Vision-related quality of life in patients with retinal vein occlusion

PURPOSE

This study aims to assess the vision-related quality of life in patients with retinal vein occlusion (RVO) among those referred to Labbafinejad Medical Center and Imam Hossein Hospital between 2019 and 2021.

METHODS

This comparative study included 37 eligible patients diagnosed with various types of RVO, with an average age of 61 ± 9. To ensure data validity, we included 74 age- and sex-matched healthy individuals. Only cases with a definitive diagnosis of RVO, confirmed by two retina specialists (ND and RN), were included. We assessed the vision-related quality of life of our participants using the National Eye Institute Visual Functioning Questionnaire-25 (NEI-VFQ-25). All participants underwent interviews.

RESULTS

In our study, we examined the vision-related quality of life in different subgroups of RVO patients. Overall, RVO patients had a significantly lower total VRQoL score compared to healthy individuals (P < 0.001), except in the subscale analysis of specific factors such as ocular pain, color vision, and driving, where no statistically significant difference was observed. A statistically significant difference was found in the comparison of subgroups, indicating lower VRQoL in central retinal vein occlusion (CRVO) patients (P = 0.010). Furthermore, a significant correlation was observed between lower VRQoL and decreased vision (P = 0.009) as well as longer disease duration (P = 0.011).

CONCLUSION

Retinal vein occlusion can significantly reduce vision-related quality of life, particularly in more severe cases.

Fundus torsion following inferior oblique muscle weakening

PURPOSE

To determine the postoperative fundus torsion following surgical inferior oblique (IO) weakening in patients with inferior oblique overaction (IOOA).

METHODS

In this interventional case series, 37 patients with IOOA ≥ +1 and reliable preoperative fundus photographs were included. IO weakening was accomplished through myectomy or anterior transposition. Fundus photography was repeated at 3 months' follow-up. The primary outcome was change of disk foveal angle (DFA), measured as the angle between the line connecting the center of the fovea and optic disk and horizontal. Success or normal fundus torsion was defined as a postoperative angle of 0° to 8° of extorsion. Residual extorsion was defined as postoperative extorsion of > 8°. Postoperative intorsion was defined as any amount of induced intorsion.

RESULTS

Mean age of patients (56% females) was 6.46 ± 6.79 years. At follow-up at least 3 months after surgery, the mean change of DFA was 7.79 ± 6.24° of reduction of extorsion after IO myectomy (P < 0.001) and 6.05 ± 6.07° after IO anterior transposition (P = 0.005). Normal fundus torsion was achieved in 50% of patients after myectomy and 36.4% of patients after anterior transposition. Residual extorsion was observed in 49% of patients; induced intorsion in 5%.

CONCLUSIONS

Using objective measurement of fundus photographs, fundus extorsion was decreased in 94.7% of patients after myectomy or anterior transposition.

The effect of topical ketorolac tromethamine on macular thickening after phacoemulsification in diabetic patients

BACKGROUND

To determine the effect of ketorolac tromethamine 0.5% in preventing post-phacoemulsification macular thickening. This randomized clinical trial. patients randomized 1:1 to receive either topical ketorolac three times a day or a placebo.

METHODS

A total of 101 eyes of 101 diabetic patients who were scheduled for phacoemulsification and had normal macular contour and thickness enrolled consecutively. The topical ketorolac and placebo were prescribed on the day before surgery and continued up to 4 weeks after surgery. Patients with proliferative diabetic retinopathy, a history of intravitreal injection in less than three months, a history of macular photocoagulation in less than 6 months, and any other concomitant ocular pathologies were excluded. Central macular thickness (CMT) and best corrected visual acuity (BCVA) was recorded in the follow-ups of 6, 12, and 24 weeks after the surgery and compared with the controls.

RESULTS

49 eyes in the case group and 52 eyes in the control group were analyzed. Mean BCVA was significantly improved in both groups at all follow-ups (P < 0.001 for all). There was no statistically significant difference regarding the BCVA in different time points except week 12 (P = 0.028) among the study group. In the case and control groups, CMT was increased at all follow-ups (P < 0.05). There was no statistically significant difference when comparing the two groups regarding the mean of CMT at any time point postoperatively (P > 0.05 for all).

CONCLUSION

Based on our findings, topical ketorolac tromethamine 0.5% is not effective in the prevention of post-phacoemulsification macular thickening in diabetic patients.

TRAIL REGISTRATION

The study protocol was registered into www.

CLINICALTRIAL

gov with the RCT registration number NCT03551808. (2018/06/11 ) CLINICAL TRIAL REGISTRATION NUMBER: NCT03551808.

Risk Factors Associated with Keratoconus in an Iranian Population

Purpose

To determine associated factors for keratoconus (KCN) in the Iranian population.

Methods

In this retrospective case-control study, 100 KCN patients and 200 age- and sex-matched individuals, who were either candidates for photorefractive keratectomy or healthy referrals from the Torfeh Eye Hospital, were included as the case and control groups, respectively. KCN patients were all registered at the Iranian National Registry of Keratoconus (KCNRegⓇ). Demographic characteristics, patients' symptoms and their habits, as well as systemic and ocular disorders were documented. Clinical examinations included best corrected visual acuity (BCVA) and refractive error measurements, biomicroscopic examination, and corneal imaging.

Results

In this case group, the frequency of mild, moderate, and severe KCN was 38%, 28%, and 34%, respectively. Parental consanguinity (odds ratio [OR] = 1.758, P = 0.029), positive familial history in patients' first degree (OR = 12.533, P < 0.001) and second degree (OR = 7.52, P < 0.001) relatives, vernal keratoconjunctivitis (OR = 7.510, P = 0.003), severe eye rubbing (OR = 10.625, P < 0.001), and systemic diseases including migraine, hypertension, and thyroid disease (OR = 6.828, P = 0.021) were found as associated factors for KCN. Lesser frequency of KCN was observed in patients with Fars ethnicity (OR = 0.583, P = 0.042), with higher levels of wealth indices (OR = 0.31, P < 0.001) and higher levels of education (OR = 0.18, P = 0.024).

Conclusion

Severe eye rubbing, vernal keratoconjunctivitis, parental consanguinity and positive familial history of KCN, low socioeconomic status, and low levels of education were significantly associated with KCN in our study population.

Torsion among Women with Acute Lower Abdominal Pain: A Retrospective Cross-Sectional Study

Background: Lower abdominal or pelvic pain is a common complaint among women and one of the most challenging findings to evaluate. We performed the present study to construct a new algorithm for predicting the chance of ovarian torsion among women with acute lower abdominal pain. Methods: This diagnostic retrospective cross-sectional study was performed on all female individuals who were referred to Imam Hossein Medical Center, Tehran, Iran, with the chief complaint of acute lower abdominal pain, and underwent laparotomy between 2010 and 2016. Clinical and paraclinical findings were evaluated to construct a predictive model for ovarian torsion. The variables were compared in 2 groups. The first group included individuals with a final diagnosis of ovarian torsion and the second group included those individuals with any diagnosis other than ovarian torsion. All data were compared between these 2 groups using SPSS software Version 21 to find the related findings with a predictive value for ovarian torsion. Results: A total of 372 participants were evaluated, of whom 116 participants (31.2%) had ovarian torsion (case group) and 256 participants had other diagnoses for their lower abdominal pain (control group). Nausea and vomiting (p < 0.001), tenderness (p < 0.001), the size of ovarian mass (p = 0.004), and the percentage of polymorphonuclear (p < 0.001) showed significant relationships with ovarian torsion as the final diagnosis. Multiple logistic regression models were constructed to predict the factors affecting ovarian torsion, and a scoring system was designed to predict ovarian torsion, with a sensitivity of 77.59% (68.9%- 84.8%) and specificity of 74.61% (68.8% 79.8%). Conclusion: The proposed model is suitable for predicting ovarian torsion and its necessary information is readily available from individuals' history, examination findings, laboratory results, and an ultrasound exam.

