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   Table of Contents - Current issue
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January-March 2022
Volume 34 | Issue 1
Page Nos. 1-127

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REVIEW ARTICLES  

Global prevalence and causes of visual impairment and blindness in children: A systematic review and meta-analysis p. 1
Abbasali Yekta, Elham Hooshmand, Mohammad Saatchi, Hadi Ostadimoghaddam, Amir Asharlous, Azadeh Taheri, Mehdi Khabazkhoob
DOI:10.4103/joco.joco_135_21  
Purpose: To determine the global prevalence and common causes of visual impairment (VI) and blindness in children. Methods: In this meta-analysis, a structured search strategy was applied to search electronic databases including PubMed, Scopus, and Web of Science, as well as the list of references in the selected articles to identify all population-based cross-sectional studies that concerned the prevalence of VI and blindness in populations under 20 years of age up to January 2018, regardless of the publication date and language, gender, region of residence, or race. VI was reported based on presenting visual acuity (PVA), uncorrected visual acuity (UCVA), and best corrected visual acuity (BCVA) of equal to 20/60 or worse in the better eye. Blindness was reported as visual acuity worse than 20/400 in the better eye. Results: In the present study, 5711 articles were identified, and the final analyses were done on 80 articles including 769,720 people from twenty-eight different countries. The prevalence of VI based on UCVA was 7.26% (95% confidence interval [CI]: 4.34%–10.19%), PVA was 3.82% (95% CI: 2.06%–5.57%), BCVA was 1.67% (95% CI 0.97%–2.37%), and blindness was 0.17% (95% CI: 0.13%–0.21%). Refractive errors were the most common cause of VI in the subjects of selected articles (77.20% [95% CI: 73.40%–81.00%]). The prevalence of amblyopia was 7.60% (95% CI: 05.60%–09.10%) and congenital cataract was 0.60% (95% CI: 0.3%–0.9%). Conclusion: Despite differences in the definition of VI and blindness, based on PVA, 3.82%, and based on BCVA, 1.67% of the examined samples suffer from VI.
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A systematic review on the role of antioxidants in thyroid eye disease p. 16
Shadi Akbarian, Samira Chaibakhsh, Mohsen Bahmani Kashkouli, Nasser Karimi, Parya Abdolalizadeh, Hossein Ghahvehchian
DOI:10.4103/joco.joco_266_21  
Purpose: To systematically review the role of antioxidants in management of patients with thyroid eye disease (TED). Methods: A literature search of the electronic databases was performed without restrictions on the date of publication till the end of March 2021, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Clinical trials, case–control studies, cohorts, case series, case reports, and experimental (including in vitro) studies in the English language were included. The primary outcome in human studies was improvement in severity, activity scores, and/or quality of life scores. There was a decrease in the level of H2O2-dependent oxidative stress, Hyaluronic acid release, reactive oxygen species, cell proliferation, or antifibrotic/antiproliferative actions in the in vitro studies. Results: Out of 374 initially screened articles, 157 studies were selected, the full texts of 82 were reviewed, and 14 papers were finally included. There were 4 clinical and 10 in vitro studies from 1993 to 2018. While β-carotene, retinol, Vitamin E, Vitamin C, melatonin, resveratrol, N-acetyl-l-cysteine, and quercetin showed some efficacy in in vitro studies; allopurinol, nicotinamide, pentoxifylline, and selenium (Se) were effective in both clinical and experimental reports. Se was the only recommended antioxidant based on one high-level randomized controlled trial. Conclusion: While different antioxidants could potentially be effective in the management of TED, no strong recommendation for any or combination of antioxidants could be made to be implemented in the daily practice.
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ORIGINAL ARTICLES Top

Retrobulbar short posterior ciliary artery hemodynamics in patients with pseudoexfoliation glaucoma and primary open-angle glaucoma p. 25
Nese Cetin Dogan, Nusret Ozdemir, Kairgeldy Aikimbaev, Emine Ciloglu
DOI:10.4103/joco.joco_59_21  
Purpose: To investigate retrobulbar blood flow changes in the short posterior ciliary arteries (SPCAs) in patients with pseudoexfoliation glaucoma (PEG) and primary open-angle glaucoma (POAG). Methods: In this prospective study, there were 22 eyes in the PEG group, 28 eyes in the POAG group, and 28 eyes with senile cataract in the control group. Peak systolic velocity (PSV), end-diastolic velocity (EDV), mean velocity (Vm), and resistivity index (RI) parameters of the temporal and nasal SPCAs were compared between the study groups. Results: Mean temporal PSV, EDV, and Vm value were significantly lower in both the POAG group and the PEG group (P = 0.049, P = 0.004, P = 0.020), respectively. Temporal SPCA RI values were not significantly different between the groups (P = 0.115). Conclusion: There are retrobulbar blood flow changes in glaucomatous compared to nonglaucomatous eyes. However, SPCAs blood flow characteristics are similar between PEG and POAG subtypes.
