Purpose: To assess digital eye strain (DES) among schoolchildren during lockdown. Methods: An online questionnaire-based, cross-sectional study was conducted. A validated, self-administered, electronic questionnaire was circulated among students of 5–18 years of age. The duration of data collection was from May 18, 2020 to May 24, 2020. Rasch-based Computer-Vision Symptom Scale was deployed to measure the DES. Results: A total of 654 students (mean age: 12.02 ± 3.9 years) completed the survey. The average per day digital device exposure was 5.2 ± 2.2 h. A total of 507 (92.8%) children reported experiencing at least one asthenopic/dry eye symptom (AS/DS). The most prevalent symptoms were eye redness (69.1%) and heaviness of eyelids (79.7%). Significant positive correlation was reported between age and per day duration of digital device exposure (Pearson correlation 0.25; P < 0.001). Computer vision syndrome (CVS) score for spectacle users was significantly higher (P < 0.001). CVS score was found to correlate significantly with age and duration of digital device exposure (P < 0.001). Conclusion: Most of the students surveyed, experienced at least one symptom of DS or AS, indicating a need to educate them about the possible deleterious effects and help them adapt to the currently evolving education system.

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Purpose: To review the diagnostic criteria for Tolosa–Hunt syndrome (THS) and utility of recent modifications. Methods: We searched PubMed for keywords Tolosa Hunt and magnetic resonance imaging. We compared the three editions of International Classification of Headache Disorders and isolated case reports and case series with the assessment of cavernous internal carotid artery (ICA) caliber to find the prevalence of vascular anomalies. We also evaluated cases of THS with the involvement of extracavernous structures and the possible role of idiopathic hypertrophic pachymeningitis (HP). Cases diagnosed falsely as THS were also reviewed for the presence of atypical features and relevance of criterion D. We assessed nonconforming cases (those with normal neuroimaging benign THS) and idiopathic inflammatory orbital pseudotumor (IIPO). Results: Vascular abnormalities were found in 36.36% of THS cases. Benign THS may also show changes in ICA caliber. Evidence suggestive of idiopathic HP could be found in 57% of cases with the involvement of extracavernous structures, such as facial nerve and pituitary gland. Both THS and IIPO are steroid-responsive pathologies with similar clinical and radiological features. False-positive diagnosis of THS results from early labeling, based solely on clinical features and symptom resolution after steroid therapy. Conclusions: Benign THS may be a result of limitation of resolution of available neuroimaging technique or early testing. Early and late vascular changes can be seen in both THS and its benign variant; some of them are not innocuous. THS may be considered a type of focal idiopathic HP. IIPO may represent an anterior variant of THS. In the absence of histopathological diagnosis, steroid-induced resolution of symptoms should be confirmed radiologically and followed-up.

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Purpose: To compare the effects of two types of mesenchymal stem cells (MSCs), activated omental cells (AOCs), and adipose tissue-derived stem cells (ADSCs) in the healing process of animal model of ocular surface alkali injury. Methods: An alkaline burn was induced on the ocular surfaces of eighteen rats divided randomly into three groups. The first and second groups received subconjunctival AOCs and ADSCs, respectively. The control group received normal saline subconjunctival injection. On the 90^th day after the injury, the eyes were examined using slit-lamp biomicroscopy. Corneal neovascularization and scarring were graded in a masked fashion. Histological evaluation of the corneal scar was performed, and the number of inflammatory cells was evaluated. Results: Corneal neovascularization scores revealed higher neovascularization in the control (0.49 ± 0.12) than the AOC (0.80 ± 0.20, P = 0.01) and ADSC groups (0.84 ± 0.24, P = 0.007). There were no statistically significant differences between the neovascularization score of the AOC and ADSC groups (P > 0.05). According to histologic evaluation, stromal infiltration was significantly more in the control group compared to AOC and ADSC groups (P < 0.05). Conclusions: Our results suggest that MSCs, even with different sources, can be used to promote wound healing after corneal chemical burns. However, the ease of harvesting ADSC from more superficial fat sources makes this method more clinically applicable.

