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An ophthalmic insight into novel coronavirus 2019 disease: A comprehensive review of the ocular manifestations and clinical hazards
Amani E Badawi, Sara S Elsheikh, Sarah Zaher Addeen, Mostafa A Soliman, Rami Abd-Rabu, Walid Shaban Abdella, Elham A Gad
October-December 2020, 32(4):315-328
Purpose: To discuss the ocular manifestations provoked by novel coronavirus 2019 (COVID-19) disease in humans, the natural history of the disease in the eye, and its treatment. Methods: We designed a narrative review of the ocular manifestations of COVID-19 based on the literature published till July 30, 2020. The databases were PubMed, Scopus, Cochrane Library, Google Scholar, and ScienceDirect. The inclusion criteria were (1) all types of clinical studies and (2) the topic was COVID-19 and its association to the eye regarding the current guidelines. Results: From 168 abstracts screened, 61 papers fully filled the inclusion criteria after the full-text screening. The 61 records include 13 case reports, 17 prospective (case series or cross-sectional) studies, 8 retrospective studies, 12 literature reviews (one systematic review), and 11 letters to the editor. The majority of the papers agreed that ophthalmic manifestations due to COVID-19 were few and rarely encountered. The main ocular pathology seemed to be conjunctivitis, where the viral polymerase chain reaction also happened to be most detectable. Posterior segment or neuro-ophthalmic manifestations were scarce. Viral genome detection in the eye as well as viral portal of entry to the globe is still vague. Conclusion: The exact incidence of ocular manifestations in COVID-19 disease is uncertain. Conjunctivitis is the most prevalent ocular manifestation. It is still a debate whether the eye is a portal of entry for infection.
  9,510 645 7
Non-surgical management options of intermittent exotropia: A literature review
Samira Heydarian, Hassan Hashemi, Ebrahim Jafarzadehpour, Amin Ostadi, Abbasali Yekta, Mohamadreza Aghamirsalim, Nooshin Dadbin, Hadi Ostadimoghaddam, Fahimeh Khoshhal, Mehdi Khabazkhoob
July-September 2020, 32(3):217-225
Purpose: To review current non-surgical management methods of intermittent exotropia (IXT) which is one of the most common types of childhood-onset exotropia. Methods: A search strategy was developed using a combination of the words IXT, divergence excess, non-surgical management, observation, overcorrecting minus lens therapy, patch/occlusion therapy, orthoptics/binocular vision therapy, and prism therapy to identify all articles in four electronic databases (PubMed, Web of Science, Google Scholar, and Scopus). To find more articles and to ensure that the databases were thoroughly searched, the reference lists of the selected articles were also reviewed from inception to June 2018 with no restrictions and filters. Results: IXT is treated when binocular vision is impaired, or the patient is symptomatic. There are different surgical and non-surgical management strategies. Non-surgical treatment of IXT includes patch therapy, prism therapy, orthoptic sessions, and overcorrecting minus lens therapy. The objective of these treatments is to reduce the symptoms and the frequency of manifest deviation by decreasing the angle of deviation or enhancing the ability to control it. Conclusions: Evidence of the efficacy of non-surgical management options for IXT is not compelling. More comprehensive randomized controlled trial studies are required to evaluate the effectiveness of these procedures and detect the most effective strategy.
  7,241 876 5
Artifacts in macular optical coherence tomography
Fatemeh Bazvand, Fariba Ghassemi
April-June 2020, 32(2):123-131
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.
  5,778 553 4
Vogt–Koyanagi–Harada is a curable autoimmune disease: Early diagnosis and immediate dual steroidal and non-steroidal immunosuppression are crucial prerequisites
Ioannis Papasavvas, Ilknur Tugal-Tutkun, Carl P Herbort
October-December 2020, 32(4):310-314
Purpose: It is crucial to subdivide Vogt–Koyanagi–Harada (VKH) disease into two subentities, initial-onset disease versus chronically evolving disease. For early diagnosis and precise follow-up of VKH choroiditis, the “Revised criteria for VKH” are no more sufficient for the appraisal of VKH and new biomarkers for disease activity are needed. It has been shown that, if initial-onset disease is treated promptly within the “therapeutic window of opportunity” and long enough with dual steroidal and non-steroidal immunosuppression, the disease can be cured in a large proportion of cases, an approach still contested. The proportion of chronic evolution and/or sunset-glow fundus (SGF) following steroidal monotherapy versus dual steroidal and non-steroidal immunosuppression was compared. Methods: A literature search was performed, identifying studies on initial-onset VKH treated either by steroidal monotherapy or dual immunosuppression. Evolution toward chronicity and/or SGF was compared in both groups. Results: Twenty studies were identified with reported long-term outcomes. In 16 studies, 802 patients received steroidal monotherapy, while in 4 studies, 172 patients received dual steroidal and non-steroidal immunosuppression. Chronic evolution and SGF occurred, respectively, in 44% and 59% in the corticosteroid-alone group versus 2.3% and 17.5% in the dual therapy group with no chronic evolution in three studies and no SGF in two studies. Conclusions: Chronic evolution and SGF are significantly less frequent in initial-onset VKH when treated with immediate dual steroidal and non-steroidal immunosuppression with a high proportion of healed cases. This combined approach seems recommended in the management of initial-onset VKH disease.