Retinal Vascular Abnormalities in Different Types of Inherited Retinal Dystrophies Assessed by Optical Coherence Tomography Angiography

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.

Pretreatment with frequent topical betamethasone in Ahmed glaucoma valve implantation

OBJECTIVE

To evaluate the efficacy of pretreatment with topical betamethasone in Ahmed glaucoma valve (AGV) implantation.

DESIGN

Randomized clinical trial.

PARTICIPANTS

Sixty-two eyes from 62 patients undergoing AGV.

METHODS

We randomly assigned patients undergoing AGV to 2 arms of the study. The case group received AGV implantation with preoperative betamethasone eye drops, and the control group did not receive preoperative betamethasone. Follow-up examinations were performed on postoperative day 1, at least weekly for 4 weeks, and then every 1 to 3 months. Our main outcome measure was the rate of success, defined as intraocular pressure (IOP) <15 mm Hg and IOP ≤18 mm Hg.

RESULTS

We analyzed 62 eyes divided to case (n = 33) and control (n = 29) groups. The success rate was significantly higher in the intervention group than in the control group at 12 months postoperatively when considering either IOP < 15 or IOP < 18 mm Hg as success (p < 0.001) and also at 6 months when considering IOP < 18 mm Hg as success (p < 0.041). The reduction in the number of antiglaucoma medications used postoperatively was significantly higher in the betamethasone group at follow-up at 1 and 3 months and 1 year.

CONCLUSION

Pretreatment with topical betamethasone in AGV implantations increases the success rate and reduces the need for medications.

A new decision making model for diagnosing acute appendicitis among non-pregnant women and its comparison with alvarado scoring system

Background: Although acute appendicitis is a common problem, it remains a difficult diagnosis to establish, particularly among females of reproductive age. The present study was conducted to devise a new decision making model for diagnosing acute appendicitis in non-pregnant women.

Methods: The present study was a retrospective study consisting of women who had undergone an appendectomy between 2007 and 2015 at the emergency department of Imam Hossein Medical Center, Tehran, Iran. The inclusion criteria were being a female, presenting with abdominal pain, being a suspected case of acute appendicitis, and undergoing an emergency appendectomy. A classification and regression tree (CART) analysis was performed to partition exam and laboratory data obtained from these patients into homogeneous groups in order to develop a prediction rule for appendicitis diagnosis.

Results: The study population included 433 non pregnant women who underwent emergency operations with a preliminary diagnosis of acute appendicis. Out of these patients, 295 patients (68.1%) were appendicitis positive based on the pathology exam results, while 138 patients had a normal appendix, indicating a negative appendectomy rate of 31.8%. The final devised CART model included hemoglobin level, PMN count, age, and history of abdominal incision and yielded a sensitivity of 82.7% and specificity of 55.8%, which were better than Alvarado prediction results for the Asian population.

Conclusion: We have devised a simple and cost effective prediction model for predicting the outcome among non-pregnant women undergoing emergency appendectomy operation with good sensitivity and specificity compared to the Alvarado model.

Management of consecutive exotropia

Purpose:

To determine the clinical characteristics and surgical outcomes of medial rectus (MR) advancement with or without lateral rectus (LR) recession in patients with consecutive exotropia.

Methods:

This interventional case series was performed on patients with consecutive exotropia of more than 15 prism diopters (PD) at least 6 months after the esotropia surgery. All patients were operated using either unilateral or bilateral MR muscle advancement with or without simultaneous LR recession. Ocular deviation at far and near distances, adduction limitation, and exoshift were investigated at the follow-ups of 1 week, as well as 1, 3, and 6 months after the surgery. Operation was considered successful when the postoperative far deviation was <10 PD.

Results:

Thirty patients were evaluated. The mean amount of MR advancement was 5.69 ± 1.33 mm with the mean dose response of 4.7 ± 3.3 and 4.55 ± 4.01 PD at 3 and 6-month follow-ups, respectively. Success rate was reduced from 93% at week 1 to 73% at month 6 due to postoperative exodrift, especially during the first 3 months. Preoperative exotropia was the only contributing factor in our study.

Conclusions:

MR advancement was an effective surgical method for consecutive exotropia correction, especially in cases with MR underaction. Bilateral MR advancement and/or LR recession are suggested in cases with higher preoperative exodeviation. The presence of postoperative exodrift indicates longer follow-ups for patients.

Lateral rectus resection versus lateral rectus plication in patients with residual Esotropia

This study was aimed to compare the surgical outcomes of lateral rectus plication and resection techniques on patients with residual esotropia. In this randomized clinical trial, a total of 57 patients with residual esotropia (31 females) who were candidates for lateral rectus resection were randomized into plication (n = 27) and resection (n = 30) groups. The inclusion criteria were residual Esotropia after uni- or bilateral medial rectus recession. Subjects with a history of prematurity, lack of central fixation, extraocular muscle palsy, systemic, ocular disorders, history of lateral rectus operation, or follow up less than 3 months were excluded. Ophthalmic examinations were conducted preoperatively and at 1, 3-, and 6-month follow-ups. Surgical success rate was considered postoperative eso- or exotropia ≤10 pd. Based on the study results, there was no statistically significant difference between the two groups regarding the pre- (plication: 27.9 ± 9.8 pd and resection: 26.4 ± 7.6 pd; P = .52) and postoperative mean angle of deviation at far distance in month 3 (plication: 5.1 ± 7.1 pd and resection: 5.4 ± 3.2 pd; P = .82). Postoperative success rate also showed similarity between these two groups at all postoperative follow-ups of months 1, 3, and 6.There was no statistically significant difference between dose responses of these groups in uni- or bilateral operations. In conclusion, lateral rectus plication and resection showed statistically similar results. Each surgical method could be selected according to surgeon's skill and comfort. We recommend plication method for patients with postoperative probability of anterior segment ischemia.

Motor and Sensory Outcomes of Infantile Exotropia: A 10-Year Study (2008-2017)

Purpose

We aimed to determine the long-term motor and sensory outcomes of patients with infantile exotropia.

Methods

In this longitudinal retrospective (historical cohort) study, the records of 76 patients with infantile exotropia were Studied. Subjects with constant exotropia manifesting before the age of 1 year who were at least 5 years old at recruitment time between 2008 and 2017 were included.

Results

The medical records of 26 patients were excluded due to not participating in follow-up examinations or having incomplete records. In total, 54 infantile exotropic patients (51.9% male) with a mean age of 11.1 ± 6.8 years and follow-up of 4.99 ± 3.58 years were studied. Postoperative sensory outcomes (central stereopsis [<60 sec/arc], peripheral fusion [60–3,000 sec/arc], and non-stereopsis [>3,000 sec/arc]) were observed in 38.9%, 38.9%, and 21.2% of patients, respectively. In terms of postoperative motor outcomes, 69%, 24%, and 7% were achieved as orthophoria, residual exotropia, and consecutive esotropia, respectively. Patients with a higher surgical age (p = 0.022) and better visual acuity (p = 0.004) had significantly better sensory outcomes, while higher preoperative deviation resulted in more suppression (p = 0.039, rs = 0.218).