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Relationship between postoperative intraocular pressure and refractive outcomes in patients after deep anterior lamellar keratoplasty p. 30
Dayna Yong Wei Wei, Liang Shen, Ray Manotosh, Anna Tan Wee Tien, Charmaine Chai Hui-Chen
DOI:10.4103/joco.joco_211_21  
Purpose: To study the effect of intraocular pressure (IOP) on refractive outcomes after deep anterior lamellar keratoplasty (DALK). Methods: This retrospective study included eyes which underwent DALK. DALK technique involved either modified Anwar big-bubble if possible or manual anterior lamellar dissection. Our main outcome measures are postoperative IOP and refractive outcomes at postoperative week and months 1, 3, 6, and 12. Results: Fifty-nine eyes of 59 patients were included. DALK was performed for optical (93.2%) and tectonic (6.8%) purposes. 76.3% of the patients had keratoconus. Anwar's big-bubble technique was successful in 30 cases. Linear mixed-model was used to analyze the effect of the highest postoperative IOP measured prior to measurement of postoperative cylinder. Patients with greater maximum postoperative IOP measured had worse postoperative cylinder (P = 0.015) and spherical equivalent (P = 0.012). Those with IOP more than 21 mmHg had worse postoperative cylinder (P = 0.050) and spherical equivalent (P = 0.054). The method of DALK and presence of suture removal were not shown to statistically affect postoperative cylinder. Conclusion: Our study shows a positive correlation between postoperative IOP and worse spherical equivalent and cylinder post-DALK, emphasizing the need for good IOP control with IOP-lowering medication(s).
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Utilizing data mining algorithms and geospatial analysis to study cataract surgeries in Florida p. 37
Mahmood Khan, Amritha Kanakamedala, Zaina Al-Mohtaseb
DOI:10.4103/joco.joco_119_21  
Purpose: To determine statewide cataract surgery rates with cataract extraction with intraocular lens implantation (CEIOL) in Florida from 2005 to 2014 among Caucasians, African–Americans, Hispanics, and Asian/Pacific Islanders. Methods: This is a retrospective database study analyzing ambulatory surgical data in Florida from 2005 to 2014. Using the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project (HCUP) and State Ambulatory Surgery and Services Databases (SASD), the authors utilized data mining algorithms to analyze and graphically represent disparities in the delivery of cataract surgery, changes in surgery volume, and demographic characteristics in patients 65 years and older in all Florida counties from 2005 to 2014. Results: Cataract surgeries performed in patients ≥65 years of age represented 1,892,132 (14.90%) of the 12,695,932 total ambulatory surgical procedures from 2005 to 2014 in the HCUP-SASD Florida database. More surgeries were performed in females versus males, P < 0.001. Caucasians, African–Americans, and Hispanics represented 82.23%, 4.95%, and 10.69% of the utilization rate of all CEIOLs, respectively. From 2005 to 2014, the average surgery volume increased by an average rate of change of 1.29%. Cataract surgery penetration in the general population observed a steady decrease from 18.82% in 2005 to 16.66% in 2014. Conclusions: Cataract surgery in Florida exhibited an unequal distribution with respect to gender and race, and select counties exhibited marked changes in surgical volume over the past 11 years. This study establishes a method for data mining and geospatial analysis to study surgical and epidemiological trends and identify disparities in delivery of healthcare.