  5,860 460 10
Management of thyroid eye disease-related strabismus
Mohammad Reza Akbari, Arash Mirmohammadsadeghi, Raziyeh Mahmoudzadeh, Amirreza Veisi
January-March 2020, 32(1):1-13
Purpose: To review various treatment methods in thyroid eye disease (TED) related strabismus. Methods: We searched in PubMed and Google Scholar and Ovid MEDLINE for keywords including TED-related strabismus, strabismus in thyroid-associated ophthalmopathy, Graves' ophthalmopathy related strabismus or squint, and restrictive strabismus. Two expert strabismus specialists selected and evaluated the English articles that were related to our paper and had been published since 2000. Some articles were added based upon the references of the initial articles. Results: One hundred fifteen articles were found, 98 of which were mostly related to the topic of this review. Management of TED-related strabismus was reviewed and categorized in non-surgical and surgical. Botulinum toxin A (BTA) is a useful non-surgical management of strabismus in an active TED and residual deviation after strabismus surgery. Postoperative under-correction is relatively more common in TED-related esotropia. Lateral rectus resection and BTA are the options to manage the problem. Muscle rectus muscle resection should be performed after maximum recession of restricted muscles. It should be avoided on a restricted or enlarged muscle. Management of TED-related vertical deviation is challenging. In these cases, the surgical treatment selected depends on forced duction test (FDT) (pre and intraoperative), orbital imaging (which muscle is enlarged), and the amount of vertical deviation (in both down-gaze and primary position). Conclusions: TED-related strabismus needs careful evaluation and management to achieve optimal outcome. Different surgical and non-surgical options are available for intervention in TED-related strabismus.
  4,968 517 3
Effect of smoking on tear stability and corneal surface
Norhani Mohidin, Adlie B Jaafar
July-September 2020, 32(3):232-237
Purpose: To determine the effect of smoking on tear stability and ocular surface of the cornea among students aged between 19 and 25 years. This study also aimed to find a correlation between tear film stability with a score of McMonnies Dry Eye Questionnaire (MDEQ) and Ocular Surface Disease Index Questionnaire (OSDI). Methods: This is a prospective, non-interventional, comparative study of 59 male (27 smokers and 32 non-smokers) undergraduates of a public university. Tear film stability was evaluated using non-invasive tear break-up time and fluorescein tear break-up time. Corneal staining was determined using Efron grading scale. MDEQ and OSDI Questionnaires were used to assess dry eye symptoms. Data were obtained from the right eye only and analyzed using descriptive and correlation analysis. Results: The age range of the participants was between 19 and 25 years. The mean age for smokers and non-smokers was 22.19 ± 2.20 and 21.22 ± 1.83 years, respectively (P = 0.07). The smoker group had statistically significant lower tear film stability than the non-smoker group (P < 0.0001). Corneal staining was statistically significant higher at the nasal and temporal parts of the cornea in smokers (P < 0.05). There was a moderate correlation between tear film stability and scores of MDEQ and OSDI. Conclusions: Tobacco smoke has a significant effect on the tear film stability, seen in reduced tear stability values among smokers. Corneal staining was found to be more extensive in the smokers. These findings would be useful to eye-care providers in the management of their dry eye patients related to smoking.
  4,825 491 11
Impact of E-schooling on digital eye strain in Coronavirus Disease Era: A survey of 654 students
Richa Gupta, Lokesh Chauhan, Abhishek Varshney
April-June 2021, 33(2):158-164
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.