Conclusions

With rates of 69% for motor success and 78.8% for sensory success, surgical outcomes of infantile exotropic patients seems to be favorable. Further studies are recommended to verify our findings.

The myo-inositol effect on the oocyte quality and fertilization rate among women with polycystic ovary syndrome undergoing assisted reproductive technology cycles: a randomized clinical trial

PURPOSE

The aim of the present study was to evaluate the effect of myo-Inositol administration on oocyte quality, fertilization rate and embryo quality in patients with PCOS during assisted reproductive technology (ART) cycles.

METHODS

Fifty infertile PCOS patients were randomly designated in two groups. In the study group, patients received daily doses of 4 g myo-Inositol combined with 400 mg folic acid and in the control group patients received only 400 mg folic acid from 1 month before starting the antagonist cycle until the day of ovum pick up. Oocyte and embryo qualities were assessed according to European Society of Human Reproduction and Embryology (ESHRE) guidelines. The gene expression of PGK1, RGS2 and CDC42 as a factor of oocyte quality in granulosa cells was analyzed using real-time RT-PCR. Levels of total antioxidant capacity (TAC) and reactive oxygen species (ROS) were evaluated by chemiluminescence assay in follicular fluid.

RESULTS

The percentage of metaphase II oocyte, fertilization rate and embryo quality significantly improved in the study group (p < 0.05), but the number of retrieved oocytes and follicle count were not statistically different between groups. Furthermore, the gene expression of PGK1, RGS2 and CDC42 was significantly higher in the study group (p < 0.05) but no differences were found between two groups in terms of TAC and ROS levels.

CONCLUSIONS

The present study findings suggest that myo-Inositol alters the gene expression in granulosa cells and improves oocyte and embryo quality among PCOS patients undergoing ART.

Comparative Assessment of Tear Function Tests, Tear Osmolarity, and Conjunctival Impression Cytology between Patients with Pterygium and Healthy Eyes

Purpose:

To compare histologic abnormalities of tear film and tear osmolarity between normal eyes and eyes with pterygium.

Methods:

This was a prospective, hospital-based, case–control study involving 95 patients (65 men, 30 women) with unilateral pterygium. The tear meniscus height (TMH), Schirmer's test-1 (SCH-1) score, Rose Bengal staining (RBS) score, tear film breakup time (TBUT), tear osmolarity (TO), and conjunctival impression cytology (CIC) were assessed in both eyes. The Chi-square and Student's t-tests were used to compare the results between the two groups. P values <0.05 were considered statistically significant.

Results:

The mean patient age was 50.9 years, with the largest age group being the 45–55 year-old bracket across both genders. Most patients (82.1%) had nasal pterygium, and 80% were involved in outside activities. The mean assessment values in the case and control groups were as follows: TMH, 0.21 vs. 0.24 mm; SCH-1, 13.2 vs. 17.8 mm; RBS, 4.38 vs. 2.51 points; TBUT, 8.7 vs. 13.2 seconds; TO, 306 vs. 299 mOsm/L (P < 0.001 in all cases). The proportions of abnormal assessment values in the case and control groups were as follows: TMH, 82.1% vs. 3.16%; SCH-1, 20% vs. 2.1%; RBS, 30.53% vs. 4.22%; TBUT, 61.05% vs. 6.3%; TO, 10.52% vs. 1.05%; CIC, 33.7% vs. 7.37% (P < 0.05 for all comparisons).

Conclusion:

This study showed that the quantity and quality of tear film, as well as the number of goblet cells, decreased, but the tear osmolarity increased in eyes with pterygium. Furthermore, the TMH, RBS results, TBUT, and CIC have more precise state of the patient's tear condition with the disease of the pterygium.

Comparing the results of intradiscal ozone injection to treat different types of intervertebral disc herniation based on MSU classification

PURPOSE

To evaluate the therapeutic efficacy of intradiscal ozone injection in reducing pain and improving patients' performance in different types of intervertebral disc herniation based on Michigan State University (MSU) classification.

PATIENTS AND METHODS

Consecutive patients with low back pain and radiculopathy treated in our center with ozone chemonucleolysis from May 2017 through to January 2018 entered the study. Patients had a disc herniation classified as group 1-A, 2-A, 1-B, 2-B, 1-C, 2-C, 1-AB or 2-AB based on MSU classification in magnetic resonance imaging. In all patients entering the study the severity of pain was recorded according to the visual analog scale criteria before and one and three months after the end of treatment. Oswestry Low Back Pain Disability Index (ODI) was used to compare patients' performance before and after the treatment.

RESULTS

In total 128 patients (60 females and 68 males) with mean age of 40.1 ± 10.7 entered the study. The patients were divided into eight groups based on MSU classification each including 16 patients. The reduction of pain severity and ODI score compared to baseline was statistically significant in all groups both in the first month and the third month after treatment. There was also a statistically significant difference between groups regarding the reduction of pain and ODI score indicating significantly worse treatment outcomes in groups 1-C, 2-C and 2-AB.

CONCLUSION

Based on our findings it seems that MSU classification can be used in patients' selection to achieve the best treatment outcome after intradiscal ozone injection among patients with lumbar disc herniation.

The relationship between abduction deficit and reoperation among patients with infantile esotropia

AIM

To determine the relationship between abduction deficit and reoperation among patients with infantile esotropia (IET).

METHODS

The records of 216 patients (432 eyes) with IET who underwent surgery, from 2010 to 2015 were studied. Patients with IET whose deviation appeared before 6mo of age and had stable preoperative deviation in two examinations with at least 2wk apart and a minimum 3mo postoperative follow up were included. Cases with early onset accommodative esotropia, congenital cataract, retinopathy of prematurity (ROP), manifest nystagmus, fundus lesions, neurologic and ophthalmic anomalies, 6^th nerve palsy and Duane's syndrome were excluded. Preoperative abduction deficit was considered from -1 to -3 grading scale. Three months after surgery, children were classified into no-need reoperation [deviation≤15 prism diopters (PD)], and need-reoperation groups (deviation>15 PD).

RESULTS

In this retrospective study, 117 female and 99 male patients with the mean surgical age of 4.7±6.4y were included. Reoperation rate was 33.3% and 16.0% in IET patients with and without abduction deficit, respectively in patients who had a history of late surgery. Abduction deficit increased the odds of reoperation by 82% [OR=1.82, 95% confidence interval (CI) =1.05 to 3.19, P=0.003] in patients who had a history of late surgery (>2 years old, P=0.021). Abduction deficit was improved significantly after operation (P<0.001).

CONCLUSION

Based on our results, abduction deficit can be considered as a risk factor of reoperation in IET patients who are operated at the age of more than 2y.

Visual acuity, endothelial cell density and polymegathism after iris-fixated lens implantation

PURPOSE

The purpose of this study was to evaluate the visual acuity as well as endothelial cell density (ECD) and polymegathism after iris-fixated lens (Artiflex® AC 401) implantation for correction of moderate to high myopia.