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Differences and limits of agreement among pentacam, Corvis-ST, and IOL-Master 700 optical biometric devices regarding central corneal thickness measurements p. 44
Sattar Rajabi, Amir Asharlous, Abbas Riazi, Mehdi Khabazkhoob, Alireza Moalej
DOI:10.4103/joco.joco_96_21  
Purpose: To investigate the differences and limits of agreement in measuring corneal thickness using Pentacam, Corvis, and intraocular lens (IOL)-Master 700 devices. Methods: This study was conducted on 37 right eyes of 21 males and 16 females (n = 37) with a mean age of 52.11 ± 6.30 years. The central corneal thickness was measured using three optical biometric devices, including Pentacam, Corvis, and IOL-Master 700. The inclusion criteria were normal eyes without any ophthalmological abnormalities, history of ocular pathology, or ocular surgery. The data obtained from these three devices were compared two by two. The correlation and agreement limits among them were analyzed using statistical techniques. Results: The mean standard deviation differences between Pentacam and Corvis, Pentacam and IOL-Master 700, as well as Corvis and IOL-Master 700 regarding the corneal thickness measurement, were 22.13 ± 8.05, 7.91 ± 8.02, and 14.21 ± 9.85 μm, respectively, which were statistically significant (P < 0.0001). Based on the investigation of the limits of agreement according to the Bland Altman method, the corresponding values between Pentacam and Corvis, Pentacam and IOL-Master 700, and Corvis and IOL-Master 700 were -16.2 to +15.4, -15.8 to +16.3, and -20.1 to +20.0 μm, respectively. Furthermore, the correlation coefficients of the measurements obtained by Pentacam and Corvis, Pentacam and IOL-Master 700, as well as Corvis and IOL-Master 700 were determined 0.957, 0.964, and 0.948, respectively (P < 0.0001). Conclusion: The results from this study indicate that the interchangeable use of these three devices is not appropriate due to statistically significant differences and broad limits of agreement among the three devices, especially between Corvis and IOL-Master 700.
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Repeatability of corneal densitometry measurements using a scheimpflug camera in healthy normal corneas p. 50
Mojgan Pakbin, Mehdi Khabazkhoob, Mohammad Pakravan, Akbar Fotouhi, Ebrahim Jafarzadehpur, Mohamadreza Aghamirsalim, Hassan Hashemi
DOI:10.4103/joco.joco_173_21  
Purpose: To determine the repeatability of corneal densitometry measured by the Scheimpflug imaging system. Methods: This cross-sectional study was conducted on photorefractive keratectomy candidates. One eye of each participant underwent imaging using Pentacam HR three times, 10 min apart. The repeatability of densitometry measurements was evaluated in four concentric annuli around the corneal apex and in different corneal depths. The repeatability of the measurements was evaluated using the intraclass correlation coefficient (ICC), repeatability coefficient (RC), and coefficient of variation (CV). The difference of repeatability between layers and zones was tested by tolerance index (TI). Results: Sixty eyes of sixty patients with a mean age of 27.76 ± 3.93 years were studied. Half of the participants were female (n = 30, 50%). ICC was above 0.9 in all corneal parts. The posterior layer and central zones showed the least variability of densitometry measurements considering the CV values. The RC was 2.06, 1.17, and 0.92 in anterior, central, and posterior layers, respectively. The RC was 0.88, 0.71, 1.51, and 4.56 in 0–2, 2–6, 6–10, and 10–12 mm circles, respectively. Only the reliability of densitometry in 10–12 mm annulus was statistically lower than the central zone (TI = 0.71). Conclusions: Corneal densitometry measurements provided by the Pentacam had good repeatability. The repeatability of densitometry measurements decreased from the center to the periphery (with an exception for 0–2 mm and 2–6 mm) and from the posterior to the anterior of the cornea. The reliability of the 10–12 mm zone was markedly less than other zones.
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Ocular biometric values and prevalence of corneal astigmatism in patients candidate for cataract surgery p. 56
Seyed Javad Hashemian, Seyed Mahyar Hashemian, Farid Karimian, Ali Hadavandkhani, Mohammad Ebrahim Jafari, Mahsa Sadat Hashemian, Yasaman Hadi, Fatemeh Nadjafi Semnani
DOI:10.4103/joco.joco_33_21  
Purpose: To analyze the biometric values and the prevalence of corneal astigmatism in cataract surgery candidates. Methods: This is a prospective study. Ocular biometric values and corneal keratometric astigmatism were measured by optical low-coherence reflectometry (Lenstar LS 900) before surgery in patients who were candidates for cataract extraction surgery. Descriptive measurements of biometric dimensions and keratometric cylinder data and their correlations with sex and age were evaluated. Results: Ocular biometric and keratometric values from 2084 eyes of 2084 patients (mean age 66.43, range 19–95 years) were analyzed. The mean values were as follows: corneal astigmatism 0.89 diopter (D), mean corneal keratometry 44.29 D, central corneal thickness 534 μ, internal anterior chamber depth (ACD) 3.11 mm, lens thickness 4.50 mm, and axial length 23.35 mm. Corneal astigmatism was <1.25 D in 1660 (79.5%) of eyes. Astigmatism was with-the-rule in 976 (46.8%) of eyes, against-the-rule (ATR) in 702 (33.7%), and oblique in 406 (19.5%). Analysis of corneal astigmatism revealed a change toward “ATR” with age which was not statistically significant. The ACD was correlated with age. The amount of corneal astigmatism had no correlation with age and sex. Conclusion: Corneal astigmatism was higher than 1.25 D in about 21% of cataract surgery candidates with slight differences between the various age ranges and had no correlation with age and sex.