  4,514 741 11
Supramaximal recession and resection surgery in large-angle strabismus: Outcomes of large interventional case series exotropia and esotropia
Mohammad Reza Talebnejad, Mohammad Karim Johari, Mohammad Reza Khalili, Mousa Zare
January-March 2020, 32(1):82-87
Purpose: To assess the postoperative surgical outcomes and the changes in deviation in patients treated by supramaximal recession and resection (R&R) of rectus muscles to correct the large-angle exotropia and esotropia. Methods: This study was a prospective interventional case series, and patients with esotropia of ≥65 prism diopter (PD) or exotropia of ≥60 PD who had undergone supermaximal R&R in non-fixating eye with lower vision in unilateral strabismus or bilateral medial rectus (BMR) recession up to 8.5 mm for esotropia and bilateral lateral rectus (BLR) recession up to 12.5 mm for exotropia in bilateral strabismus were enrolled. Successful results were achieved if postoperation deviation was <10 PD for esotropia and <15 PD for exotropia during their final examinations. Results: A total of 131 cases (48 patients with esotropia and 83 patients with exotropia) were included. The mean ages of the patients with esotropia and exotropia were 16.83 ± 15.06 and 23.19 ± 11.29 years, respectively. The mean preoperative esodeviations for bilateral and unilateral surgeries were 69.5 ± 6.5 and 80.7 ± 10.3, respectively, and these values for bilateral and unilateral exodeviations surgeries were 67.3 ± 7.6 and 74.2 ± 12.1, respectively. The overall successful outcomes were achieved in 50% of the esotropic patients and 79.5% of the exotropic patients. At final follow-up examination, no patient had diplopia on lateral gazes. Conclusion: Based on our surgical results, it is possible to consider monocular recession-resection surgery in non-fixating eye (with poor vision) or BLR and BMR recession in both eyes as a viable option for surgical treatment of large angles deviations.
  4,851 323 2
The surgical outcomes of limbal allograft transplantation in eyes having limbal stem cell deficiency
Muhammet Derda Ozer, Emre Altınkurt, Yusuf Cem Yilmaz, Ali Ceyhun Gedik, Nilufer Alparslan
April-June 2020, 32(2):132-141
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 5th 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.
  4,349 341 5
Delhi infectious keratitis study: Update on clinico-Microbiological profile and outcomes of infectious keratitis
Manisha Acharya, Javed Hussain Farooqui, Tanuj Gaba, Arpan Gandhi, Umang Mathur
July-September 2020, 32(3):249-255
Purpose: To study the clinico-microbiological profile and outcomes of infectious keratitis (IK) at a tertiary eye care center in North India. Methods: This is a retrospective, hospital-based, cross-sectional study. One thousand seven hundred and eighty-six corneal microbiological reports were identified from January 2017 to December 2018, out of which 625 patients of IK fulfilled the inclusion criteria. They underwent microbiological examination which included corneal scrapings, culture, and antibiotic sensitivity. Demographic features, signs and symptoms, risk factors such as associated trauma, previous ocular surgery, and use of corticosteroids were also recorded. Results: Of the 625 patients, 68.2% were male and 31.8% were female. The age group affected most was the sixth decade; 21.9% (137 cases). Trauma was the most common associated risk factor in 151 cases (24.2%) followed by previous ocular surgery in 111 (17.8%). Out of the 625 corneal scrapings, 393 (62.9%) were culture-positive. Bacterial culture accounted for 60.6% (238/393) and fungal cultures were 143 (36.4%). More than 50% of the bacterial keratitis cases and more than 60% of the fungal cases had a favorable outcome. Staphylococcus sp. and Fusarium sp. were the most common bacteria and fungus isolated, respectively. Only one-third of the cases required surgical intervention, and the remaining two-thirds were managed medically. Conclusions: In the current study, cultures were positive in 63% of cases, and the majority of cases had bacterial growth. Surgical intervention was needed in one-third of the cases. Management of corneal infections is incomplete without a good microbiological workup. Ophthalmologists should be encouraged to learn and practice basic staining procedures, and this should start early in the training years.