PATIENTS AND METHODS

In this retrospective cross-sectional study, 55 eyes from 29 patients undergoing iris-fixated lens implantation for correction of myopia (-5.00 to -15.00 D) from 2007 to 2014 were evaluated. Uncorrected visual acuity, best spectacle-corrected visual acuity, refraction, ECD and polymegathism (coefficient of variation [CV] in the sizes of endothelial cells) were measured preoperatively and 6 months postoperatively.

RESULTS

In the sixth month of follow-up, the uncorrected vision acuity was 20/25 or better in 81.5% of the eyes. The best-corrected visual acuity was 20/30 or better in 96.3% of the eyes, and more than 92% of the eyes had a refraction score of ±1 D from the target refraction. The mean corneal ECD of patients before surgery was 2,803±339 cells/mm2, which changed to 2,744±369 cells/mm2 six months after surgery (p=0.142). CV in the sizes of endothelial cells before the surgery was 25.7%±7.1% and six months after surgery it was 25.9%±5.4% (p=0.857).

CONCLUSION

Artiflex iris-fixated lens implantation is a suitable and predictable method for correction of moderate to high myopia. There was no statistically significant change in ECD and polymegathism (CV in the sizes of endothelial cells) after 6 months of follow-up.

Vitamin B12 Deficiency as a Cause of Neurotrophic Keratopathy

Introduction:

Neurotrophic keratitis is a rare degenerative corneal disease caused by an impairment of trigeminal corneal innervation, leading to a decrease or absence of corneal sensation. Here, we present a case of neurotrophic keratopathy caused by B12 deficiency in a 34 years old man who had a progressive decrease in visual acuity and corneal involvement since 3 months before being referred to our ophthalmology clinic.

Result and Discussion:

Based on our clinical findings and with the diagnosis of B12 deficiency we started B12 treatment for the patient. After 3 weeks the patient showed a dramatic response with corneal sensation reversal, an increase of visual acuity, improved neurotrophic keratopathy and significantly improved neurological findings. To the best of our knowledge, there is no report regarding vitamin B12 deficiency induced keratopathy and this is the first report that describes this aspect of vitamin B12 deficiency.

Vitamin B12 Deficiency as a Cause of Neurotrophic Keratopathy

Introduction:

Neurotrophic keratitis is a rare degenerative corneal disease caused by an impairment of trigeminal corneal innervation, leading to a decrease or absence of corneal sensation. Here, we present a case of neurotrophic keratopathy caused by B12 deficiency in a 34 years old man who had a progressive decrease in visual acuity and corneal involvement since 3 months before being referred to our ophthalmology clinic.

Result and Discussion:

Based on our clinical findings and with the diagnosis of B12 deficiency we started B12 treatment for the patient. After 3 weeks the patient showed a dramatic response with corneal sensation reversal, an increase of visual acuity, improved neurotrophic keratopathy and significantly improved neurological findings. To the best of our knowledge, there is no report regarding vitamin B12 deficiency induced keratopathy and this is the first report that describes this aspect of vitamin B12 deficiency.

A New Approach to an Old Concept for Reducing Shoulder Pain Caused by Gynecological Laparoscopy

BACKGROUND

The purpose of this study was to introduce a technique to extract the remaining peritoneal gas in order to improve the post-laparoscopic shoulder pain.

METHODS

This study included 12 patients undergoing laparoscopic gynecologic procedures between February and March 2016 in Minimally Invasive Techniques Research Center, Pars Hospital, Tehran, Iran. For complete suction of the air from abdominal cavity, the air was first vacuumed from the pelvic cavity in Trendelenburg position and then the patients were put in anti-Trendelenburg position. In this position, as the remaining gas was shifting toward subdiaphragmatic area, the suction tube was shifted to a position next to the camera canal and the remaining air was suctioned. A 10 point visual analogue scale was used to measure the severity of patients' post-operative shoulder pain.

RESULTS

The mean VAS for shoulder pain was 0.8±1.7 4 hr post-surgery. At 12 hr post-surgery, the mean VAS was 0.8±1.5. At 24 hr post-surgery, the mean VAS for shoulder pain was 0.3±0.8. Finally, 48 hr post-surgery, the VAS score for all patients was zero.

CONCLUSION

Our approach for emptying the abdominal cavity from residual gas after laparoscopic procedures seems to be useful in preventing post-operative shoulder pain among patients undergoing gynecological laparoscopic surgeries. Further studies are suggested to compare the effect of our proposed method with other methods.

Renal Hemosiderosis among Iranian Transfusion Dependent β-Thalassemia Major Patients

Background: In recent years, the success in management of thalassemic patients, has allowed for some previously unrecognized complications including renal abnormalities to emerge. This prospective study aimed to investigate kidney iron overload by means of MRI T2* and also renal function based on laboratory tests for early markers of glomerular and tubular dysfunction among adult Iranian transfusion-dependent thalassemia major patients. Subjects and Methods: Two-hundred and two patients with transfusion-dependent β-thalassemia major were included in this study in Zafar Adult Thalassemia Center, Tehran, Iran. For all patients, kidney MRI T2* as well as evaluation of BUN, creatinine, uric acid, calcium, phosphorus, sodium (Na), potassium (K), total protein, albumin, cystatin C, serum ferritin β2-microglobulin, NAG (N-acetyl-beta-D-Glucosaminidase), and urine protein were performed. Results: One-hundred and fourteen female and 88 male transfusion-dependent β-thalassemia major patients with mean age of 30.1 ± 9.4 participated in the present study. We found that 77.7% of our patients had kidney hemosiderosis based on MRI T2*. Also, 67 patients (33.2%) had elevation of serum cystatin C, and 104 patients (51.5%) had reduced estimated glomerular filtration rate (e-GFR). Increased urinary excretion of NAG and hypercalciuria were found in 50% and 79.2% of participants, respectively. Conclusion: Renal hemosiderosis and asymptomatic renal dysfunction are prevalent among transfusion- dependent β-thalassemia major patients which necessitate regular screening with early markers of glomerular and tubular dysfunction. Further studies in order to investigate the correlation between renal hemosiderosis and early markers of kidney dysfunction among these patients are recommended.

Correlation between Heart, Liver and Pancreas Hemosiderosis Measured by MRI T2* among Thalassemia Major Patients from Iran

INTRODUCTION

Major thalassemia patients need lifelong transfusions. The consequence of these repeated transfusions is iron accumulation in different organs. The main aim of the present study was to investigate the correlation between heart, liver and pancreas hemosiderosis in thalassemic patients from Iran.

METHODS

This cross-sectional study was conducted on 164 major thalassemia patients at Zafar Adult Thalassemia Center, a referral thalassemia center in Tehran, Iran, from May to November 2014.  All patients were on regular blood transfusion at 2-4 week intervals to keep their hemoglobin at a level of 7-9 gr/dL before each transfusion. Demographic data were gathered from patients' history. MRI T2* of liver, heart and pancreas were performed for all patients.

RESULTS

There were a moderate correlation between pancreatic T2* and cardiac T2* relaxation times (r = 0.42, P < 0.001), a moderate correlation between T2* of pancreas and liver (r = 0.41, P < 0.001), and a weak correlation between T2* relaxation times of heart and liver (r = 0.31, P < 0.001).

CONCLUSION

Poor correlation between liver and heart, as well as a weak to moderate correlation between pancreas and liver T2* relaxation times indicate that relying on liver MRI T2* to predict the exact condition of pancreas or heart iron overload might not be a reliable approach in thalassemia major patients. Our findings suggest the advantage of using pancreas and heart MRI T2* as a non-invasive method for estimation of iron overload instead of relying on liver MRI T2*.

