Purpose: To identify and explain different artifacts in macular optical coherence tomography (OCT). Methods: For this comprehensive review, a PubMed and Google Scholar (January 1995–October 2018) search was conducted by the researchers, using the keywords such as OCT, artifacts, artefact, and macula. Results: We reviewed the main OCT artifacts including software break-down or misidentification of retinal layers, incomplete segmentation error, complete segmentation failure, mirror artifact (inverted artifact), cut edge artifact, degraded image scan, out-of-register artifact, off-center artifact, motion artifact, foveal duplication, segmentation shift, blink artifact, static or fixed image artifact, linear artifact, and perfluorocarbon liquid-producing artifact. Conclusions: There are various artifacts in OCT image scans. The identification of these artifacts may help in accurate interpretations of OCT images in clinical settings that can affect the diagnosis and management of different retinal disorders.

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Purpose: To report the limbal allograft transplantation and penetrating keratoplasty (PK) results in limbal stem cell deficiency (LSCD)-developed eyes because of chemical or thermal injury. Methods: Medical records of 18 eyes of 14 patients who had undergone keratolimbal allograft (KLAL) or living-related conjunctival limbal allograft (lr-CLAL) with or without PK and followed up at least 1 year postoperatively were evaluated retrospectively. The preoperative LSCD grade was noted in all patients. Rejection incidents, recurrence of LSCD, and corneal graft clarity along with a visual improvement during the follow-up were noted. The complications rate due to surgery or injury itself, for instance, glaucoma and cataract, were evaluated. The limbal allograft tissue survival analysis and corneal allograft survival analysis were done to reveal the differences in both the procedures. The existence of normal corneal epithelium and improvement in visual acuity were accepted as the surgical success criteria. Results: In the limbal allograft transplantation group, the survival rates of the allograft tissue were 65 ± 10.7% at 1 year and 36.6 ± 11.4% at 3 years in lr-CLAL and 66.7 ± 15.7% at 12 months and 53.3 ± 17.3% at 18 months in KLAL-transplanted eyes. The survival rate of corneal allograft at the 5^th postoperative year was lower in the simultaneous procedure compared to the staged procedure, but it was not statistically significant (25.7 ± 25.8% vs. 62.5 ± 17.1%, P = 0.75). The ambulatory vision was achieved in 10 eyes (56%) after a mean follow-up time of 93.8 ± 37.8 months. The visual acuity level has increased in 12 eyes (67%) in which the limbal allograft transplantation was applied. The ambulatory visual acuity level was achieved (≤1.0 logMar [20/200]) in 10 eyes (56%). In addition, two or more Snellen lines' gain in the best corrected visual acuity was observed in 12 eyes of 18 (67%) at the last follow-up, and there was not any significant difference between the KLAL and lr-CLAL. Conclusions: Ocular surface integrity was longer in KLAL than in lr-CLAL transplantation, but it was not statistically significant. The staged procedure was more convenient than the simultaneous procedure in terms of corneal allograft clarity maintenance in limbal allograft-employed eyes.

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Purpose: To present the management of upside-down Descemet membrane endothelial keratoplasty (DMEK) following combined phacoemulsification with DMEK (phaco-DMEK) in cases of Fuchs endothelial dystrophy (FED). Methods: This is a comparative interventional case series extracted from a prospective interventional case series (clinical outcome of DMEK combined with phacoemulsification for FED). We report five cases of upside-down DMEK. Two cases of upside-down DMEK were managed with re-orientation and the other two with repeat DMEK. The 5^th case underwent an initial re-orientation and then a subsequent repeat graft. Graft re-orientation and repeat surgery were performed 9–20 days after initial phaco-DMEK. All the five cases were followed up over a 6-month period, and the following outcomes were assessed: best corrected visual acuity (BCVA), contrast sensitivity (CS), central corneal thickness, endothelial cell density (ECD), and central macular thickness. Results: At the final 6-month postoperative follow-up, all the five cases achieved good outcomes in terms of BCVA and CS. Overall, the results were comparable to 32 control cases. One case of re-orientation and the case of re-orientation with subsequent repeat DMEK performed slightly less well than control cases in terms of postoperative ECD. Conclusions: Re-orientation of the original DMEK scroll in cases of upside-down DMEK can be a safe and cost-effective alternative to repeat DMEK. If re-orientation does not result in corneal deturgescence, a repeat DMEK may be done subsequently.

