Purpose: To determine the distribution of keratometry values in a wide age range of 6-90 years. Methods: In this cross-sectional study, samples were selected from two villages in Iran using multi-stage random cluster sampling. After completing optometry and ophthalmic examinations for all cases, corneal imaging was done using Pentacam, and keratometry values were determined. Results: Of the 3851 selected people, 3314 people participated in the study, and after applying the exclusion criteria, analyses were done on data from 2672 people. Mean age of the participants was 36.30 ± 18.51 years (from 6 to 90 years). Mean keratometry (mean-K) in flat and steep meridians was 42.98 (42.9-43.06) diopters (D) and 43.98 (43.91-44.07) D, respectively. Average of mean-K was 43.48 (43.41-43.56) D. Mean-K increased linearly up to the age of 70 years, and the cornea became slightly flat afterwards (coefficient = 0.01; P < 0.001). Mean-K was significantly higher in females (P < 0.001). Myopic cases had the highest mean-K (P < 0.001). The correlation of mean-K with age, gender, central corneal thickness, anterior chamber depth, pupil diameter, and spherical equivalent was investigated in a multiple regression model. Only older age and female gender showed a statistically significant association with mean-K. Overall, 31.62% (29.14-34.09) of the sample in this study had at least 1.0 D of corneal astigmatism. Conclusions: This is one of the few studies worldwide that demonstrates changes in keratometry in a wide age range from childhood to old age. Results indicated that age and gender are variables associated with keratometry.

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Purpose: To describe a case of pachychoroid disease most compatible with central serous chorioretinopathy (CSC) presented with a large relapsing retinal pigment epithelial detachment (PED) associated with only a small amount of subretinal fluid (SRF) in the background of macular drusen in an elderly patient mimicking neovascular age-related macular degeneration (AMD). Methods: This was a review of 32 months of the clinical course and findings on multimodal imaging including fundus photography, optical coherence tomography, fundus fluorescein angiography (FFA), indocyanine green angiography (ICGA), and optical coherence tomography angiography (OCTA). Results: A large relapsing PED sometimes with small amount of SRF at its apex was found in the background of macular drusen in the right eye of a 63-year-old Thai woman. The relapses of the PED showed an apparent association with recent steroid exposure. Multimodal imaging demonstrated the characteristics of pachychoroid diseases with pachyvessels and choroidal hyperpermeability. The PED and SRF responded well to anti-vascular endothelial growth factor (anti-VEGF) therapy, especially aflibercept, but could also be spontaneously resolved without anti-VEGF. No evidence of choroidal neovascularization or polyps could be identified by serial FFA, ICGA, and OCTA even when the retinal pigment epithelium was completely flat with no obscuration by PED. Conclusions: A large PED with little SRF could present signs of CSC. This clinical presentation could be confused with neovascular AMD, and multimodal retinal imaging was crucial to guide correct diagnosis and management.

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Purpose: To report a case of progressive Chiari malformation type I (CIM) in a patient with unilateral sporadic retinoblastoma (RB) treated with intra-arterial chemotherapy (IAC) and enucleation. Methods: A 5-year-old male patient with a history of RB in his left eye treated with IAC and enucleation presented to our clinic for routine RB surveillance. Radiotherapy had not been used for the treatment of his RB. Results: A progressive herniation of cerebellar tonsils through the foramen magnum was detected on follow-up magnetic resonance imaging (MRI). Brain and cervical MRI revealed no central nervous system mass, hydrocephalus, or syringomyelia. There was no history of head trauma. Conclusion: Progressive CIM may occur in unilateral sporadic RB.

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Purpose: To report a case of bilateral scleral compromise in a male patient with hereditary porphyria cutanea tarda (PCT). Methods: Case report. Results: A 57-year-old male was referred to the Cornea Service at Hospital de Clinicas in Buenos Aires for bilateral scleral thinning. He claimed ocular discomfort and photophobia. Slit-lamp biomicroscopy revealed an oval area of deep scleral thinning without uveal prolapse, adjacent to a conjunctival hyperemic zone in the interpalpebral area, 2 mm temporal to the limbus in the right eye. The left eye presented with a conjunctivalized scleral thinning in the interpalpebral area, 2 mm temporal to the limbus. Physical examination revealed facial hyperpigmentation and hypertrichosis and multiple hypopigmented scars in hands and nails. His family history was positive for PCT. The diagnosis was made by urine porphyrin test and genetic molecular testing. In an attempt to reduce ocular and systemic levels of porphyrins, the patient was treated with oral hydroxychloroquine and repeated phlebotomies, altogether with specially designed glasses to avoid local exposure to sunlight. Conclusions: Scleral involvement is a rare manifestation of PCT. An adequate treatment, including interdisciplinary management may ameliorate ocular signs and symptoms.