Auditory Brainstem Response Wave Amplitude Characteristics as a Diagnostic Tool in Children with Speech Delay with Unknown Causes

Speech delay with an unknown cause is a problem among children. This diagnosis is the last differential diagnosis after observing normal findings in routine hearing tests. The present study was undertaken to determine whether auditory brainstem responses to click stimuli are different between normally developing children and children suffering from delayed speech with unknown causes. In this cross-sectional study, we compared click auditory brainstem responses between 261 children who were clinically diagnosed with delayed speech with unknown causes based on normal routine auditory test findings and neurological examinations and had >12 months of speech delay (case group) and 261 age- and sex-matched normally developing children (control group). Our results indicated that the case group exhibited significantly higher wave amplitude responses to click stimuli (waves I, III, and V) than did the control group (P=0.001). These amplitudes were significantly reduced after 1 year (P=0.001); however, they were still significantly higher than those of the control group (P=0.001). The significant differences were seen regardless of the age and the sex of the participants. There were no statistically significant differences between the 2 groups considering the latency of waves I, III, and V. In conclusion, the higher amplitudes of waves I, III, and V, which were observed in the auditory brainstem responses to click stimuli among the patients with speech delay with unknown causes, might be used as a diagnostic tool to track patients' improvement after treatment.

Effect of Photorefractive Keratectomy on Optic Nerve Head Topography and Retinal Nerve Fiber Layer Thickness Measured by Heidelberg Retina Tomograph 3

Purpose:

To determine whether photorefractive keratectomy (PRK) has a significant effect on optic nerve head (ONH) parameters and peripapillary retinal nerve fiber layer (RNFL) thickness measured by the Heidelberg Retina Tomograph 3 (Heidelberg Engineering GmbH, Heidelberg, Germany) in eyes with low to moderate myopia.

Methods:

This prospective, interventional case series, includes 43 consecutive myopic eyes which were assessed on the day of PRK and 3 months postoperatively using the HRT3. Among the stereometric parameters, we compared disc area, linear cup disc ratio, cup shape measure, global rim area, global rim volume, RNFL height variation contour and mean RNFL thickness; out of the Glaucoma Probability Score (GPS) we assessed changes in global value, rim steepness temporal/superior, and temporal/inferior, as well as cup size and cup depth before and after PRK.

Results:

Mean refractive error before and after PRK were −3.24 ± 1.31 and −0.20 ± 0.42 diopters, respectively. No significant change occurred in disc area, linear cup disc ratio, cup shape measure, rim area and rim volume among the stereometric parameters; and in rim steepness temporal/superior and rim steepness temporal/inferior in the GPS before and after PRK using the default average keratometry. However, RNFL height variation contour, mean RNFL thickness, and cup size and depth were significantly altered after PRK (P < 0.05).

Conclusion:

PRK can affect some HRT3 parameters. Although the most important stereometric parameters for differentiating normal, suspect or glaucomatous patients such as rim and cup measurements in stereometric parameters were not changed.

Prevalence of Amblyopia and Refractive Errors Among Primary School Children

Purpose:

To determine the prevalence of amblyopia and refractive errors among 7 to 12-year-old primary school children in Tehran, Iran.

Methods:

This population-based cross-sectional study included 2,410 randomly selected students. Visual acuity was tested using an E-chart on Yang vision tester. Refractive errors were measured by photorefractometry and cycloautorefraction. Strabismus was checked using cover test. Direct ophthalmoscopy was used to assess the anterior segment, lens opacities, red reflex and fundus. Functional amblyopia was defined as best corrected visual acuity ≤20/40 in one or both eyes with no anatomical problems.

Results:

Amblyopia was present in 2.3% (95% CI: 1.8% to 2.9%) of participants with no difference between the genders. Amblyopic subjects were significantly younger than non-amblyopic children (P=0.004). Overall, 15.9% of hyperopic and 5.9% of myopic cases had amblyopia. The prevalence of hyperopia ≥+2.00D, myopia ≤-0.50D, astigmatism ≥0.75D, and anisometropia (≥1.00D) was 3.5%, 4.9%, 22.6%, and 3.9%, respectively. With increasing age, the prevalence of myopia increased (P<0.001), that of hyperopia decreased (P=0.007), but astigmatism showed no change. Strabismus was found in 2.3% of cases. Strabismus (OR=17.9) and refractive errors, especially anisometropia (OR=12.87) and hyperopia (OR=11.87), were important amblyogenic risk factors.

Conclusion:

The high prevalence of amblyopia in our subjects in comparison to developed countries reveals the necessity of timely and sensitive screening methods. Due to the high prevalence of amblyopia among children with refractive errors, particularly high hyperopia and anisometropia, provision of glasses should be specifically attended by parents and supported by the Ministry of Health and insurance organizations.

Customized Clinical Practice Guidelines for Management of Adult Cataract in Iran

Purpose:

To customize clinical practice guidelines (CPGs) for cataract management in the Iranian population.

Methods:

First, four CPGs (American Academy of Ophthalmology 2006 and 2011, Royal College of Ophthalmologists 2010, and Canadian Ophthalmological Society 2008) were selected from a number of available CPGs in the literature for cataract management. All recommendations of these guidelines, together with their references, were studied. Each recommendation was summarized in 4 tables. The first table showed the recommendation itself in clinical question components format along with its level of evidence. The second table contained structured abstracts of supporting articles related to the clinical question with their levels of evidence. The third table included the customized recommendation of the internal group respecting its clinical advantage, cost, and complications. In the fourth table, the internal group their recommendations from 1 to 9 based on the customizing capability of the recommendation (applicability, acceptability, external validity). Finally, customized recommendations were sent one month prior to a consensus session to faculty members of all universities across the country asking for their comments on recommendations.

Results:

The agreed recommendations were accepted as conclusive while those with no agreement were discussed at the consensus session. Finally, all customized recommendations were codified as 80 recommendations along with their sources and levels of evidence for the Iranian population.

Conclusion:

Customization of CPGs for management of adult cataract for the Iranian population seems to be useful for standardization of referral, diagnosis and treatment of patients.

Correlating Whole-Body Bone Mineral Densitometry Measurements to Those From Local Anatomical Sites

Background:

Using the same cutoff points for whole-body measurements as for site-specific measurements will result in underestimation of osteoporosis.

Objectives:

We assessed the correlation between densitometry measurements for the whole body with those for the femur, lumbar spine, and forearm to evaluate the possibility of replacing site-specific values with whole-body measurements.

Patients and Methods:

In this cross-sectional study, we evaluated all patients referred to a single rheumatology clinic for bone mineral density measurements from 2009 to 2010. All patients who had bone mineral density measurements taken from the hip, lumbar spine, forearm, and whole body were enrolled in the study. Standard bone mineral density measurements were performed using a dual energy X-ray absorptiometry device (Hologic Delphi A; Hologic, Bedford, MA, USA). Bone mineral density, Z-score, and T-score were measured for all patients and all body regions.