  4,190 388 11
Ophthalmic manifestations of rosai-Dorfman disease in five patients
Babak Masoomian, Sara E Lally, Jerry A Shields, Carol L Shields
July-September 2020, 32(3):238-243
Purpose: To report clinical features, pathology characteristics, and treatment outcomes of five patients with Rosai-Dorfman disease (RDD). Methods: A retrospective case series of patients with RDD from the Ocular Oncology Service of Wills Eye Hospital between 1974 and 2018. Results: There were six eyes of five patients (3 males, 2 females) with ophthalmic manifestations of RDD. The mean age at the initial presentation was 33 years (median 35, range 10–52 years). Before referral, the tumor was initially suspected to be lymphoma (n = 3), idiopathic orbital inflammation (n = 2), or pterygium (n = 1). The disease was unilateral (n = 4) or bilateral (n = 1). The mean duration of symptoms was 9 months (median 8, range 5–24 months). The disease produced nodules in the conjunctiva (n = 4) or orbit (n = 2). Two patients with conjunctival involvement had corneal involvement. One patient with bilateral conjunctiva lesions demonstrated bilateral orbital involvement and bilateral anterior uveitis. The mean tumor basal dimension was 13 mm (median 9, range 6–27 mm) for conjunctiva lesions and 37 mm (median 37, range 34–40 mm) for orbital lesions. The main symptom (per patient) included proptosis (n = 2), palpable mass (n = 1), and foreign body sensation (n = 2). No patient experienced pain or tenderness. Palpable, nontender lymphadenopathy was detectable in two patients in the cervical and inguinal lymph nodes. Systemic involvement with paranasal sinusitis and mediastinal/pulmonary lymphadenopathy occurred in two patients, both with orbital involvement. Surgical resection was performed for all patients. At a mean follow-up of 31 months (median 12, range, 10–76 months) after the surgery, tumor control was achieved in all six eyes without local recurrence. Conclusion: In this series of six eyes with RDD, patients with orbital and/or intraocular disease were more likely to demonstrate lymphadenopathy and systemic involvement, while those with unilateral perilimbal conjunctival tumors remained localized.
  4,160 409 5
Management of upside-down descemet membrane endothelial keratoplasty: A case series
Ahmed Shalaby Bardan, Mohamed B Goweida, Hesham F El Goweini, Christopher S Liu
April-June 2020, 32(2):142-148
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 5th 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.
  4,059 308 4
Recurrent pterygium: A review
Leila Ghiasian, Bijan Samavat, Yasaman Hadi, Mona Arbab, Navid Abolfathzadeh
October-December 2021, 33(4):367-378
Purpose: To summarize the recent evidence regarding different aspects of pterygium recurrence. Methods: Human-based studies from PubMed, Scopus, and Google Scholar were identified using the following keywords: conjunctival disease, pterygium, recurrent pterygium, pterygium recurrence, pterygium management/surgery, conjunctival autograft (CAU), amniotic membrane graft/transplant, and adjuvant therapy (January 2009 to February 2021). We reviewed risk factors associated with the recurrence of pterygium, timing of recurrence, medical treatments to prevent from recurrence, and nonsurgical and surgical alternatives for management of recurrence. Results: Dry eye disease, black race, and young age are considered definite risk factors for recurrence. However, fleshy appearance of the pterygium and preoperative size remain controversial. Surgical techniques such as excessive suturing, insufficient conjunctival graft size, thick conjunctival graft with remained Tenon tissue, and postoperative graft retraction are considered possible risk factors for recurrence. Using fibrin glue instead of sutures can further reduce recurrence rates. Although recurrence could occur even after many years, most recurrences happen in the first 3–6 months after surgery. Multiple kinds of adjuvant medications are used before, during, or after the operation including mitomycin C (MMC), 5-fluorouracil (5-FU), corticosteroids, and anti-vascular endothelial growth factors (anti-VEGFs). Multiple weekly subconjunctival 5-FU injections are shown to be safe and effective in halting the progression of recurrent pterygium. Although topical bevacizumab is found to inhibit the growth of impending recurrent pterygium, the effect is mostly temporary. CAU is superior to amniotic membrane transplantation in the treatment for recurrent pterygia. Conclusions: There is yet to be a panacea in treating recurrent pterygium. Currently, there is not a globally accepted recommendation for treating recurrent pterygium with anti-VEGFs or 5-FU as a nonsurgical treatment. We strongly recommend using MMC as an adjunct to surgery in recurrent cases, with consideration of its specific complications. CAU is the most effective surgical treatment for recurrent pterygium, and other new surgical therapies need further investigation.