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Purpose: To evaluate reading performance in different preferred retinal loci (PRLs) using a Persian version of a Minnesota Low Vision Reading (MNREAD) chart in Persian-speaking patients with age-related macular degeneration (AMD). Methods: In this cross-sectional study, 35 patients with AMD were assessed. The reading performance was investigated by the MNREAD chart without using low vision aids. The location of PRL was determined monocularly using an MP1 microperimeter (Nidek Technologies, Padua, Italy). The anatomical location of the fovea was determined using optical coherence tomography (OCT). Images were taken with the MP1 microperimeter, and Spectralis HRA-OCT device was processed using graphic software to determine the location of the PRL on the retina. Results: Thirty-five patients (51 eyes) with a mean age of 73.8 ± 7.7 years (range, 54–88 years) were assessed. Mean best corrected distance visual acuity (logMAR) was 0.65 ± 0.35 (range, 0.2–1.3). Mean levels of reading acuity (RA) (P = 0.009) and critical print size (CPS) (P = 0.015) were significantly different in different locations of PRL. Average scores of maximum reading speed (MRS) (P = 0.058) and reading accessibility index (ACC) (P = 0.058) were not statistically significant in different locations of PRL. There was a positive correlation between PRL-fovea distance and RA (P < 0.001, r = 0.591) and CPS (P < 0.001, r = 0.614). Significant negative correlations were observed between PRL-fovea distance and MRS (P < 0.001, r = −0.519) and ACC (P < 0.001, r = −0.545). Conclusions: This study provides evidence for differences in the reading performance of Persian-speaking patients with AMD in different PRL locations. The average scores of all reading indices obtained in the right-field PRL are lower than those in other areas and are highly correlated with the PRL-fovea distance.

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Purpose: To explore the correlation between retinal capillary non-perfusion and the distribution of retinal neovascularization and vascular leakage (VL) in patients with proliferative diabetic retinopathy (PDR). Methods: Ultra-widefield angiograms of 96 eyes of 69 patients with PDR were reviewed for the proportion of non-perfused area to total gradable area, and for the presence of neovascularization and VL. Results: Retinal neovascularization was distributed as such: neovascularization elsewhere (NVE), 57.3%; neovascularization of the disc (NVD), 11.5%; both neovascularization of the disc and elsewhere (NVED), 31.3%. The proportion of non-perfused retina, so-called ischemic index, was greater in eyes with NVED compared to eyes with NVE only, but not when compared to NVD only. Overall, 83% of eyes had VL. The presence and the extent of VL correlated with the proportion of the ischemic index. While VL and ischemic index were more severe in the mid-periphery and far-periphery, the majority of NVE was located in the posterior pole. Conclusions: The presence of both NVD and NVE is associated with a greater ischemic index than NVE alone. Although both VL and ischemic index is significantly higher in peripheral zones, the majority of neovascularization occurs at the posterior pole.

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Purpose: To determine intraocular pressure (IOP) changes after intravitreal bevacizumab or ranibizumab injection administered for various retinal disorders. Methods: A retrospective chart review of 796 eyes of 574 patients receiving intravitreal ranibizumab (0.5 mg) and/or bevacizumab (1.25 mg) injection for different retinal diseases from March 2009 to December 2016 was performed. Ocular hypertension (OHT) was defined as IOP >21 mmHg or an increase in IOP of >5 mmHg from the baseline. IOP at the baseline and at various time periods after the injection was evaluated in the injected eyes and fellow control eyes. Results: One hundred and thirty-one eyes received either a single dose of bevacizumab or ranibizumab intravitreal injection unilaterally, 222 patients received single injection in both the eyes (n = 444 eyes), and 221 eyes received multiple doses of the injection. OHT was noted in 11 eyes (1.38%), of which 3 eyes (0.38%) had transient OHT and 8 eyes (1%) had delayed and sustained OHT and among them, 3 eyes (0.4%) progressed to glaucoma. Preinjection IOP was significantly higher in the treated eyes when compared to the control untreated eyes (P = 0.006). Conclusions: Incidence of delayed and sustained OHT is low after a single or multiple intravitreal bevacizumab and ranibizumab injections. Clinicians should be aware of possibility of OHT or glaucoma after the procedure.