Results:

The mean age of the 152 participating patients was 56.7 ± 12.6 years, and 97.4% were female. Pearson correlation coefficients of the whole-body bone mineral density values compared with site-specific values in patients over age 50 were 0.66 – 0.75. Using T-score cutoff points of -1 and -2.5 for osteopenia and osteoporosis, whole-body measurements underestimated the percentage of abnormal patients compared with the site-specific measurements (all P < 0.001). Using receiver operating characteristic (ROC) analysis, the whole-body bone mineral density showed respective areas under the curve of 0.96 and 0.84 for the diagnosis of abnormal hip bone mineral density and osteoporosis.

Conclusion:

Using the same cutoff points for whole-body measurements as for site-specific measurements will result in overestimation or especially underestimation of osteopenia and osteoporosis diagnosis. Choosing new and appropriate cutoff points for whole-body densitometric measurements when we want to substitutes this assessment instead of site specific measurements seems mandatory and will decrease the rate of false diagnoses of densitometric deficiencies in these anatomical sites.

A Rare Case of Gestational Gigantomastia with Hypercalcemia: The Challenges of Management and Follow up

BACKGROUND

Gigantomastia is a breast disorder marked by exaggerated rapid growth of the breasts, generally bilaterally. Since this disorder is very rare and has been reported only in sparse case reports its etiology has yet to be fully established. Treatment is aimed at improving the clinical and psychological symptoms and reducing the treatment side effects; however, the best therapeutic option varies from case to case.

CASE PRESENTATION

The present report described a case of gestational gigantomastia in a 30-year-old woman, gravida 2, parity 1, 17 week pregnant admitted to Pars Hospital, Tehran, Iran, on May 2014. The patient was admitted to hospital at week 17 of pregnancy, although her breasts initially had begun to enlarge from the first trimester. The patient developed hypercalcemia in her 32nd week of pregnancy. The present report followed this patient from diagnosis until the completion of treatment.

CONCLUSION

Although gestational gigantomastia is a rare condition, its timely prognosis and careful examination of some conditions like hyperprolactinemia and hypercalcemia is essential in successful management of this condition.

Refractive Outcomes, Contrast Sensitivity, HOAs, and Patient Satisfaction in Moderate Myopia: Wavefront-Optimized Versus Tissue-Saving PRK

PURPOSE

To compare refractive outcomes, contrast sensitivity, higher-order aberrations (HOAs), and patient satisfaction after photorefractive keratectomy for correction of moderate myopia with two methods: tissue saving versus wavefront optimized.

METHODS

In this prospective, comparative study, 152 eyes (80 patients) with moderate myopia with and without astigmatism were randomly divided into two groups: the tissue-saving group (Technolas 217z Zyoptix laser; Bausch & Lomb, Rochester, NY) (76 eyes of 39 patients) or the wavefront-optimized group (WaveLight Allegretto Wave Eye-Q laser; Alcon Laboratories, Inc., Fort Worth, TX) (76 eyes of 41 patients). Preoperative and 3-month postoperative refractive outcomes, contrast sensitivity, HOAs, and patient satisfaction were compared between the two groups.

RESULTS

The mean spherical equivalent was -4.50 ± 1.02 diopters. No statistically significant differences were detected between the groups in terms of uncorrected and corrected distance visual acuity and spherical equivalent preoperatively and 3 months postoperatively. No statistically significant differences were seen in the amount of preoperative to postoperative contrast sensitivity changes between the two groups in photopic and mesopic conditions. HOAs and Q factor increased in both groups postoperatively (P = .001), with the tissue-saving method causing more increases in HOAs (P = .007) and Q factor (P = .039). Patient satisfaction was comparable between both groups.

CONCLUSIONS

Both platforms were effective in correcting moderate myopia with or without astigmatism. No difference in refractive outcome, contrast sensitivity changes, and patient satisfaction between the groups was observed. Postoperatively, the tissue-saving method caused a higher increase in HOAs and Q factor compared to the wavefront-optimized method, which could be due to larger optical zone sizes in the tissue-saving group.

Macular thickness and amblyopia

Purpose:

To compare macular thickness in children with functional amblyopia and those without amblyopia using optical coherence tomography (OCT).

Methods:

This case-control study was conducted on 93 children aged 3–10 years including 44 cases with unilateral amblyopia and 49 subjects without amblyopia. Amblyopic eyes were considered as the case group and their fellow eyes as internal controls; eyes of non-amblyopic children served as the external control. Macular thickness of all eyes were measured by optical coherence tomography in the center (foveola), 1 mm ring (fovea), and 3 and 6 mm rings and compared.

Results:

Although macular thickness was generally not different between the study groups, there was a significant difference in central macular thickness between eyes with moderate to severe amblyopia and the external controls (P = 0.037). Foveal thickness difference exceeding 10 microns between fellow eyes was detected in a larger number of amblyopic children as compared to non-amblyopic controls (P = 0.002). Mean foveal thickness was greater in boys (P = 0.037) but there was no significant difference in foveal thickness among various types of refractive errors.

Conclusion:

Although there was no significant relationship between macular thickness and amblyopia, foveolar thickness in eyes with moderate to severe amblyopia was significantly greater than the external controls. Further studies with more cases of moderate to severe amblyopia are recommended.

Treatment results of high dose cabergoline as an adjuvant therapy in six patients with established severe ovarian hyper stimulation syndrome

BACKGROUND

The beneficial role of cabergoline as a prophylactic agent to prevent ovarian hyper stimulation syndrome (OHSS) among high-risk patients has been demonstrated in previous studies. But data for its role as a treatment for established severe OHSS is still limited. We represent the treatment results of high dose oral cabergoline in management of six patients after the syndrome is established.

CASE

High-dose oral cabergoline (1 mg daily for eight days) was prescribed as an adjuvant to symptomatic treatment for six hospitalized patients with established severe OHSS following infertility treatment cycles. In two cases OHSS resolved rapidly despite the occurrence of ongoing pregnancy.

CONCLUSION

Considering the treatment outcomes of our patients, high dose cabergoline did not eliminate the need for traditional treatments, but it was a relatively effective and safe therapy in management of established severe OHSS, and prevented the increase in its severity following the occurrence of pregnancy.

Early postoperative alignment as a predictor of 6-month alignment after intermittent exotropia surgery

PURPOSE

The angle of postoperative deviation changes over time in patients undergoing surgery for intermittent exotropia. The aim of the current study was to assess the relationship between the motor alignment at 1 week and 6 months after exotropia surgery.

METHODS

The records of 81 patients who underwent surgery for intermittent exotropia from 2002 to 2012 at Imam Hussein Medical Center and had at least 6 months of postoperative follow-up were retrospectively reviewed. Each patient underwent complete eye examination and had surgery for orthophoria. Patients were divided into three groups according to their 1-week postoperative alignment (undercorrection [exotropia > 10 prism diopters (PD)], orthophoria [exotropia ≤ 10 PD and esotropia ≤ 5 PD], and overcorrection [esotropia > 5 PD]).

RESULTS

The postoperative success rates for 1 week and 6 months were 75.3% and 76.5% respectively. Of 61 orthophoric, 13 undercorrected, and 7 overcorrected patients at 1 week postoperatively, 51 (83.6%), 7 (53.8%), and 2 (28.6%) patients, respectively, preserved their initial alignment at 6 months (P = .024 for orthophoria). The type of surgery had no effect on the results at 6 months. Reoperation was needed in 10 (12.3%) of our patients at the 6-month follow-up (7 undercorrected and 3 orthophoric patients).