  3,704 656 -
The identification and stereochemistry analysis of a novel mutation p.(D367Tfs*61) in the CYP1B1 gene: A case report
Ahmad Reza Salehi Chaleshtori, Masoud Garshasbi, Ali Salehi, Mehrdad Noruzinia
January-March 2020, 32(1):114-118
Purpose: To investigate the presence of a probable genetic defect(s) that may cause primary congenital glaucoma (PCG) in a seven-year-old female patient. Methods: A seven-year-old female patient and her family received genetic counseling and underwent full clinical examinations by an expert ophthalmologist. The patient's genomic DNA was subjected to the targeted gene capture and next-generation sequencing (NGS) along with Sanger sequencing method. The 3D structure prediction and stereochemistry analysis were performed for both mutant and wild-type forms of the CYP1B1 protein. Results: The clinical examinations indicated that the diagnosis of PCG was correctly made. We identified a novel homozygous deletion in which a “C” nucleotide was deleted from the final exon of the Cytochrome P450 Family 1 Subfamily B Member 1 (CYP1B1) gene. The 3D molecular modeling of the CYP1B1 protein predicted significant structural changes could occur in this protein as a result of the mutation mentioned earlier. The stereochemistry analysis revealed mutant features of the protein, as well as significant misfolding and possible malfunctions in the mutant form of the CYP1B1 protein. Conclusions: This mutation might cause a frameshift in the translation process, leading to the malfunction of the CYP1B1 protein and development of glaucoma. This newly-identified mutation could be regarded as potential deletion mutation in genetic counseling and molecular examination for the detection of PCG disease in Iran.
  4,148 208 -
Development and validation of the persian version of the MNREAD acuity chart
Roghiyeh Elham, Ebrahim Jafarzadepur
July-September 2020, 32(3):274-280
Purpose: To develop the Persian version of MNREAD acuity charts and test their repeatability in a normal adult population. Methods: Two hundred sentences were constructed using the most frequent words of 8-year-olds schoolbooks. The number of characters and sentence length were adjusted based on the design principles of the Minnesota Low Vision Reading Test. Two Persian language teachers checked the sentences for syntax and meaning. The accepted sentences were read by 20 adults and then by 20 children. Using RADNER charts method, the sentences with inappropriate reading time and repeated errors were excluded. Thirty-eight sentences were approved to create charts. To check the charts' validity and repeatability, 20 adults read both charts and a paragraph of a daily newspaper. Reading acuity, critical print size, and maximum reading speed were calculated. The measured reading speeds were compared to the readers' reading speeds for a paragraph of a daily newspaper. Bland-Altman plots were used to evaluate the agreement between the two charts. Results: Thirty-eight selected sentences were used in the final printed charts. There were significant correlations between maximum reading speed for Charts 1 and 2 (r = 0.87, P <0.0001), Chart 1 and newspaper paragraph (r = 0.73, P = 0.001), and Chart 2 and newspaper paragraph (r = 0.83, P = 0.0001). Correlations were observed between reading acuities and critical print sizes of two charts (r = 0.72, P <0.002 and r = 0.77, P = 0.00). The 95% limits of agreement in reading acuity, critical print size, and reading speed between Charts 1 and 2 were ± 0.034 logMAR, ±0.11 logMAR, and ±8.00 words per minute, respectively. Conclusion: The designed Persian MNREAD charts are repeatable and could be used reliably to calculate near acuity, reading speed, and critical print size in Persian-speaking people.
  4,076 274 1
Tolosa–Hunt syndrome: A review of diagnostic criteria and unresolved issues
Paromita Dutta, Kamlesh Anand
April-June 2021, 33(2):104-111
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.
  3,827 519 7
Outcome of corneal collagen cross-linking in keratoconus: Introducing the predictive factors
Alireza Peyman, Awat Feizi, Mazdak Ganjalikhani-Hakemi, Fahimeh Hosseini-Nasab, Mohsen Pourazizi
January-March 2020, 32(1):19-25
Purpose: To evaluate the multiple pretreatment characteristics and topographic factors of keratoconus (KC) patients and their relationship to clinical outcomes of corneal collagen cross-linking (CXL). Methods: In this prospective study, 61 patients (106 eyes) with KC as candidates for CXL were included. Demographic data including age, sex, place of birth and residence, atopic constitution, family history, rubbing history, sleep apnea, and blood group were collected via a structured checklist. Complete ophthalmologic examination and tear collection to assess tear interleukin 6 (IL-6) and tumor necrosis factor alpha (TNF-α) level were performed. Topometric parameters were evaluated using a rotating Scheimpflug topography device. Changes in best corrected visual acuity (BCVA) and maximum keratometry (K-max) were considered the main predicted variables. Predictive variables were analyzed by univariate and multivariate regression. Results: The use of multivariate analysis changes in K-max was significantly associated with rubbing frequency (coefficient = 0.94, P = 0.02), blood group (coefficient = 4.52, P = 0.005), pretreatment corneal asphericity (coefficient = −3.99, P ≤ 0.001), and pretreatment central keratoconus index (CKI) (coefficient = −55.38, P = 0.001). Regarding the changes in BCVA, the multivariate analysis showed a significant association with place of birth (coefficient = −0.08, P = 0.03), pretreatment BCVA (coefficient = −0.67, P < 0.001), pretreatment central corneal thickness (CCT) (coefficient = −0.005, P = 0.04), and pretreatment keratoconus index (KI) (coefficient = 0.53, P = 0.04). Other parameters assessed in the multivariable analysis did not appear to have an individual effect on treatment outcomes. Conclusion: Our results demonstrated that blood group, rubbing of eye, place of birth, corneal asphericity, pretreatment BCVA, CKI, KI, and CCT were statistically associated with the outcome of KC following CXL.