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Purpose: To evaluate choroidal changes in central serous chorioretinopathy (CSCR) patients after water-drinking test (WDT). Methods: This prospective study included treatment-naïve acute and chronic CSCR eyes and healthy controls. Intraocular pressure and optical coherence tomography measurements with choroidal vascular index (CVI) measurements were done at baseline. Patients were asked to drink 1 L of water, and tests were repeated at 15, 30, and 45 min. Results: Fifty-six eyes from 42 patients were enrolled. Choroidal area, luminal area, and stromal area were higher at baseline in eyes with acute CSCR compared to healthy controls. Chronic CSCR eyes showed an increase in choroidal area and stromal area and a decrease in the luminal area at 15 min. There was a significant decrease in CVI at 30 and 45 min in chronic CSCR and CVI at 45 min in fellow eyes of acute CSCR. Repeated-measures analysis of variance (ANOVA) showed a significant change in central macular thickness in acute CSCR, choroidal thickness in fellow eyes of acute CSCR, stromal area, and total choroidal area in chronic CSCR. Mixed model ANOVA showed that the change in various choroidal parameters seen had no interaction with the eye type. Conclusion: Although change in various parameters was seen in acute CSCR, chronic CSCR, and fellow eyes of acute CSCR following WDT, the change was not significantly different among the groups.

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Purpose: To report the visual outcomes of intravitreal (IVT) anti-vascular endothelial growth factor (anti-VEGF) in inflammatory choroidal neovascularization (iCNV). Methods: A retrospective study of 43 eyes of 38 patients with active choroidal neovascularization (CNV) related to ocular inflammatory disease, treated with IVT injections of anti-VEGF (bevacizumab, ranibizumab, or aflibercept), with or without associated systemic anti-inflammatory therapy, at Fattouma Bourguiba University Hospital, Monastir, Tunisia (24 eyes of 23 patients) and at Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy (19 eyes of 15 patients) from January 1, 2013, to December 31, 2018. Results: The mean age was 35.5 ± 16.4 years. The sex ratio male:female was 0.27. Seventeen eyes (39.5%) of 17 patients (44.7%) had only anti-VEGF injections, and 26 eyes (60.5%) of 21 patients (45.3%) had anti-VEGF injections and associated systemic anti-inflammatory therapy. Bevacizumab was injected in 36 eyes (83.7%), ranibizumab in six eyes (14%), and aflibercept in one eye (2.3%). Mean follow-up was 20.3 ± 19.2 months (range, 6–106 months). Mean visual acuity improved from 0.8 ± 0.37 logMAR (approximate Snellen equivalent 20/125) to 0.51 ± 0.42 logMAR (approximate Snellen equivalent 20/63) (P < 0.001). Mean central macular thickness on optical coherence tomography decreased from 403.7 ± 121.9 to 293.7 ± 82.8 μm (P < 0.001). Mean gain of vision was 2.9 ± 3.1 lines. The mean number of injections was 2.5. Twenty eyes (46.5%) received a single injection. There were no side effects related to the IVT injections of anti-VEGF. Conclusions: CNV is a sight-threatening complication of uveitis. IVT anti-VEGF seems to be an effective and safe treatment for iCNV when inflammation is controlled.

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Purpose: To evaluate corneal endothelial health after cataract surgery without viscoelastic substance (VS). Methods: A prospective, non-randomized, case-series study was developed, and phacoemulsification cataract surgery without VS was performed on 1324 eyes between September 2015 and September 2018. As main outcomes, mean endothelial cell density (ECD) and mean central corneal thickness (CCT) were assessed before surgery and then 6 and 12 months after surgery. Data are summarized as mean, standard deviation (SD), and 95% confidence intervals (CI). Results: A total of 1324 eyes were operated, and 31 were excluded by intraoperative complications. The mean ECD baseline was 2506 cells/mm² (SD = 215, CI = 2494–2518); 6 months after surgery, it was 2328 cells/mm² (SD = 213, CI = 2316–2340); and 1 year after surgery, it was 2265 cells/mm² (SD = 214, CI = 2253–2277). In terms of percentage differences, the mean ECD decrease was 9.4% after 1 year. The mean preoperative CCT was 531.6 μm (SD = 34.8, CI = 529.7–533.5); 6 months after surgery, it was 537.7 μm (SD = 38.2, CI = 535.6–539.8); and 1 year after surgery, it was 537.9 μm (SD = 37.9, CI = 535.8–540.0). The mean CCT increased 1.2% 1 year after surgery. Conclusions: Phacoemulsification cataract surgery can be completely performed without VS, with very low intraoperative complications. The postoperative ECD and CCT changes occurred primarily during the first 6 months, and the changes decreased during the second semester.

