)-tests (P = 0.05). The microbial sampling with paper points showed antibacterial efficacy of NaOCl, LTAPP, ozone and saline in descending order, respectively (P < 0.05). The microbial sampling with dentin chips demonstrated a superior efficacy of LTAPP compared with NaOCl in the middle third (P < 0.05), while both had similar effects in coronal and apical thirds (P > 0.05). NaOCl and LTAPP were better than ozone at the coronal and middle parts of the root canals (P < 0.05). These findings led us to suggest that LTAPP, which has no thermal and chemical effects, may be of great aid in endodontic treatment.

SIGNIFICANCE AND IMPACT OF THE STUDY

The present study handles different perspectives on chemomechanical preparation of root canals. Ozone and low-temperature atmospheric pressure plasma (LTAPP) were investigated to determine whether they could be an alternative for NaOCl. Up to now, chemical solutions (NaOCl, chlorhexidine digluconate, etc...) have been used to disinfect the root canals. When the reported effects of LTAPP on biological and chemical decontamination were taken into consideration, a question rose whether it has antimicrobial efficacy in root canals infected with E. faecalis. According to the findings of the present study, LTAPP may constitute a promising aid in endodontics in disinfection of root canals.