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Comparison of two different contrast sensitivity testing methods in patients with low vision p. 60
Deniz Altinbay, Esra Sahli, Aysun Idil
DOI:10.4103/joco.joco_147_21  
Purpose: To assess the agreement between two different contrast testing modalities using the index of contrast sensitivity (ICS) in patients with low vision. Methods: Thirty-eight patients with low vision were included in the study. Contrast sensitivity (CS) was measured binocularly with both the Vector vision-standardized CS test (CSV-1000E, Vector Vision Co, Greenville, Ohio, USA) and the MonPack 3 (Metrovision, France) after refractive correction for each participant. Based on the data from the two tests, the ICS was calculated. The Bland–Altman technique was used to evaluate the agreement between ICSs obtained from different test methods. Results: Range of best corrected visual acuity was 0.50–1.00 logMAR. According to the median logCS values, CS values were highest at 3 cycles per degree (cpd) for the CSV-1000E test and at 1.5 cpd for the Metrovision MonPack 3 test. The median ICS for CSV-1000E was −0.22 (95th percentile 4.75), and the median ICS for Metrovision MonPack 3 was 0.08 (95th percentile 1.65). The mean difference was 0.655 (between −3.82 and 5.13) within limits of agreement (LoA). The difference and mean values between the two CS test measurements were found to be within LoA range. Conclusions: An agreement was found between the Metrovision MonPack 3 test and the standard CSV-1000E test results in patients with visual impairment. However, the agreement range was within very wide limits. Therefore, it was thought that they may not be used interchangeability in clinical practice.
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Assessing accuracy of okulix ray-tracing software in calculating intraocular lens power in the long cataractous eyes p. 67
Alireza Jamali, Mahmoud Jabbarvand, Amir Asharlous, Asgar Doostdar, Soodeh Bordbar, Mehdi Khabazkhoob
DOI:10.4103/joco.joco_136_20  
Purpose: To investigate the accuracy of Okulix ray-tracing software in calculating intraocular lens (IOL) power in the long cataractous eyes and comparing the results with those obtained from Kane, Holladay 1 with optimized constant, SRK/T with optimized constant, Haigis with optimized constant, and Barret Universal 2 formulas. Methods: The present study evaluates the refractive results of cataract surgery in 85 eyes with axial length > 25 mm and no history of ocular surgery and corneal pathology. IOL power calculation was performed using the Okulix software. The performances of Okulix software in comparison with the five other formulas were evaluated by predicted error, mean absolute error, and mean numerical error 6 months after surgery. Results: The mean calculated IOL power by the Okulix software was +13.48 ± 4.19 diopter (D). The mean of the 6-month postoperative sphere and spherical equivalent were +0.18 ± 0.63 and -0.34 ± 0.78 D, respectively. Also, the 6-month spherical equivalent in 56.6% and 80% of eyes were within ±0.05 and ±1.00 D, respectively. The predicted error (P < 0.001) and the mean numerical error (P < 0.001) were different between the six studied methods; however, we were not able to find any significant differences in the mean absolute error among six studied methods (P: 0.211). Conclusion: The present study showed acceptable performance of the Okulix software in IOL power calculation in long eyes in comparison with the other five methods based on the postoperative refractive error, calculated mean absolute error, and mean numerical error.