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Purpose: To investigate the changes in the optical corneal densitometry as an objective method in assessing the corneal light back-scattering before and 1 year after the annular intracorneal inlay (AICI) implantation into the keratoconic corneas. Methods: Changes in the optical corneal densitometry, visual acuity, refractive, and tomographical status were assessed before and 1 year after the AICI implantation into the corneas with different stages of keratoconus. Optical corneal densitometry was evaluated using the Pentacam-HR in 0–2, 2–6, 6–10, and 10–12 mm rings in the anterior 120 μ, central layers, posterior 60 μ and also the total value were measured for cornea in the Grey Scale Unit criterion. Results: Totally, 34 patients with keratoconus were studied; the uncorrected and best corrected visual acuity were increased after the surgery (0.98 ± 0.25 to 0.53 ± 0.30 logMAR, P < 0.001 and 0.26 ± 0.18 to 0.19 ± 0.14, P = 0.007 logMAR, respectively); the spherical equivalent was decreased from −4.45 ± 2.25 to − 2.06 ± 2.01 D (P = 0.004). AICI implantation led to an increase in the amount of optical corneal densitometry in 0–2 mm central, 2–6 mm central, 6–10 mm central, total central, 2–6 mm posterior, and 2–6 mm total rings (all, P < 0.05); however, a decrease was observed in 0–2 mm anterior ring (P = 0.049). Results of statistical analysis showed that the total optical corneal densitometry, anterior total, and posterior total back-scattering did not change after the AICI implantation (all, P > 0.05). Conclusions: Our results revealed a significant improvement in the visual function, including refractive error and visual acuity following the AICI implantation. Changes in the optical corneal densitometry were different in distinct regions and layers however, the total amount did not change after the AICI implantation.

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Purpose: To evaluate the efficacy of three-muscle surgery for the treatment of large-angle exotropia with particular attention to the success rate and mean dose-response ratio. Methods: In a retrospective study, medical records were reviewed for 48 patients with exodeviation between 50 and 80 prism diopter (PD) who underwent bilateral lateral rectus recession as well as one medial rectus resection. Sex, age at surgery, presence of amblyopia, amount of preoperative and postoperative deviation, total amount of recessed and resected muscles, dose-response ratio, and associated vertical deviations were analyzed. Results: The mean age of patients at surgery was 25.4 ± 14.3 years old (range, 1–55). The mean preoperative deviation was measured 62.8 ± 7.5 PD (range, 50–80 PD). The mean amount of total recession and resection was 23 ± 1.3 mm. After a mean follow-up of 15 ± 25 months (range, 3–144), 85.4% of patients were within 10 PD of orthophoria. The mean postoperative deviation decreased to 3.8 ± 7.5 PD (range, 0–30 PD). A mean dose-response ratio of 2.5 ± 0.3 PD/mm (range, 0.9–3.1 PD/mm) was found. Of all patients, 14.6% demonstrated undercorrection. Conclusion: Simultaneous surgery on three muscles is an effective method in resolving large-angle exotropia and results in excellent outcomes with low risk of undercorrection.

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Purpose: To evaluate the results of overminus lens therapy in the management of children with intermittent exotropia or X(T). Methods: In this retrospective study, 163 consecutive patients with X(T) who were treated with overminus spectacles with at least 12 months of follow-up were included in the study. The outcome measures were the level of X(T) control evaluated using the Jampolsky's qualitative assessment method and refractive error changes under overminus lens treatment. Results: The mean angle of deviation at the initial visit was 24.7 ± 15.1 prism diopters (PD) that improved to 10.6 ± 4.2 PD with overminus glasses with a median follow-up of 38 months (P = 0.02). One hundred and nine patients (66.8%) achieved good controlled X(T) or orthotropia by overminus lens therapy after 1 year. Three patients progressed to esotropia, which disappeared after discontinuing overminus lens therapy. Overminus lens therapy did not have a statistically significant effect on the mean spherical equivalent of cycloplegic refraction in each eye (right eye: P = 0.13; left eye: P = 0.15). Conclusions: Overminus lens therapy can be effective for improving the control of X(T) in young children. It can defer the requirement for surgery or decrease the rate of surgical intervention.