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Purpose: To assess the visual outcome and complications following retropupillary-fixated iris-claw intraocular lens (IOL) implantation. Methods: For this retrospective, non-comparative study, chart review of patients who underwent retropupillary iris-claw IOL implantation for the correction of aphakia from July 2014 to October 2018 and had a minimum postoperative follow-up of 2 months was carried out. Postoperative corrected distance visual acuity (CDVA), intraocular pressure (IOP), and complications were noted. Results: One hundred and twenty-two eyes of 122 patients (mean follow-up: 7.48 ± 5.2 months, range, 2 months-3.5 years) were enrolled in the study. The mean logMAR CDVA improved from 1.36 ± 0.52 preoperatively to 0.5 ± 0.42 postoperatively, at the last follow-up visit (P < 0.0001). The final CDVA improved in 110 eyes (90.2%), remained unchanged in 8 eyes (6.6%), and worsened in 4 eyes (3.3%). In cases of pre-existing cystoid macular edema (CME) or excessive intraoperative manipulations, 0.05 ml of 4 mg intravitreal triamcinolone acetonide (IVTA) was injected at the end of the surgery. Twenty eyes (16.4%) had transient ocular hypertension (OHT), 6 eyes (4.9%) had persistent OHT, and 2 eyes (1.6%) progressed to glaucoma. Choroidal detachment was noted in 2 eyes (1.6%), CME in 6 eyes (4.9%), 2 eyes (1.6%) had retinal detachment, 20 eyes (16.4%) had significant ovalization of pupil, 8 eyes (6.6%) had one haptic disenclavation, 1 eye (0.8%) had corneal decompensation, and 1 eye (0.8%) had endophthalmitis. Conclusions: Retropupillary iris-claw IOL provides good visual rehabilitation with a few complications. Its ease of insertion and short surgical time makes it a good option to correct aphakia in patients with an inadequate capsular support.

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Purpose: To determine the vision-related quality of life (VR-QoL) and its dimensions in corneal transplant recipients. Methods: This cross-sectional study was carried out on 100 patients who underwent penetrating keratoplasty. Data collection tools included a demographic questionnaire, satisfaction questionnaire, and Persian version of the 39-item National Eye Institute Visual Functioning Questionnaire (NEI-VFQ 39). Results: The composite score of VR-QoL in corneal transplant recipients was 54.39 ± 9.22 (32.9–71.01). The highest mean score among subscales was related to color vision (74.75 ± 27.63) and the lowest related to dependency (31.06 ± 31.02). The results showed that there is a reverse correlation between VR-QoL with both age (r = −0.364;P < 0.001) and the numbers of years after the transplantation (r = −0.362;P < 0.001). However, there was a correlation between satisfaction and VR-QoL (r = 0.679;P < 0.001). Furthermore, the results showed that there is a significant difference in VR-QoL between men and women (P < 0.001) and also a significant difference in VR-QoL between unilateral and bilateral graft recipients (P < 0.001). Conclusions: The corneal transplant has the highest impact on color vision and the lowest on dependency. Moreover, the results of this study provide a comprehensive picture for the state of vision and overall health status of patients for health-care providers to enhance the patient care.

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Purpose: To define the incidence, characteristics, and management of eyelid basal cell carcinoma (BCC) in Central Spain. Methods: This retrospective study investigates the characteristics and the outcome of eyelid BCC from 2000 to 2016 in a central region of Spain. Data were collected on demographics, skin phenotype, location of the eyelid lesion, clinical and histological diagnosis, surgery, commitment of surgical margins, and recurrence rate. Results: Primary eyelid BCC occurred in a mean of 20.6 lesions a year or 9.4/100,000 inhabitants/year. The mean age of BCC carriers was 69.4 ± 16.2 years, with no gender difference (P = 0.479), predominantly affecting Fitzpatrick II–III skin (81.3%) (P < 0.001). The most common location was the inner canthus (154/45.7%) (P < 0.001) and type nodular (215 cases/63.8%) (P < 0.001). The surgical margins were affected in 69 (20.5%) individuals, and the recurrence rate was 5.6 (95% confidence interval, 3.2–8.3) significantly higher in affected margins (P < 0.001). The most common location for recurrence was the inner canthus (P = 0.003), and the most common histological type for recurrence was sclerosing (16.7%), then multinodular (12.5%), and infiltrating (10.4%) with no significant difference (P = 0.27). Conclusions: The frequency of occurrence of eyelid BCC is much less than the estimated crude incidence for skin tumors involving all areas of the body in the Spanish population. Eyelid BCC is more common in the seventh decade of life, with no predilection for gender. Nodular histological type is the most common. The recurrence rate is 5.6%, depending on site and affected margins, even though clear free margins also can present with recurrence.