CONCLUSIONS

Early postoperative alignment of intermittent exotropia at 1 week can be considered a predictor of orthophoria at 6 months, whereas fewer cases in other groups made predicting their alignment at 6 months statistically difficult. Reoperation was needed in 12.3% of cases at the 6-month follow-up.

Central Corneal Thickness in Highly Myopic Eyes: Inter-device Agreement of Ultrasonic Pachymetry, Pentacam and Orbscan II Before and After Photorefractive Keratectomy

PURPOSE

To determine inter-device agreement for central corneal thickness (CCT) measurement among ultrasound pachymetry, rotating Scheimpflug imaging (Pentacam, Oculus, Wetzlar, Germany), and scanning slit corneal topography (Orbscan II, Bausch & Lomb, Rochester, NY, USA) in highly myopic eyes before and after photorefractive keratectomy (PRK).

METHODS

This prospective comparative study included 61 eyes of 32 patients with high myopia who underwent PRK. Six month postoperative CCT values were compared to preoperative values in 27 patients (51 eyes) who completed the follow up period. To determine the level of agreement, Pentacam and Orbscan II readings were compared to ultrasonic pachymetry measurements as the gold standard method.

RESULTS

Mean CCT measurements with ultrasound, Pentacam, and Orbscan II before PRK were 557µm, 556µm, and 564µm, respectively; and 451µm, 447µm, and 438µm 6 months after surgery in the same order. Preoperatively, the 95% limits of agreement (LoA) with ultrasound measurements were -20μm to 17μm for Pentacam and -21μm to 33μm for Orbscan II. Six months postoperatively, the 95% LoA were -30μm to 23μm for Pentacam and -69μm to 43μm for Orbscan II.

CONCLUSION

Preoperatively, CCT measurements were higher with Orbscan II as compared to ultrasound. Postoperatively, both Pentacam and Orbscan II measurements were lower than those obtained with ultrasound, but Pentacam had better agreement. The use of ultrasound, as the gold standard method, or Pentacam both appear to be preferable over Orbscan II among patients with high myopia.

Congenital pulmonary airway malformation

BACKGROUND

Congenital cystic adenomatoid malformations (CCAMs) are considered rare developmental anomalies of the lower respiratory tract. These are hamartomatous abnormalities of the lung with adenomatoid proliferation of cysts resembling bronchioles and ususally occur sporadically occur and unilaterally with single lobe involvement.

METHOD

A 6-year-old girl was admitted to our center because of prolonged fever and non-productive cough lasting3 months before admission.

RESULTS

The only other complaint was night sweating. She did not have dyspnea and did not mention any respiratory symptoms. On examination, coarse crackle and decreased lung sounds in the left side were detected. White blood cell count was 9.100 /µL, hemoglobin was 11.2 g/dL, erythrocyte sedimentation rate was 50 and C-reactive protein was 1+. IgA and IgM for hydatid cyst were tested and both were raised (14 and 1.4, respectively).

CONCLUSION

The patient underwent surgery, with the probable diagnosis of hydatid cyst but in operating room diagnosis was changed and it was adenomatoid cystic malformation. In follow-up, she was in good general condition without any post-surgical complaints (Fig. 3, Ref. 11).

Surgical results of consecutive exotropia

PURPOSE

To determine the success rates of different surgical procedures and the risk factors of surgical failure among patients with consecutive exotropia.

METHODS

Forty patients with exotropia were observed at least 6 weeks after their esotropia surgery. Surgical planning was based on the medial rectus muscle function. Lateral rectus weakening in patients with normal medial rectus function, medial rectus strengthening for patients with limited medial rectus function (-1 to -3), and combined procedure occurred when the correction of each type of surgery was less than the amount of deviation. Postoperatively, patients were divided into success (8 prism diopters [PD] or less) or failure (8 PD or greater) groups. The follow-up period was at least 3 months.

RESULTS

The mean preoperative exotropia was 29 ± 13 PD, which was reduced to 7 ± 7 PD postoperatively (P < .001). Successful results were achieved in 31 patients (77.5%), 17 (81%) in lateral rectus weakening, 10 (83%) in medial rectus strengthening, and 4 (57%) in the combined procedure group. More preoperative exodeviation was observed in the failure group compared to the success group (P = .015).The mean dose response was 2.27 ± 0.92 PD/mm in the lateral rectus weakening, 4.25 ± 2.27 PD/mm in the medial rectus strengthening, and 2.31 ± 0.66 PD/mm in the combined procedure groups.

CONCLUSION

If the choice of surgical planning is based on medial rectus function and the amount of exodeviation, satisfactory alignment would be achieved in the majority of patients with consecutive exotropia. The preoperative amount of exodeviation was the only risk factor of surgical failure in the study.

Relation between serum ferritin and liver and heart MRI T2* in beta thalassaemia major patients

There is a need for higly accurate non-invasive methods for assessing organ iron content in thalassaemia patients. This study evaluated the relation between serum ferritin level, liver enzyme levels and hepatitis C antibody and liver and heart iron deposition assessed by MRI T2*. Data were obtained from the medical records of 156 thalassemia major patients in Tehran. There was a moderate negative correlation between serum ferritin and liver MRI T2* relaxation time (r = -0.535) and a weak negative correlation between serum ferritin and heart MRI T2* relaxation time (r = -0.361). Hepatitis C infection and liver enzyme levels did not confound or modify the relation between ferritin and liver or heart MRI T2*. Liver and heart MRI T2* readings were poorly correlated (r = 0.281). Routine evaluation of liver and heart iron content using MRI T2* is suggested to better evaluate the haemosiderosis status in thalassemia patients.

Hypotropic dissociated vertical deviation; a case report

PURPOSE

To report the clinical features of a rare case of hypotropic dissociated vertical deviation (DVD).

CASE REPORT

A 25-year-old female was referred with unilateral esotropia, hypotropia and slow variable downward drift in her left eye. She had history of esotropia since she had been 3-4 months of age. Best corrected visual acuity was 20/20 in her right eye and 20/40 in the left one when hyperopia was corrected. She underwent bimedial rectus muscle recession of 5.25mm for 45 prism diopters (PDs) of esotropia. She was orthophoric 3 months after surgery and no further operation was planned for correction of the hypotropic DVD.

CONCLUSION

This rare case of hypotropic DVD showed only mild amblyopia in her non-fixating eye. The etiology was most probably acquired considering hyperopia as a sign of early onset accommodative esotropia.

Resistance to Clopidogrel among Iranian Patients Undergoing Angioplasty Intervention

To study the resistance to standard dosage of clopidogrel among Iranian patients following percutaneous coronary intervention measured by platelet aggregation test. Patients undergoing percutaneous coronary intervention in Imam Hussein Medical center, Tehran, Iran, who were under treatment with aspirin, but had no history of clopidogrel usage, entered the study. Patients received standard dosage of clopidogrel (Plavix(®), Sanofi, France, 600 mg loading dose and 75 mg/day afterward). Platelet aggregation was measured using light transmission aggregometer. The response to the drug was categorized as complete resistance (platelet aggregation decreased less than 10%), intermediate resistance (platelet aggregation decreased between 10 to 30%) and complete response (platelet aggregation decreased to 30% or more). All patients were evaluated for major adverse cardio vascular events one month after the angioplasty based on MACE criteria by phone contact. Thirty-one patients with a mean age of 59 ± 13 entered the study. Sixty-five percent of patients showed complete response to clopidogrel (95% CI: 45% to 81%), 22% showed intermediate resistance (95% CI: 10-41%) and 13% showed complete resistance (95% CI: 4-30%). One month after the angioplasty, no major adverse cardiovascular event was recorded. Based on our findings, it seems that there is no major difference between Iranian population and other studies regarding the resistance to clopidogrel. Due to the limited number of participants in our study, further investigations with higher number of patients are recommended to more precisely calculate the percentage of resistance among Iranian patients.