  3,950 371 4
Ocular abnormal head posture: A literature review
Mohamad Reza Akbari, Masoud Khorrami-Nejad, Haleh Kangari, Alireza Akbarzadeh Baghban, Mehdi Ranjbar Pazouki
October-December 2021, 33(4):379-387
Purpose: To provide a comprehensive review on different characteristics of abnormal head postures (AHPs) due to different ocular causes, its measurement, and its effect on facial appearance. Methods: In this review article, PubMed, Scopus, and Google Scholar search engines were searched for the scientific articles and books published between 1975 and September 2020 based on the keywords of this article. The selected articles were collected, summarized, classified, evaluated, and finally concluded. Results: AHP can be caused by various ocular or nonocular diseases. The prevalence of ocular causes of AHP was reported to be 18%–25%. 1.1% of patients presenting to ophthalmology clinics has AHP. The first step in evaluating a patient with AHP is a correct differential diagnosis between nonocular and ocular sources by performing comprehensive eye examinations and ruling out other causes of orthopedic and neurological AHP. Ocular AHP occurs for a variety of reasons, the most important of which include nystagmus, superior oblique palsy, and Duane's retraction syndrome. AHP may be an essential clinical sign for an underlying disease, which can only be appropriately treated by the accurate determination of the cause. Long-standing AHP may lead to facial asymmetry and secondary muscular and skeletal changes. Conclusion: In conclusion, a proper differential diagnosis between nonocular and ocular causes, knowledge of the different forms of AHP and their measurement methods, accurate diagnosis of the cause, and proper and timely treatment of ocular AHP can prevent facial asymmetry and secondary muscular and skeletal changes in the patients.
  3,807 354 1
Long-term intraocular pressure changes after pars plana vitrectomy: An 8-year study
Arash Omidtabrizi, Vahid Ghavami, Masoud Shafiee, Razieh Bayani, Touka Banaee
October-December 2020, 32(4):335-342
Purpose: To investigate the long-term changes of intraocular pressure (IOP) after pars plana vitrectomy (PPV). Methods: This was a retrospective historical cohort study. Patients with a history of vitrectomy in one eye by a single surgeon were enrolled. IOP of the operated eye was compared to the fellow eye. Previous scleral buckling, IOP rise due to surgical/anatomic complications, silicone oil (SO) emulsification, and contralateral ocular hypertension/glaucoma at recruitment were exclusion criteria. “Significant IOP rise” (>6.0 mmHg) and development of open angle glaucoma (OAG) were the main outcome measures. Results: Two hundred and twenty-five eyes were included. Mean and median follow-up duration were 20.6 and 9.0 months, respectively. Mean baseline IOP and mean final IOP were 13.53 ± 3.75 mmHg and 16.52 ± 6.95 mmHg, respectively (P < 0.001). Forty-three patients developed “significant IOP rise” with no statistically significant relation to the indication of vitrectomy, the postoperative lens status, and number of vitrectomies (P = 0.410, P = 0.900, and P = 0.160, respectively). SO injection raised the probability of IOP rise in the long-term (P = 0.028). OAG occurred in 17 patients (7.5%) with no association to SO tamponade (P = 0.840). “Significant IOP rise” and OAG occurred in 3 and 1 control eyes, respectively, significantly lower than the rates in study eyes (P < 0.001). Conclusion: Mean IOP slightly rose in the long-term after PPV. SO tamponade was associated with IOP rise in the long-term but not with the incidence of OAG. Both IOP rise and OAG were more probable after vitrectomy.