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Purpose: To evaluate the patient satisfaction of intravitreal bevacizumab (IVB) injection services for ocular complications of diabetes mellitus (DM) at a referral center. Methods: Patients with diabetic macular edema (DME) and diabetic retinopathy (DR) who had undergone IVB injections between March and September 2018 were interviewed by telephone using two questionnaires. First, demographic information, medical history, and the Patient Satisfaction Questionnaire Short Form (PSQ-18) 5-point scale were collected. Then, the Retinopathy Treatment Satisfaction Questionnaire (RetTSQ) 7-point scale was completed. Total scores are presented on a 100-point scale, with 100 indicating complete satisfaction. Results: Two hundred and fifty patients (145 with DME and 105 with DR) were interviewed (mean age: 61 ± 10 years; male-to-female ratio: 1:1.5). The response rate was 96%. Twenty-one patients had only one injection. Two hundred and forty-eight (99.2%) patients had insurance. The mean number of total injections was 12.2 ± 11.5. Seventy (28%), forty-seven (18.8%), sixty-one (24.4%), and seventy-two (28.8%) patients underwent IVB treatment for <6 months, between 7 and 12 months, between 13 and 24 months, and >25 months, respectively. The mean total and overall scores were 90.8 ± 22.5 (completely satisfied) and 88.7 ± 16.6 (completely satisfied) based on PSQ-18 and RetTSQ, respectively. Financial problems and appointment scheduling systems were the highest cases of dissatisfaction. Conclusion: The majority of patients were highly satisfied with IVB injections for the management of ocular complications of DM. The appointment taking procedure, waiting times, out-of-pocket expenses, and access to the hospital should be improved.

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Purpose: To evaluate filtering bleb characteristics using anterior segment optical coherence tomography (AS-OCT) and analyze correlations between these parameters and intraocular pressure (IOP). Methods: The study included 54 eyes of 43 patients who underwent trabeculectomy with mitomycin-C. The patients were divided into two groups based on mean postoperative IOP. The criterion for surgical success was mean unmedicated postoperative IOP ≤18 mmHg. Patients with IOP values >18 mmHg were prescribed anti-glaucoma drops and classified as a surgical failure. All patients underwent AS-OCT, and maximum bleb height, maximum bleb wall thickness, and maximum fluid-filled cavity height were measured. AS-OCT bleb parameters were compared between the successful and failed groups. Results: Of the 54 eyes, 37 (68.5%) were in the successful group, and 17 (31.5%) were in the failed group. Mean preoperative IOP values in the successful and failed groups were 26.9 ± 6.5 mmHg and 22.9 ± 4.9 mmHg, preoperatively, versus postoperative values of 13.3 ± 2.1 mmHg and 22.8 ± 2.8 mmHg, respectively. Mean postoperative follow-up time was 17.4 ± 9.5 months in the successful group and 19.1 ± 10.1 months in the failed group (P = 0.22). In the successful and failed groups, mean bleb height was 1473.7 ± 150.6 μm and 1165.4 ± 217 μm (P < 0.001), bleb wall thickness was 670.5 ± 119.9 μm and 538.8 ± 144.3 μm (P = 0.001), and fluid-filled cavity height was 736.5 ± 196.8 μm versus 532.5 ± 226.2 μm (P = 0.001), respectively. Conclusions: The results of this study showed that higher AS-OCT values for bleb height, wall thickness, and fluid-filled cavity height were associated with greater functional success. These parameters may be helpful in determining bleb functionality.

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Purpose: To evaluate acute changes in intraocular pressure (IOP) and their short-term effects on the peripapillary retinal nerve fiber layer (RNFL) thickness after intravitreal bevacizumab (IVB) injection. Methods: Fifty-eight eyes of 37 patients with treatment-naïve diabetic macular edema or exudative age-related macular degeneration were included in the study. Patients were divided into two groups, and the participants of each group received 3 monthly injections of IVB. IOP was measured right before the injection, immediately after the injection, and 5 min and 20 min after each injection. Peripapillary, RNFL thickness was measured before the injection and 1 month after the third injection. In the second group, anterior chamber (AC) paracentesis was performed before IVB injection. Results: IOP values after injection in all sessions were significantly higher in the first group (P < 0.001). The peripapillary RNFL thickness changes 1 month after the third injection was not statistically significantly different in each group (P = 0.816 and 0.773 for the first and second groups, respectively). Conclusion: AC paracentesis is an effective modality to reduce the acute rise in IOP. The effect of acute IOP elevation on the peripapillary RNFL thickness was not statistically significant.

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