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Purpose: To evaluate the effects of low-level laser therapy (LLLT) on the retina with diabetic retinopathy (DR). Methods: Eight Wistar rats were used as a control group, and 64 rats were injected intraperitoneally with 55 mg/kg of streptozotocin to induce diabetes and served as a diabetic group. After the establishment of the DR, the rats were separated into (a) 32 rats with DR; did not receive any treatment, (b) 32 rats with DR were exposed to 670 nm LLLT for 6 successive weeks (2 sessions/week). The retinal protein was analyzed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis, total antioxidant capacity (TAC), hydrogen peroxide (H₂O₂), and histological examination. Results: LLLT improved retinal proteins such as neurofilament (NF) proteins (200 KDa, 160 KDa, and 86 KDa), neuron-specific enolase (NSE) (46 KDa). Moreover, the percentage changes in TAC were 46.8% (P < 0.001), 14.5% (P < 0.01), 4.8% and 1.6% (P > 0.05), and in H₂O_2, they were 30% (P < 0.001), 25% (P < 0.001), 20% (P < 0.01), and 5% (P > 0.05) after 1, 2, 4, and 6 weeks, compared with the control. DR displayed swelling and disorganization in the retinal ganglion cells (RGCs) and photoreceptors, congestion of the capillaries in the nerve fiber layer, thickening of the endothelial cells' capillaries, and edema of the outer segment of the photoreceptors layer. The improvement of the retinal structure was achieved after LLLT. Conclusion: LLLT could modulate retinal proteins such as NSE and NFs, improve the RGCs, photoreceptors, and reduce the oxidative stress that originated in the retina from diabetes-induced DR.

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Purpose: To present a case of bilateral Brown syndrome who presented as a unilateral disease and then showed the disease in the fellow eye in an older age. Methods: A 4-year-old girl presented with congenital Brown syndrome of the left eye and underwent a superior oblique weakening procedure in that eye, but then developed Brown syndrome in the right eye which required two more surgeries on the right eye to attain an acceptable alignment. Results: Her orbital computed tomography scan revealed that the distance between the annulus of Zinn and trochlea (Z-T distance) was 41.2 mm in both sides, which was comparatively longer than her age- and sex-matched cases. This finding can suggest a possible mechanism of Brown syndrome development in some patients. Conclusion: Bilateral Brown syndrome can present as a sequential disease, and its radiologic finding may be associated with increased Z-T distance.

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Purpose: To determine economic inequality in visual impairment (VI) and its determinants in the rural population of Iran. Methods: In this population-based, cross-sectional study, 3850 individuals, aged 3–93 years were selected from the north and southwest regions of Iran using multi-staged stratified cluster random sampling. The outcome was VI, measured in 20 feet. Economic status was constructed using principal component analysis on home assets. The concentration index (C) was used to determine inequality, and the gap between low and high economic groups was decomposed to explained and unexplained portions using the Oaxaca–Blinder decomposition method. Results: Of the 3850 individuals that were invited, 3314 participated in the study. The data of 3095 participants were finally analyzed. The C was −0.248 (95% confidence interval [CI]: −0.347 - −0.148), indicating a pro-poor inequality (concentration of VI in low economic group). The prevalence (95% CI) of VI was 1.72% (0.92–2.52) in the high economic group and 10.66% (8.84–12.48) in the low economic group with a gap of 8.94% (6.95–10.93) between the two groups. The explained and unexplained portions comprised 67.22% and 32.77% of the gap, respectively. Among the study variables, age (13.98%) and economic status (80.70%) were significant determinants of inequality in the explained portion. The variables of education (coefficient: −4.41; P < 0.001), age (coefficient: 14.09; P < 0.001), living place (coefficient: 6.96; P: 0.006), and economic status (coefficient: −7.37; P < 0.001) had significant effects on inequality in the unexplained portion. Conclusions: The result showed that VI had a higher concentration in the low economic group, and the major contributor of this inequality was economic status. Therefore, policymakers should formulate appropriate interventions to improve the economic status and alleviate economic inequality.