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Purpose: To analyze microvascular changes in patients with retinitis pigmentosa (RP) with relatively preserved visual acuity (VA), using swept source optical coherence tomography (SS-OCT) angiography to correlate results to macular function and structure. Methods: This was a case–control study conducted over 70 eyes of 35 RP patients with relatively preserved VA. All patients underwent a complete ophthalmic examination, including SS-OCT, OCT angiography (OCT-A), fundus autofluorescence (FAF), and multifocal electroretinogram (mfERG). Thirty-four eyes of 34 healthy controls of age-, sex-, and axial length-matched (control group), were also analyzed. The main outcome measures were foveal and parafoveal vascular densities (FVDs and PFVDs) in the superficial capillary plexus (SCP) and deep capillary plexus (DCP), foveal avascular zone (FAZ) and its enlargement coefficient and their correlation with macular function (by means of VA and mfERG), and structure (by means of FAF and SS-OCT). Results: In the RP group, PFVD was 25.99 ± 5.2% in the SCP and 34.47 ± 2.37% in the DCP and were significantly lower as compared to control group (P < 0.0001; P = 0.0026, respectively). Enlargement coefficient of FAZ was 1.78 ± 0.79. We found a statistically significant correlation between VA and PFVD in the DCP (P < 0.0001), FAZ disruption in the SCP (P = 0.006) and enlargement coefficient of FAZ (P = 0.01). The parafoveal DCP density was significantly correlated with P1 amplitude (P = 0.005) in rings 2, 3, 4, and 5 of the mfERG. We found a statistically significant correlation between parafoveal density in the DCP, thickness of ganglion cell complex (GCC) (P = 0.001), and the width of ellipsoid band (P = 0.041). Parafoveal SCP density was also correlated to GCC (P = 0.033). Conclusions: We showed that vascular alteration in RP begins at the level of the DCP, which affects the outer retina and leads to a narrowing of the ellipsoid. The alteration of the SCP would occur later in the evolution of the disease. Vascular changes occur early during RP and were highly correlated to retinal function and structure. OCT-A seems to be a good tool to quantify vascular network loss and could play a central role in staging, prognosis, and monitoring disease progression.

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Purpose: To report two cases of typical multiple evanescent white dot syndrome (MEWDS), in which swept-source optical coherence tomography angiography (SS-OCTA) revealed transient areas of flow deficit at the level of the choriocapillaris. Methods: The SS-OCTA images of two female patients with typical MEWDS were analyzed at the onset of the disease and during follow-up. Results: The patients were aged 24 and 25 years, respectively. Previous medical history was unremarkable in both cases. The diagnosis of MEWDS was made on the basis of typical clinical findings and results of fundus autofluorescence, fluorescein angiography, and optical coherence tomography. At presentation, SS-OCTA showed a few small hypointense areas of flow deficit at the level of the choriocapillaris in both cases. During follow-up, SS-OCTA showed complete resolution of choriocapillaris flow voids. Conclusion: Both our patients with typical acute MEWDS showed SS-OCTA multifocal small areas of flow reduction at the level of the choriocapillaris, with full recovery during the follow-up. This finding supports the hypothesis of transient, primary, or secondary choriocapillaris hypoperfusion in typical MEWDS.

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Purpose: To evaluate the efficacy of intravitreal bevacizumab (IVB) combined with intravitreal methotrexate (IVM) in the treatment of diabetic macular edema (DME). Methods: In this prospective, interventional contralateral eye study, patients with bilateral DME were randomly allocated to receive three monthly injections of IVB (1.25 mg/0.05 mL) plus IVM (400 μg; 0.16 cc) or IVB alone. The outcome measure was changes in the best corrected visual acuity (BCVA), central macular thickness (CMT), and central macular volume (CMV). Results: Thirty-six treatment-naive eyes of 18 patients with a mean age of 62.38 ± 6.2 years were included in the study. BCVA logMAR changed from 0.95 ± 0.53 at baseline to 0.75 ± 0.53 in the combination group and from 0.72 ± 0.57 to 0.49 ± 0.50 in the IVB alone group at 1 month after the 3^rd injection. BCVA improvement in both groups was not statistically significant compared with the baseline value (P > 0.99). Compared with the baseline values, mean CMT and CMV were reduced in both groups; however, these changes did not reach a significant level. The differences of CMT changes between the groups were not statistically significant at month 1 (P = 0.82), month 2 (P = 0.21), and month 3 (P = 0.10). Furthermore, the differences of CMV changes between the groups were not statistically significant at month 1 (P = 0.76), month 2 (P = 0.82), and month 3 (P = 0.11). Conclusions: This pilot study demonstrated no significant therapeutic effects for IVB combined with IVM compared to IVB alone in treatment-naive DME patients over a 3-month course.