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Efficacy of balanced torsional phacoemulsification tip for cataract surgery p. 74
Huri Sabur, Sayime Aydin Eroglu, Salih Sertac Azarsiz
DOI:10.4103/joco.joco_105_21  
Purpose: To compare the efficacy of the Intrepid® Balanced torsional phacoemulsification tip to that of the 30° Ozil® and 45° Kelman® tips using Centurion Vision System. Methods: This study included 150 eyes that underwent torsional phacoemulsification surgery using 30° Ozil® tip (Group 1, 48 eyes), Intrepid® Balanced tip (Group 2, 52 eyes), or 45° Kelman® tip (Group 3, 50 eyes). Ultrasound time (UST), cumulative dissipated energy (CDE), average phaco power, average torsional amplitude, balanced salt solution volume, aspiration and operation time, and preoperative, postoperative corrected distance visual acuity, central corneal thickness were recorded. Results: The mean UST, CDE, average phaco power, average torsional amplitude were 49.9 ± 15.7 s, 10.8 ± 4.5%-s, 23.9 ± 4.6%, and 51.4 ± 5.7% in the Ozil® group and 47.5 ± 10.6 s, 5.3 ± 2.2%-s, 12.5 ± 5.3%, and 28.9 ± 7.2% in the Intrepid® Balanced group, and 48.1 ± 12.7 s, 6.9 ± 3.3%-s, 18.9 ± 5.9%, and 39.2 ± 7.9% in the Kelman® group, respectively. The CDE, average phaco power, and average torsional amplitude of the Intrepid® Balanced group were significantly lower than other groups (P < 0.05). There was no statistically significant difference between the three groups in terms of UST and operation time (P > 0.05). Conclusion: Intrepid® Balanced tip, by means of its distinctive “double bent” design and balanced energy distribution, offers more effective phacoemulsification compared to conventional 30° Ozil® and 45° Kelman® tips.
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Vision-related quality of life in patients with inherited retinal dystrophies p. 80
Saeideh Shojaei, Hamideh Sabbaghi, Yadollah Mehrabi, Narsis Daftarian, Koorosh Etemad, Hamid Ahmadieh
DOI:10.4103/joco.joco_172_21  
Purpose: To evaluate the effect of inherited retinal dystrophies (IRDs) on vision-related quality of life (VRQoL) among IRDs' patients in Iran. Methods: This cross-sectional study was conducted on 192 patients with different types of IRDs who were randomly selected from registered patients in the Iranian National Registry for Inherited Retinal Dystrophy (IRDReg®). All ophthalmic findings were collected based on the recorded data in IRDReg®. Moreover, the eligible participants were interviewed to fill out the National Eye Institute Visual Functioning Questionnaire-25 (NEI VFQ-25) to assess their VRQoL. Ordinal logistic regression was used to evaluate the possible association of the different clinical and nonclinical factors such as demographic information, socioeconomic status, and visual function with VRQoL. Results: The overall mean of a composite score of VRQoL was 45. All subscales obtained from the NEI VFQ-25 questionnaire except general health, mental health, and ocular pain had a significant negative correlation with logMAR best corrected visual acuity (BCVA) and near visual acuity variables. There was a statistically significant relationship between VRQoL and factors like age (odds ratio [OR] = 0.91, 95% confidence interval [CI]: 0.87–0.94), employment status (OR = 1.37, 95% CI: 1.05–4.74), logMAR BCVA (OR = 0.31, 95% CI: 0.19–0.49) and normal color vision (OR = 1.92, 95% CI: 1.74–5.01). Conclusion: The VRQoL of patients with IRDs in this study was low. BCVA could be an indicator to show VRQoL.