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Purpose: To describe optical coherence tomography (OCT) characteristics of central serous chorioretinopathy (CSCR) without any hyperfluorescent leakage on fundus fluorescein angiography (FFA). Methods: This was a multicentric, retrospective, observational study of ten eyes of ten patients with CSCR without any hyperfluorescence leakage on FFA. Baseline patient characteristics, best corrected visual acuity, and OCT parameters like relative retinal pigment epithelium (RPE) reflectivity at the presumed leak site and control site were measured. Results: Increased macular thickness, neurosensory detachment, and choroidal thickness were seen at the site of maximum subretinal fluid (SRF). Out of ten eyes, nine had photoreceptor outer segment (PROS) disruption (46% ± 26.33%) at the site of SRF pocket, and five had presumed former leak site characterized by PROS thinning. The presumed leak site demonstrated higher RPE reflectivity compared to the control site (0.92 ± 0.04 vs. 0.87 ± 0.04; P = 0.0058). Conclusion: CSCR without hyperfluorescent leakage on FFA may have PROS damage and changes in RPE hyperreflectivity.

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Purpose: To study the clinical and the functional findings in glaucomatous patients under preserved eye drops having ocular surface alterations and to analyze their risk factors. Methods: A cross-sectional study of 155 glaucomatous patients was conducted. All of them answered the “Ocular Surface Disease Index” (OSDI) questionnaire and had a complete and precise evaluation of the ocular surface state including a Schirmer I test, a tear break-up time evaluation, eyelid, conjunctival, and corneal examination with a Fluorescein and a Lissamin green test. We studied factors that could influence the OSDI score and each type of ocular surface alteration (age, sex, glaucoma treatment duration, number and type of the active principle, and Benzalkonium Chloride [BAK] use). Results: BAK was used in 80% of cases. The OSDI score was ≥13, in 61.3% of cases. The biomicroscopic signs of ocular surface disease were at least minimal in 87.1% of cases. The main predictors of OSDI score increase were the glaucoma treatment duration (P = 0.01, t = 2.618), the number of molecules used (P = 0.018, t = 2.391), and the use of BAK (P = 0.011, t = 2.58). The severity of the biomicroscopic signs correlated with these same risk factors. Fixed combination was statistically associated with a lower incidence of superficial punctate keratitis (SPK) and corneal and conjunctival staining in the Lissamine green test (P < 0.001). Beta-blockers were associated with a significantly higher risk of SPK and corneal or conjunctival staining in the Lissamine green test (P < 0.001). Conclusions: Preserved antiglaucomatous eye drops alter the patients' ocular surface. The main risk factors were advanced age, duration of glaucoma treatment, multiple therapies, and the use of BAK.

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Purpose: To determine the prevalence of fusional vergence dysfunction (FVD) and its relationship with age, sex, and refractive errors in a population-based study. Methods: In this cross-sectional study, all residents of Mashhad, northeast of Iran, aged >1 year were subjected to random stratified cluster sampling. After selecting the participants, they all underwent complete optometric examinations including the measurement of visual acuity and refraction, assessment of binocular vision and accommodative status, and slit-lamp biomicroscopy. Results: Of 4453 invited individuals, 3132 participated in the study. After applying the exclusion criteria, statistical analysis was performed on the data of 1683 participants. The prevalence of FVD was 3.2% in all participants, 4.0% in men, and 2.9% in women (P = 0.234). The prevalence of FVD increased linearly with aging from 2.3% in the age group of 10–19 years to 5.4% in the age group of 40–49 years (P = 0.034). The prevalence of myopia, hyperopia, and emmetropia was 11.1%, 29.6%, and 59.3% in participants with FVD and 16.7%, 26.4%, and 57% in participants without FVD, respectively (P = 0.570). Multiple logistic regression analysis only showed a significant association between age and FVD (odds ratio =1.03 95% confidence interval: 1.02–1.05, P = 0.031). Conclusion: The prevalence of FVD in this study was higher than most previous reports and increased significantly with aging. FVD had no significant association with sex and refractive errors.