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Purpose: To report the prevalence of honorary authorship (HA) among different journals in the ophthalmological literature Methods: An online survey was conducted among corresponding authors of six journals with the highest impact factors in the ophthalmological field. The survey consists of questions regarding (1) demographics, (2) awareness of authorship guidelines, and (3) application of authorship guidelines on their current surveyed article. Furthermore, respondents were asked if they felt that according to their understanding of the International Committee of Medical Journal Editors (ICMJEs) guidelines, a coauthor on their current article did not deserve authorship (perceived HA). Furthermore, respondents were asked if coauthors performed solely nonauthor tasks (ICMJE-defined HA). Results: Out of the 1688 surveys sent, 333 were returned, leading to a response rate of 19.7%. Eighty-four and a half percent of all respondents were aware of the ICMJE guidelines. When deciding on order of authorship, most authors decided as a group (43.8%), followed by the senior author deciding (30.1%), and 77 articles were decided by the first author (23.4%). When asked if respondents believed that any of their coauthors did not make sufficient contributions to be included as an author, 8.8% affirmed. One hundred and thirty-one respondents stated that any of their coauthors performed only one or more nonauthor tasks, making the rate of ICMJE-defined HA 39.8%. Conclusions: HA is present throughout all journals surveyed despite endorsement of the ICMJE guidelines by these same journals. The discrepancy between self-perceived HA and ICMJE-defined HA suggests the necessity for modifications to our authorship system or a contemporary revision to the ICMJE guidelines.

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Purpose: To describe the association of change in the baseline hemoglobin levels with the development of interferon (INF) retinopathy after the start of pegylated INF (PEG INF) and ribavirin for hepatitis C virus treatment. Methods: This was a retrospective chart review conducted on 12 patients on PEG INF and ribavirin with baseline examination and follow-up during the treatment regimen: 6 developed INF-induced retinopathy and 6 patients were without retinopathy. Serial hemoglobin values for both the groups were recorded at the time of the retinopathy diagnosis in affected patients and the nadir in those without retinopathy. The total percent reduction of hemoglobin was calculated for both the groups. Results: Hemoglobin concentration levels between control and INF retinopathy patients tended to be slightly lower in the group that developed retinopathy. There was no threshold hemoglobin concentration under which the rate of developing retinopathy significantly increased. Greater than 25% drop in hemoglobin conferred a statistically significant risk in the development of INF-associated retinopathy. Conclusion: Patients starting PEG INF and ribavirin require baseline testing and subsequent follow-up based on the rapidity of the decrease in hemoglobin levels to identify the development of retinopathy with treatment.

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Purpose: To determine the prevalence of ptosis and nystagmus in the general rural population in Iran. Methods: Two villages were selected from the north and southwest of Iran using a multi-stage cluster sampling approach. After selection of the participants and inviting them to a complete eye exam, they all had vision tests and an ophthalmic examination. Vision tests included measurement of visual acuity, refraction, and the cover test. Then the slit-lamp exam was performed, and the diagnosis of ptosis and nystagmus was determined by an ophthalmologist. Results: Of the 3851 invitees, 3314 people participated in the study. The prevalence of ptosis in this study was 2.23% [95% confidence interval (CI): 1.73-2.74], and 45.3% of the cases were bilateral ptosis. The prevalence of ptosis was lowest in the 21-30 year (0.2%) and the under 5 year (0.8%) age groups, and the highest prevalence was observed in people over 70 years of age (6.7%) (P < 0.001). The prevalence of ptosis was higher in illiterate people than those with an academic education level (P = 0.012). The prevalence of astigmatism was 62.8% in those with ptosis and 34.2% in those without ptosis (P < 0.001). The prevalence of nystagmus was 0.39% (13 cases). Conclusions: This study found that the prevalence of ptosis is relatively high in the general rural population in Iran, and the prevalence increases with age. Astigmatism is significantly high among cases with ptosis, and its prevalence has an inverse relation with the level of education. Nystagmus also had a high prevalence in this population.