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A review of transposition techniques for treatment of complete abducens nerve palsy
Mohammad Reza Akbari, Babak Masoomian, Arash Mirmohammadsadeghi, Motahhareh Sadeghi
July-September 2021, 33(3):236-246
Purpose: To review various types of extraocular muscle transposition procedures for management of strabismus in sixth cranial nerve palsy with little lateral rectus (LR) muscle function, along with their pros and cons. Methods: We performed a comprehensive review of transposition procedures in sixth cranial nerve palsy, based on literature published anytime up to March 2021. A thorough search through PubMed and Cochrane databases was performed. All types of clinical studies on different transposition procedures in LR palsy, were included. Results: Eighty-six original articles in English, with full text or abstracts available, were included in the review, among which 16 are prospective studies, 48 retrospective, 3 review articles, 1 randomized clinical trial, 17 case reports, and 1 letter. Vertical rectus transposition has demonstrated promising results, especially in abduction improvement and expansion of binocular diplopia-free visual field, albeit the possible adverse effects such as anterior segment ischemia, especially in the presence of medial rectus contracture, and induced vertical deviation may become troublesome. Partial muscle transposition, single muscle transposition, and also transposition without tenotomy have all been introduced to reduce the risk of multiple muscle manipulation and ischemia. On the other hand, different adjustable transpositions are being utilized to manage concomitant or induced vertical deviations. Conclusion: Transposition procedures are highly effective in the treatment of esotropia caused by complete LR palsy. Various techniques for vertical muscle transposition have been proposed, with each of them having certain advantages and disadvantages.
  3,832 306 1
Analysis of age, gender, and refractive error-related changes of the anterior corneal surface parameters using oculus keratograph topography
Nasrin Moghadas Sharif, Negareh Yazdani, Leila Shahkarami, Hadi Ostadi Moghaddam, Asieh Ehsaei
July-September 2020, 32(3):263-267
Purpose: To assess refractive error, gender, and age-related differences in corneal topography of a normal population with Oculus Keratograph 4. Methods: This cross-sectional study included a total of 500 normal eyes of 500 individuals with ages ranging from 10 to 70 years. All participants underwent detailed ocular examinations, including visual acuity measurement, slit-lamp examination, and refractive error evaluation. Slit-lamp examination was performed for all individuals to rule out apparent corneal diseases. Corneal topography parameters were assessed using Oculus Keratograph. The data were analyzed based on gender, refractive error, and age groups using independent sample t-test and one-way analysis of variance. Results: Of a total of 500 participants (age: 29.51 ± 11.53 years) recruited for the present study, 66.4% were female, and 33.6% were male. The mean spherical equivalent of refraction was − 0.98 ± 1.65 diopters. Significant differences were noted in steep keratometry (P = 0.035) and corneal astigmatism (P = 0.014) between genders. Assessment of the data based on refractive error revealed significant differences in an index of vertical asymmetry (P < 0.001), index of height asymmetry (P = 0.003), and index of height decentration (P = 0.011). Considering age groups, significant differences were observed in flat keratometry readings (P < 0.001), mean corneal astigmatism (P = 0.02), minimum radius of curvature (P = 0.037), and apex power (P < 0.001). Conclusions: There was a prominent variation in some topographic parameters based on gender, age, and refractive error. The information on corneal parameters obtained with Oculus Keratograph from normal eyes provides a reference for comparison with diseased corneas.
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Evaluation of the initial optical coherence tomography parameters in anticipating the final visual outcome of central retinal vein occlusion
Muhammet Derda Ozer, Muhammed Batur, Selma Mesen, Serek Tekin, Erbil Seven
January-March 2020, 32(1):46-52
Purpose: To evaluate the predictive and associated factors in determining the visual outcome in patients having central retinal vein occlusion (CRVO)-related macular edema (ME). Methods: The charts of the patients who were treated due to CRVO-related visual disturbance were reviewed. The optical coherence tomography (OCT) images of eyes were analyzed, and disorganization of retinal inner layers (DRILs), ellipsoid zone (EZ) and external limiting membrane (ELM) disruption length, hyper-reflectivity of retinal inner layer (HRIL) existence, baseline and final visual acuity (VA), subfoveal thickness (SFT), subretinal fluid (SRF), and injection numbers were noted. The regression and correlation analyses were applied. Results: Thirty eyes of thirty patients were included in the study. The mean follow-up time was 17.5 ± 11 (8–47) months. The mean baseline VA was 1.4 ± 0.7 (0.2–3.1) logMAR. A total of 87 intravitreal injections were applied for the treatment of ME during the follow-up. The initial mean central subfield thickness was 795 ± 264 (1470–398) μm. HRIL and SRF were observed in 16 and 23 eyes at the initial visit, respectively. The final mean VA was 1.2 ± 0.9 (0.1–3.1) logMAR. At the final visit, additional OCT parameters were evaluated. The mean DRIL length was 463 ± 324 μm. The mean disruption length of EZ and ELM was 367 ± 247 μm and 414 ± 327 μm, respectively. The final mean SFT was 290 ± 91 μm. SRF presence at the initial visit was found to be associated with elongated EZ and ELM disruption length at the final visit (P = 0.03 and P = 0.04, respectively). On linear regression analyses, none of the baseline features (SRF, SFT, and HRIL) except baseline poor best corrected visual acuity were found to be predictive in anticipating the final visual outcome (P = 0.04). On linear bivariate analysis, the final poor visual outcome was found to be affected by EZ disruption length of ≥500 μm at the last visit (P = 0.02). Conclusion: Baseline VA was the only predictive factor in anticipating the final visual outcome. At the final visit, extensive disruption length of EZ in the subfoveal area was associated with a poor visual outcome.