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Purpose: To investigate the retinal vascular characteristics among patients with different types of inherited retinal dystrophies (IRDs). Methods: This comparative cross-sectional study was conducted on 59 genetically confirmed cases of IRD including 37 patients with retinitis pigmentosa (RP) (74 eyes), 13 patients with Stargardt disease (STGD) (26 eyes), and 9 patients with cone-rod dystrophy (CRD) (18 eyes). Both eyes of 50 age- and sex-matched healthy individuals were investigated as controls. All participants underwent optical coherence tomography angiography to investigate the vascular densities (VDs) of superficial and deep capillary plexus (SCP and DCP) as well as foveal avascular zone area. Results: In RP, significantly lower VD in whole image (P = 0.001 for DCP), fovea (P = 0.038 for SCP), parafovea (P < 0.001 for SCP and DCP), and perifovea (P < 0.001 for SCP and DCP) was observed compared to controls. In STGD, VD of parafovea (P = 0.012 for SCP and P = 0.001 for DCP) and fovea (P = 0.016 for DCP) was significantly lower than controls. In CRD, the VD of parafovea (P = 0.025 for DCP) was significantly lower than controls. Whole image density was significantly lower in RP compared to STGD (P < 0.001 for SCP) and CRD (P = 0.037 for SCP). VD in parafovea (P = 0.005 for SCP) and perifovea (P < 0.001 for SCP and DCP) regions was significantly lower in RP compared with STGD. Also, foveal VD in STGD was significantly lower than RP (P = 0.023 for DCP). Conclusion: Our study demonstrated lower VDs in three different IRDs including RP, STGD, and CRD compared to healthy controls. Changes were more dominant in RP patients.

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Purpose: To report a rare case of primary pneumosinus dilatans (PSD) and to specify the cardinal imaging findings associated with this condition. Methods: A 20-year-old patient presented with bilateral profound visual loss as a result of primary PSD. A detailed review of clinical findings and presumed pathophysiological basis of vision loss was performed. Results: Other than undiagnosed primary hypothyroidism, no other abnormalities were found. With the diagnosis of PSD, the patient underwent optic nerve decompression through transnasal sphenoidotomy. However, after nine months of follow-up, no improvement in the patient's vision was attained. Conclusion: Unlike previous reports of favorable visual results after sphenoidotomy and bilateral decompression of the optic nerves, vision recovery was not achieved in this case.

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Purpose: To report a rare paradoxical development of systemic sarcoidosis in a patient taking adalimumab manifesting as multifocal choroidal infiltrates and seventh nerve palsy. Methods: This was a single patient case report. Results: A 30-year-old man with a history of psoriatic arthritis on adalimumab presented with intermittent fevers and headaches. Initial infectious serology and initial ophthalmic examination were within normal limits. Over the next month, he developed a seventh nerve palsy, unilateral decreased visual acuity, and bilateral multifocal choroidal infiltrates. The patient was diagnosed with systemic sarcoidosis secondary to tumor necrosis factor alpha (TNFα) inhibitor use after a hilar lymph node biopsy. Upon treatment with high-dose oral corticosteroids, the patient's symptoms and choroidal lesions significantly improved. Conclusion: This case report illustrates a rare presentation of ocular, neurologic, and systemic sarcoidosis presenting as a bilateral multifocal choroiditis and seventh nerve paresis in a patient treated with adalimumab. We highlight the importance of obtaining an ophthalmic evaluation in the management of this rare adverse effect of TNFα inhibitors.

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Purpose: To report a case of Sturge–Weber syndrome (SWS) complicated with uncontrolled glaucoma and serous retinal detachment (SRD) in the left eye that evolved with complete resolution after trabeculectomy. Methods: We report the case of a 10-year-old boy with SWS complicated with uncontrolled glaucoma and SRD in the left eye. In primary evaluation, he presented with a left-sided nevus flammeus affecting upper eyelid and best corrected visual acuity of 20/50 on the affected eye. Fundus examination revealed glaucomatous optic nerve neuropathy and diffuse choroidal hemangioma with overlying SRD, which were confirmed with spectral domain optical coherence tomography. Right eye was unremarkable. Results: The patient underwent trabeculectomy with mitomycin-C on the affected eye. Two weeks later, he presented with normalization of the intraocular pressure and substantial resolution of subretinal fluid (SRF), which improved to complete resolution of the SRD at 2 months of follow-up. In addition, there was an improvement of visual acuity from 20/50 to 20/40. Conclusion: This is the first report to describe a case of SWS associated with SRD and resolution of SRF after trabeculectomy.