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Comparison of clinical outcomes of intravitreal bevacizumab and aflibercept in Type 1 prethreshold retinopathy of prematurity in posterior Zone II p. 87
Amir Eftekhari Milani, Masood Bagheri, Mohamad Reza Niyousha, Leila Rezaei, Somayyeh Hazeri, Samad Safarpoor, Maryam Abdollahi
DOI:10.4103/joco.joco_193_21  
Purpose: To evaluate the efficacy and safety of intravitreal injection (IVI) of bevacizumab (IVB) versus aflibercept (IVA) in premature infants with type 1 prethreshold retinopathy of prematurity (ROP) in the posterior Zone II. Methods: The study was a multicenter, historical cohort of premature newborns diagnosed with type 1 prethreshold ROP in the posterior Zone II, treated with IVB or IVA. Demographic features, complications, and treatment outcomes were then compared between the two groups. Results: Seventy-six patients received aflibercept (the IVA group), and 210 received bevacizumab (the IVB group). The two groups were not significantly different in terms of postmenstrual age (PMA) at the time of ROP diagnosis and other known risk factors for ROP development and progression. All eyes in both the groups responded to IVI; however, recurrence was observed in four eyes (1.9%) in the IVB group and 12 (15.8%) in the IVA group (P = 0.001). Recurrence occurred 9.1 ± 0.83 (5–12) and 15.5 ± 0.98 (12–18) weeks after primary treatment in the IVB and IVA groups, respectively (P = 0.000). In the IVA group, retinal vascularization was completed in 38.18 ± 6.5 weeks (21–48) after IVI, and it happened in 23.86 ± 9.3 weeks (13–60) in the IVB group (P = 0.009). Furthermore, vascularization reached the peripheral retina in 73.25 ± 6.5 (56–84) and 58.75 ± 8.8 (45–93) weeks, PMA in the IVA and IVB groups, respectively (P = 0.03). No acute postoperative complications were observed in the treated eyes in either group. Conclusion: This study shows that both IVA and IVB are effective and well tolerated for the management of type 1 prethreshold ROP in the posterior Zone II; however, IVA needs a significantly longer time for vascularization completion and has a higher recurrence rate compared with IVB.
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B-Scan ultrasonography findings in unilateral posterior scleritis p. 93
Arash Maleki, Maria Ruggeri, Amanda Colombo, Soheila Asgari, Sydney Look-Why, Shimy Apoorva, C Stephen Foster
DOI:10.4103/joco.joco_267_21  
Purpose: To evaluate the B-scan ultrasound findings in unilateral posterior scleritis. Methods: This was a retrospective observational case series at a tertiary uveitis clinic. The study population included patients who had been diagnosed with milder forms of unilateral posterior scleritis since 2010 and had B-scan ultrasonography of that eye. The healthy eye of each patient was considered the control eye for that patient. Results: The average age of patients was 50.2 ± 17.8 (range, 18–67). Posterior scleritis was idiopathic in 6 (66.7%) patients and associated with rheumatoid arthritis in two and HLA-B27 ankylosing spondylitis in one patient. The thickness of the thickest area in the diseased eye was 2.08 ± 0.49 (range, 1.35–3.2) and the control eye was 1.53 ± 0.38 (range, 1.03–2.3). The difference between the symptomatic and control eye was statistically significantly different (P = 0.02). 1.7 mm was the cut-off-point on the receiver operating characteristics curve with the highest combined sensitivity and specificity of 87.5% and 88.9%, respectively. Comparing the thickness of the thickest section of the symptomatic eye of one patient with the same section in the other eye of the same patient, there was a difference of 20% or more in sclero-choroidal complex. Conclusions: In this study, the sclero-choroidal complex thickness higher than 1.7 mm has the highest combined sensitivity and specificity. Comparing the thickest section of the symptomatic eye of one patient with the same section in the other eye can be diagnostic.
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Ocular manifestations of newly diagnosed acute leukemia patients p. 100
Reza Mirshahi, Fariba Ghassemi, Leili Koochakzadeh, Mohammad Faranoush, Zahra Ghomi, Azim Mehrvar, Seyed Asadollah Mousavi, Seyyed Reza Safaee Nodehi
DOI:10.4103/joco.joco_10_21  
Purpose: To present primary ocular manifestations in acute leukemia. Methods: This cross-sectional descriptive hospital-based study evaluated all newly diagnosed leukemia patients of three referral hospitals of Tehran University of Medical Sciences in 2015–2016 and Mahak Hospital in Tehran in 2017. Exclusion criteria included the patients with the previous history of chemotherapy, cases of relapsing disease, and the patients with a history of ocular disease or other systemic conditions with ophthalmic manifestations. Results: A total of 85 patients (170 eyes) were evaluated in our study, including 29 children (34.1%) and 43 females (50.6%). The mean patient age was 37.84 ± 11.91 years in the adult group and 6.28 ± 4.70 years in the pediatric category. Ophthalmic involvement was seen in 27 patients (31.8%), including 6 pediatric patients (20.7%) and 21 adult patients (37.5%). Two patients (2.3%) had direct infiltration by leukemic cells and 76 patients (89.41%) of patients were asymptomatic. There was a correlation between ophthalmic involvement and platelet count and hemoglobin level. In patients with ocular signs, higher mortality rates were observed. Conclusions: At the time of diagnosis in acute leukemia patients, complete ophthalmic evaluation including dilated fundus examination is suggested as ocular involvement in these patients is common and sometimes asymptomatic. Ophthalmic involvement in leukemic patients should be identified in a timely manner, particularly in individuals with low platelet counts and hemoglobin levels, due to the potential prognostic relevance.