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Purpose: To describe a case of primary vitreoretinal lymphoma (PVRL) that initially presented and managed as dry type age-related macular degeneration (AMD). Methods: A 69-year-old male was referred to us by decreased vision. Results: On funduscopy, a few small hard drusen at the posterior pole of the right eye and many large confluent drusen in the left eye were observed. Optical coherence tomography findings included the hyperreflective drusenoid materials in the subretinal pigment epithelium (sub- RPE) space which was similar to previous imaging records except for decreased area and height of pigment epithelial detachments and RPE and ellipsoid zone attenuation in some areas appeared. The thickness of the retina was normal, but the choroid appeared to be slightly decreased compared to the left eye. Patient has been followed up with the diagnosis of AMD for 1 year. After the right hemiparesis presentation, he underwent craniotomy and biopsy that made the diagnosis evident. Conclusion: PVRL/primary central nervous system lymphoma may be one of the most important masquerades of AMD, but a significantly waxing and waning course may help to make correct diagnosis.

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Purpose: To determine economic inequality in unmet refractive error (RE) need and its determinants in deprived rural population of Iran. Methods: In this population-based study, two villages were randomly selected from among underserved villages of Iran. After selecting the participants, optometric examinations, including uncorrected and corrected visual acuity and subjective and manifest refraction, were done for all the participants. Then, unmet need for glasses was determined. Concentration index (C) was used to assess inequality, and Oaxaca–Blinder decomposition method was applied to decompose the gap between the two groups based on the determinants. Results: Of 3851 samples, 3314 participated in the study (response rate = 86.05%). The data of 3255 participants were used for analysis. The value of C and 95% confidence interval (CI) was −0.088 (−0.157 to −0.020), indicating a pro-poor inequality in unmet need. The prevalence (95% CI) of unmet need was 11.74% (9.25–14.22) in the poor and 6.51% (4.96–8.06) in the rich, with a gap of about 5% in favor of the rich (P < 0.001). A marked percentage of the gap was due to the explained portion (b = 5.73; P = 0.031). In the explained portion, the variable of economic status (b = 3.48; P = 0.004) and myopia (b = 0.88; P = 0.031) caused inequality in favor of the rich and against the poor, respectively. In the unexplained portion (b = −0.51; P = 0.372), the variables of education (P = 0.002) and place (P = 0.001) had statistically significant effects on inequality. Conclusions: There is a significant pro-poor economic inequality in the prevalence of unmet need in rural areas of Iran. Although part of this inequality is related to variables such as education and myopia, a major portion (two thirds) of this inequality may be due to the direct effect of economic inequality.

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Purpose: To determine the changes in serum levels of free vascular endothelial growth factor (VEGF), insulin-like growth factor-1 (IGF-1), and growth parameters in infants with retinopathy of prematurity (ROP) who received intravitreal injection of the bevacizumab (IVB). Methods: A prospective interventional case series study, including 10 infants with Type 1 ROP was conducted. Using the enzyme-linked immunosorbent assay, serum levels of VEGF and IGF-1 were measured before, 1 month and 2 months after treatment with IVB in both eyes. Growth parameters, including weight, length, and head circumference and their Fenton's z-score, were also measured. Results: Serum VEGF levels were suppressed 1 month after IVB (P = 0.007) and then increased between 1 and 2 months (P = 0.064). Z-scores of all growth parameters except weight z-score decreased in the 1^st and 2^nd months. Conclusion: Serum VEGF levels showed a transient reduction after IVB which lasted at least 2 months. Growth velocity of premature infants may be affected by anti-VEGF therapy and should be followed with particular attention.

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Purpose: To report the effect of topical bromfenac, a non-steroidal anti-inflammatory drug (NSAID), in a case of neovascular age-related macular degeneration (AMD). Methods: An 85-year-old woman presented with a complaint of visual acuity reduction in the right eye. Comprehensive ophthalmological examination and retinal imaging were performed. Results: Best corrected visual acuity was 2/100. Fundus examination showed reticular pseudodrusen and a small hemorrhage in the fovea. Fluorescein angiography showed an active neovascular membrane. Spectral-domain optical coherence tomography (SD-OCT) confirmed diagnosis and revealed subretinal and intraretinal fluid. The patient refused recommended intravitreal anti-vascular endothelial growth factor treatment and received topical bromfenac 0.09% twice daily. Follow-up with SD-OCT showed subretinal followed by intraretinal fluid reduction at 16 weeks after treatment. Conclusion: Short-term reduction of subretinal and intraretinal fluid was observed with topical bromfenac monotherapy in neovascular AMD.

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