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Purpose: To report a case of central retinal artery (CRA) occlusion secondary to prepapillary loop in a 13-year-old girl. Methods: A 13-year-old girl presented with a history of sudden visual loss in her left eye. Results: Fundus examination confirmed thrombosis in a prepapillary arterial loop causing CRA occlusion and extensive retinal ischemia. Macular region was watered by an anomalous macular branch, which explained her 20/20 vision central vision. Conclusion: Congenital prepapillary vascular loops are rare and usually asymptomatic. We report a case of central artery occlusion confirmed by multimodal imaging.

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Purpose: To evaluate the outcome of eyes with large Descemet's membrane (DM) perforation during deep anterior lamellar keratoplasty (DALK). Methods: A retrospective, interventional case series of 12 eyes with completed DALK, despite DM perforation larger than 4 mm in its widest dimension. The main outcome measures included graft clarity, endothelial cell density (ECD), corrected distance visual acuity (CDVA), and DM detachment. Results: The mean age of patients was 26.8 ± 11.4 years. Preoperative pathology included keratoconus (n = 10), macular dystrophy (n = 1), and postmicrobial keratitis corneal scar (n = 1). The average size of DM perforation was 6.5 mm ± 1.3 mm. At the end of the follow-up period (median 15 months, range 6–53 months), the mean CDVA was 0.32 ± 0.09 logMAR and the mean ECD was 1830.8 ± 299.7 cells/mm². Nine patients (75%) developed DM detachments postoperatively and was managed by intracameral air injection once in six eyes, and twice in three eyes. Other complications included persistent localized stromal edema at the site of DM defect in one eye and Urrets Zavalia syndrome in one eye. Conclusion: Completing DALK in eyes with large DM perforation provides good visual acuity, endothelial cell count and may be superior to penetrating keratoplasty regarding long-term graft survival if confirmed in future comparative studies.

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Purpose: To evaluate medication and follow-up adherence in incarcerated patients examined at an academic glaucoma clinic, in comparison to nonincarcerated controls. Methods: Retrospective, case-control study. Consecutive prisoners presenting for initial visits in the Glaucoma Clinic at the Illinois Eye and Ear Infirmary between December 2015 and December 2017 were included in the study. Nonincarcerated patients seen in the same Glaucoma Clinic with similar initial visit dates, age, race, sex, and disease severity were selected as controls. Glaucoma Clinic visits from each patient were reviewed until December 2018. Examination information, surgical intervention, follow-up and treatment recommendations, and patient-reported medication usage were recorded for each visit. Number of visits, loss to follow-up, follow-up delays, and medication nonadherence were studied as primary outcome measures. Results: Twenty-four prisoners and 24 nonincarcerated controls were included. Prisoners had an average of 2.46 ± 2.38 visits during the study period, compared to 5.04 ± 3.25 for controls (P = 0.001). Follow-up visits occurred more than 30 days after the recommended follow-up time in 57.4% (95% confidence interval [CI]: 44.2%–70.6%) of prisoners, compared to 17.9% (95% CI: 10.2%–25.6%) of controls (P < 0.00001). 70.8% of prisoners (95% CI: 66.3–74.5%) were lost to follow-up, compared to 29.2% of controls (95% CI: 25.5%–32.9%; P < 0.01). Medication nonadherence rates were similar between prisoners (13.6%; 95% CI: 12.1%–15.2%) and controls (12.0%; 95% CI: 11.4%–12.6%; P = 0.78). Conclusions: Glaucoma follow-up adherence was significantly worse in prisoners compared to a nonincarcerated control population. Further study into causative factors is needed.

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Purpose: To investigate the availability and content of educational statements or recommendations disseminated by U. S. ophthalmologic organizations regarding perioperative management of antithrombotic agents for ophthalmic and orbital surgery, given the highly variable management of these agents by U. S. ophthalmologists and limited consensus recommendations in the literature. Methods: National U. S. ophthalmic surgical organization websites were systematically examined for educational statements, which were reviewed for discussion of perioperative management of antithrombotic agents including antiplatelet and anticoagulant medications. A “statement” was defined as either: (a) a guideline directed toward ophthalmologists or (b) a surgical/clinical educational posting directed toward ophthalmologists or patients. Results: Fourteen surgical organizations were identified, with eight of these publishing clinical/surgical educational statements. A total of 3408 organizational statements were identified, with 252 (7.4%) and 3156 (92.6%) statements directed toward physicians and patients, respectively. In total, 0.3% (9/3408) of statements discussed perioperative management of antithrombotics. These accounted for 0.8% (2/252) of ophthalmologist-directed statements and 0.2% (7/3156) of patient-directed statements. The majority of patient-directed statements (57.1%, 4/7) recommended that patients discuss antithrombotic cessation with their ophthalmologists, though ophthalmologist-directed information regarding these medications was scant or absent. Conclusions: Educational material from U. S. ophthalmologic organizations regarding perioperative management of antithrombotics is notably lacking despite the fact that ophthalmic and orbital surgeries carry unique vision-threatening hemorrhagic risks. Given these risks, as well as the medicolegal consequences of hemorrhagic complications in ophthalmic surgery, increased dissemination of educational material, and consensus statements by ophthalmic surgical organizations on the perioperative management of antithrombotics may be justified.