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Epidemiological status of thyroid eye disease in Central Iran p. 106
Bahram Eshraghi, Mojgan Nikdel, Maryam Abbasi
DOI:10.4103/joco.joco_223_21  
Purpose: To focus on clinical manifestations and epidemiology of thyroid eye disease (TED) in Central Iran's population. Methods: In this retrospective case study, we analyzed all patients with TED who were referred to our oculoplastic clinic from 2015 to 2019. The patients' epidemiological characteristics and clinical presentation were compared between different thyroid disease groups and genders. Results: Overall, 383 patients (155 male; 40.5% and 228 female; 59.5%) were included. The mean age was 39.55 years (standard deviation ± 13.45, range 10–72). Most patients (89%) were hyperthyroid with the highest duration of ocular involvement among all categories (25.6 months). The most common signs on ophthalmic examinations were proptosis (80.4%), followed by eyelid retraction (72.3.0%). TED was classified as mild in 24.5%, moderate to severe in 67.6%, and sight-threatening in 7.9%. Thirty patients (7.8%) had active TED. Conclusions: This series with a relatively more significant number of TED cases in Central Iran found similar epidemiological and clinical characteristics of TED compared to other studies from Iran. Most of our patients were hyperthyroid, with more females compared to males. Proptosis and eyelid retraction were the most common manifestations. Most TED patients were classified as moderate to severe.
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CASE REPORTS Top

Contralateral autokeratoplasty, pars plana vitrectomy for luxated cataract, and flanged intrascleral intraocular lens fixation p. 112
Francisco Lucero Saa, Federico Andrés Cremona, Mariano Cotic, Pablo Chiaradía
DOI:10.4103/joco.joco_93_21  
Purpose: To describe a case of a combined procedure including autokeratoplasty, pars plana vitrectomy (PPV), and scleral intraocular lens (IOL) fixation. Methods: Case report. Results: We describe a case of an 85-year-old patient presenting a right, blind eye with a clear cornea and a left eye with acceptable visual potential but affected by bullous keratopathy, aphakia, and a posteriorly dislocated nucleus. The patient underwent a contralateral autokeratoplasty, PPV, and flanged intrascleral IOL fixation with double needle technique. After 24 months of follow-up, the graft remained clear, and the IOL was stable. Conclusions: Complex cases comprising anterior and posterior segments pathology sometimes require combined procedures. A shortage of corneal tissue in developing countries is common. In strictly selected cases, autokeratoplasty may be an option and is associated with fewer complications than allograft corneal transplantation. Sutureless novel techniques for intrascleral fixation of IOL have shown good results and reliable lens stability.
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Intracameral injection of methotrexate for treatment of epithelial ingrowth p. 115
Farhad Salari, Ghasem Fakhraie, Fahimeh Asadi Amoli, Mehran Zarei-Ghanavati
DOI:10.4103/JOCO.JOCO_159_21  
Purpose: To report a case of intracameral injection of methotrexate (MTX) to treat the epithelial ingrowth that occurred following glaucoma surgery. Methods: A case report of a 40-year-old male with epithelial ingrowth after implantation of Ahmed glaucoma valve. Results: The patient was treated with 11 doses of weekly intracameral MTX (400 mg/0.1 ml). Clinical evidence of recurrence was not observed after 11 months of follow-up. Discussion: Intracameral MTX can be used as an alternative for the treatment of epithelial ingrowth.