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Quantitative analysis of microvascular network with optical coherence tomography angiography and its correlation with visual acuity in retinal vein occlusion
Meriem Ouederni, Mohamed Ben Hadj Khalifa, Hela Sassi, Fehmy Nefaa, Oumaima Ayed, Monia Cheour
October-December 2021, 33(4):453-460
Purpose: To analyze the macular microvascular network and the correlations between visual acuity and quantitative parameters using optical coherence tomography angiography (OCTA) in eyes with retinal vein occlusion (RVO). Methods: We conducted a prospective cross-sectional study including patients with unilateral RVO. We performed 4.5 mm × 4.5 mm macular OCTA angiograms for assessment of quantitative parameters in both superficial and deep capillary plexuses (SCP, DCP). Area of foveal avascular zone (FAZ), vascular density (VD), skeleton density (SD), fractal dimension (FD), vessel diameter index (VDI), and lacunarity (LAC) were analyzed. Results: Seventy eyes of 35 patients were enrolled. As compared to fellow eyes, OCTA analysis in eyes with RVO showed larger FAZ, lower VD, lower SD, lower FD, higher VDI, and increased LAC in both plexuses (All P < 0.05). The enlargement of FAZ in the SCP was associated with visual loss (P = 0.025, r = 0.378). In the DCP, visual acuity was negatively correlated with parafoveal VD, SD, and FD (P = 0.004, r = −0.472; P = 0.003, r = −0.482 and P = 0.036, r = −0.308, respectively). Stepwise multivariate regression analysis showed that lower SD and lower FD in the DCP remained correlated with poorer visual acuity (P = 0.04, r = −0.261 and P = 0.032, r = −0.264, respectively). Conclusions: OCTA provides quantitative parameters to analyze retinal microvasculature in eyes with RVO. These OCTA biomarkers could be used to predict the impact of macular ischemia and capillary dropout on visual acuity in RVO.
  3,881 121 -
Serum 25-hydroxyvitamin D, selenium, zinc and copper in patients with keratoconus
Siamak Zarei-Ghanavati, Bahareh Yahaghi, Samira Hassanzadeh, Majid Ghayour Mobarhan, Hamid Reza Hakimi, Pardis Eghbali
January-March 2020, 32(1):26-31
Purpose: To assess the possible association between keratoconus (KC) and serum levels of 25-hydroxyvitamin D (25OHD), Selenium (Se), Zinc (Zn), and Copper (Cu) and to compare it with age-matched healthy subjects. Methods: One hundred patients with KC and 100 normal subjects were included. The two groups were compared for serum 25OHD and serum levels of three trace elements: Se, Zn, and Cu. These factors were also compared between groups with different KC stages. Results: Serum levels of vitamin D, Zn, Cu, and Se were significantly different between the KC and normal groups (P = 0.006, P = 0.015, P = 0.004, and P = 0.038, respectively). Although a lower level of 25OHD was found in severe stages of KC, it was not significantly different among different KC groups (P = 0.441). KC stage groups were not significantly different for mean serum Zn, Cu, and Se (P = 0.130, P = 0.98, P = 0.113, respectively). Although the Cu/Zn ratio was higher in cases than in controls, there was no significant difference between the two groups and between KC stages (P = 0.168, P = 0.143, respectively). Conclusion: Lower serum 25OHD, Cu, Zn, and Se were found in the KC group compared to the control group. The results of this study suggest that a lower antioxidative activity may be involved in the possible etiology of KC.
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Surgical outcomes of retropupillary-fixated iris-claw intraocular lens
Tarannum Mansoori, Satish Gooty Agraharam, Sravanthi Sannapuri, Sunny Manwani, Nagalla Balakrishna
April-June 2020, 32(2):149-153
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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