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Purpose: To compare intraocular pressure (IOP) values measured by ocular response analyzer (ORA) in contact lens-induced corneal warpage, normal, and keratoconic eyes. Methods: In a prospective, observational case–control study, 94 eyes of 47 warpage-suspected cases and 46 eyes of 23 keratoconic patients were enrolled. Warpage-suspected cases were followed until a definite diagnosis was made (warpage, nonwarpage normal, or keratoconus). ORA tonometry and corneal biomechanics testing were performed for all cases in each visit. We had 2–3 measured corneal-compensated IOP (IOPcc) and Goldmann-correlated IOP (IOPg) for each patient (based on group) with at least 2-week interval. Results: After following up of warpage-suspected patients, finally 44 eyes of 22 patients had confirmed soft contact lens-related corneal warpage. Forty-six eyes of 23 people were finally diagnosed as nonwarpage normal eyes. Forty-six eyes of 23 known keratoconus patients were also included for comparison. The demographic and refractive data were not different between the warpage and nonwarpage normal groups but were different in the keratoconus group. Both IOPcc and IOPg were statistically different with the highest value in the warpage group followed by normal and keratoconus groups; the same trend was observed in central corneal thickness (CCT). The mean of IOPg was 14.94 ± 2.65, 13.7 ± 2.33, and 10.86 ± 3 and IOPcc was 15.73 ± 2.4, 15.28 ± 2.43, and 14.08 ± 2.55 in the warpage, normal, and keratoconus groups, respectively. IOPg and IOPcc in the warpage group (based on baseline diagnosis) did not regress to become closer to IOP of normal eyes after discontinuation of contact lens in their follow-up visits (P value for IOPg and IOPcc trends in the warpage group was 0.07 and 0.09 controlling for CCT, respectively). Both IOPcc and IOPg were significantly lower in keratoconic eyes in comparison with normal eyes. After correction for the confounding effect of CCT, a lower IOPcc in keratoconus versus warpage remained significant (P = 0.02). Conclusion: Both IOPcc and IOPg were statistically different with the highest value in the warpage group followed by normal and keratoconus groups, just like their CCT. After correction for the confounding effect of CCT, there was no statistically significant difference between the three groups in their measured IOPcc and IOPg except for IOPcc in keratoconus versus warpage (P = 0.02).

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Purpose: To evaluate the dimensions of lower punctum in a sample of Iranian normal population using spectral domain anterior segment optical coherence tomography (OCT). Methods: In this cross-sectional study, 102 eyes of 102 healthy volunteers were enrolled. All participants underwent a detailed history and complete ophthalmic examination. Lower punctum metrics were measured using OCT (Spectralis, Heidelberg) with the anterior segment module. External punctal diameter was defined as the largest diameter at the surface of the punctum. Internal punctal diameter was measured at two different depths of 100 μm and 500 μm from the external surface. Measurements were repeated for 30% of data by another grader. The agreement was measured using intraclass correlation coefficient (ICC). Results: The mean age of the participants was 61.5 ± 7.9 years. The mean external punctal diameter was 425.6 ± 124.3 μm. The mean internal punctal diameter at 100 μm and 500 μm was 183 ± 97.5 μm and 77.7 ± 51.4 μm, respectively. The agreement between the graders was high in assessing all punctal characteristics (ICC >0.9 for all measurements). Conclusion: The spectral domain OCT can be used for measuring lower punctum diameter with acceptable reproducibility.

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