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Trans-scleral cyclophotocoagulation in refractory pigment dispersion-like glaucoma secondary to ciliary body melanoma p. 118
Mohammad Banifatemi, Naveed Nilforushan, Ahad Sedaghat, Arezoo Miraftabi, Navid Abolfathzadeh
DOI:10.4103/joco.joco_269_21  
Purpose: To report a case of ciliary body melanoma with acute high intraocular pressure (IOP) due to pigment dispersion, treated by limited trans-scleral cyclophotocoagulation (TSCPC) and plaque radiotherapy. Methods: A 33-year-old woman was referred to clinic with acute ocular pain and decreased visual acuity from 1 week before presentation. The IOP was 55 mmHg accompanied by red eye, perilimbal injection, mild corneal edema (stromal and epithelial), scattered pigment dust on central corneal endothelium, 4+ anterior chamber pigments, and pigmented cells. Gonioscopy revealed a bulging mass posterior to the iris root, about 2 o'clock width alongside a heavy dark brown pigmentation of all angle structures. Ultrasound biomicroscopy confirmed a ciliary body mass of about 4.5 mm × 4 mm × 3.3 mm in the superior ciliary region, in favor of melanoma. Due to no response to maximal antiglaucoma therapy, a limited TSCPC in the inferior hemisclera was done. After control of the IOP, plaque radiotherapy with Ru-106 was done. Results: Three days after the cyclophotocoagulation, IOP decreased to 18 mmHg. Visual acuity reached to 20/25 and IOP remained 18 mmHg, with timolol/dorzolamide drop twice a day. Anterior chamber pigments gradually decreased, and antiglaucoma and steroid drops were tapered during 1 month, thereafter. The IOP was 14–16 mmHg with timolol/dorzolamide bid at months 3 and 6 of follow-up and 21–22 mmHg without any drop at months 12 and 18, with no sign of glaucomatous optic neuropathy. Conclusion: Limited cyclophotocoagulation may be a good choice for controlling the high refractory IOP in cases of intraocular neoplasms such as ciliary body melanoma, which are planned for salvage therapy such as plaque radiotherapy.
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Bilateral central retinal vein occlusion and stevens-johnson syndrome associated with Coronavirus-19: A case report p. 121
Hamidreza Hasani, Benyamin Hakak-Zargar, Sahar Mohammad Poor Nami, Nami Mohammadian Khonsari
DOI:10.4103/joco.joco_277_21  
Purpose: To report a case of bilateral central retinal vein occlusion (CRVO) associated with coronavirus-19 (COVID-19) infection. Methods: A 43-year-old man presented to the emergency department with flu-like symptoms, severe erythema, a rash on his face, and respiratory distress. He was admitted to the intensive care unit, and the reverse transcriptase-polymerase chain reaction test was positive for the severe acute respiratory syndrome coronavirus-2 virus. The routine blood work was unremarkable. The dermatologist noted positive Nikolsky's sign, and the patient was diagnosed with Stevens–Johnson syndrome (SJS), which affected 18% of his body and was later confirmed by skin biopsy. Later, he reported worsening vision. Results: Ophthalmic examination and fundus fluorescein angiography showed bilateral CRVO. Despite best medical efforts, including treatment with systemic dexamethasone and remdesivir, the patient died on the 6 days of his hospitalization. Conclusion: This was a rare bilateral CRVO and SJS case in a young patient, probably caused by the COVID-19 infection.
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Anaglyphic three-dimensional movie: A simple binocular method to treat anisometropic or strabismic amblyopia in adults p. 124
Arash Mirmohammadsadeghi, Motahhareh Sadeghi, Abolfazl Kasaee, Mohammad Reza Akbari
DOI:10.4103/joco.joco_101_21  
Purpose: To evaluate the efficacy of anaglyphic three-dimensional movies to treat adults with anisometropic or strabismic amblyopia. Methods: This is an interventional case series. The seven cases were put on a trial frame containing subjective refraction, fogging plus lenses for the dominant eye, correcting prism, and anaglyphic red-cyan plastic spectacles. Patients participated in 20 sessions of 1.5 h of anaglyphic three-dimensional animated movie watching in the office. Significant visual acuity (VA) improvement was defined as improvement ≥0.2 in logMAR values. Change in octaves of stereopsis was defined as halving the arcsec or 0.3 change in log arcsec. Results: The average age was 26.9 ± 10.0 (16–42) years. The mean VA in amblyopic eye improved significantly from 0.42 ± 0.19 (0.15–0.7) logMAR to 0.25 ± 0.15 (0.1–0.5) logMAR after completion of sessions (P = 0.02), and four cases showed significant VA improvement. The mean stereoacuity improved significantly from 2.6 ± 0.3 (2.1–2.9) log arcsec to 2.1 ± 0.5 (1.7–2.9) log arcsec (P = 0.04). Four cases showed ≥2 octaves improvements in stereopsis. Conclusion: A simple and readily available method of amblyopia treatment can be effective in some adult cases.
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