The prevalence of reoperation and related risk factors among patients with congenital esotropia

PURPOSE

To determine the prevalence rate and related risk factors of reoperation among patients with congenital esotropia.

METHODS

One hundred fifty-seven children with congenital esotropia were divided into two groups after at least one operation: children with deviation within 10 PD (n = 89; success group) and those with deviation greater than 10 PD or history of reoperation (n = 68; failure group). The relationship of risk factors such as age at first operation and primary congenital esotropia of less than 30 or more than 50 PD and accompanying factors such as inferior oblique muscle overaction (> +1), dissociated vertical deviation, lateral rectus muscle underaction, and A-V pattern with reoperation were studied. Final sensory status of children 5 years and older was evaluated by Worth 4-dot and Titmus tests.

RESULTS

Reoperation was indicated in 32.4% of children who had residual esotropia greater than 15 PD after 3 months following their first operation. Congenital esotropia greater than 30 PD (P = .002) and lateral rectus muscle underaction of −1 to −2 (P < .005), were statistically different between the two groups. Initial operation at younger than 3 years was more likely to achieve gross stereopsis in children 5 years and older (P = .032).

CONCLUSION

Congenital esotropia greater than 30 PD and lateral rectus muscle underaction were found to be risk factors of reoperation.

T2-star (T2*) magnetic resonance imaging for assessment of kidney iron overload in thalassemic patients

BACKGROUND

Improved survival in thalassemic patients has lead to the manifestation of morbidities such as renal dysfunction. This involvement suggests the need for a reliable and non-invasive method to assess the degree of kidney iron overload. We conducted the present study to evaluate the relationship between serum ferritin levels, liver, heart, and kidney MRI gradient echo (T2*) relaxation times in thalassemic patients, as a step to evaluate the feasibility of using MRI T2* to assess the degree of kidney iron overload.

METHODS

This was a prospective study of 120 (60 males, 60 females) regularly transfused thalassemic patients (mean age: 25.9 ± 9 years) who suffered from major and intermediate thalassemia. Patients attended an adult thalassemia clinic located in Tehran, Iran. Cardiac, hepatic and renal MRI T2* were performed. Serum ferritin levels were measured.

RESULTS

Our results indicated a moderate correlation between kidney MRI T2* relaxation time and serum ferritin (r = -0.446, P < 0.001). Kidney MRI T2* relaxation time weakly correlated with liver MRI T2* relaxation time (r = 0.388, P < 0.001) and cardiac MRI T2* relaxation time (r = 0.338, P = 0.023).

DISCUSSION

The moderate correlation between kidney MRI T2* relaxation time and serum ferritin, and its weak correlation with liver and heart T2* relaxation times indicate that relying on liver and heart MRI T2*, as well as serum ferritin levels to predict the exact condition of kidney iron overload might not be a reliable approach. Our findings suggest the use of kidney MRI T2* as a noninvasive method for evaluating renal iron overload in thalassemic patients. Further studies to investigate the relation between kidney MRI T2* relaxation times and renal function, as well as the cost benefit of using this method, are suggested.

Intranasal midazolam compared with intravenous diazepam in patients suffering from acute seizure: a randomized clinical trial

OBJECTIVE

Acute seizure attack is a stressful experience both for health care personnel and parents. These attacks might cause morbidity and mortality among patients, so reliable methods to control the seizure preferably at home should be developed. This study was performed to measure the time needed to control seizure attacks using intranasal midazolam compared to the common treatment (intravenous diazepam) and to evaluate its probable side effects.

METHODS

This study was conducted as a not blind randomized clinical trial among 60 patients coming to Imam Ali Hospital, Zahedan, Iran. The patients were 2 months to 15 years old children coming to our emergency department suffering from an acute seizure episode. Intranasal midazolam was administered 0.2 mg/kg equally dropped in both nostrils for case group and intravenous diazepam was administered 0.3mg/kg via IV line for control group. After both treatments the time needed to control the seizure was registered by the practitioner. Pulse rate and O2 saturation were recorded at patients' entrance and in minutes 5 and 10 after drug administration.

FINDINGS

The time needed to control seizure using intranasal midazolam (3.16±1.24) was statistically shorter than intravenous diazepam (6.42±2.59) if the time needed to establish IV line in patients treated by intravenous diazepam is taken into account (P<0.001). The readings for O2 saturation or heart rate did not indicate a statistically significant difference between two groups of patients either at entrance or 5 and 10 minutes after drug administration.

CONCLUSION

Considering the shorter time needed to control acute seizure episodes compared to intravenous diazepam and its safety record, intranasal midazolam seems to be a good candidate to replace diazepam, as the drug of choice, in controlling this condition.

A survey on pulmonary pathogens and their antibiotic susceptibility among cystic fibrosis patients

OBJECTIVE

This study was performed to investigate frequency and antimicrobial susceptibility of pulmonary pathogens in cystic fibrosis (CF) patients.

METHODS

129 pediatric patients with CF were enrolled in this cross-sectional study. Microbiological cultures were performed based on sputum or pharyngeal swabs. Antibiotic susceptibilities of the isolated bacteria were determined by the disk diffusion method.

RESULTS

The main infecting pathogens were Pseudomonas aeruginosa (38.8%), Klebsiella pneumoniae (11.6%) and Staphyloccus areus (9.3%), respectively. The most active antibiotics included rifampin (91.7% susceptibility), vancomycin (85%) and imipenem (83.5%). Emerging resistance against aminoglycosides was observed.

CONCLUSION

Regarding in vitro susceptibility results, cyclic treatment of long-term oral azithromycin and inhaled tobramycin could prophylactically be applied, and during exacerbations, imipenem or ceftazidime in combination with an aminoglycoside such as amikacin could be considered the drugs of choice.

Partial radiofrequency ablation of the spleen in thalassemia

PURPOSE

To investigate the efficiency of partial radiofrequency ablation of the spleen in patients with thalassemia major and intermedia.

MATERIALS AND METHODS

Partial radiofrequency ablation of the spleen was performed in 19 thalassemic patients (10 females, nine males) with a mean age of 12.7 years (age range, 7-30 years). This group of patients consisted of 11 patients with thalassemia major and nine with thalassemia intermedia. The procedure was performed under intravenous sedation and was complete in 29-35 min.

RESULTS

The ratio of the ablated volume to the whole spleen ranged from 5.3% to 23% (mean, 9.83 ± 5.56%). A significant increase was found in the platelet count after radiofrequency ablation of the spleen (P = 0.002). No statistically significant difference was found in hemoglobin levels (P = 0.171) or transfusion intervals (P = 0.054) before and after radiofrequency ablation. Additionally, no statistically significant relationship was observed between the ablation ratio and hemoglobin levels (P = 0.233) and between the ablation ratio and transfusion interval (P = 0.822). No major complication occurred due to this interventional procedure.

CONCLUSION

A single percutaneous radiofrequency ablation of the spleen reduces thrombocytopenia in thalassemic patients with splenomegaly but does not change the hemoglobin levels or transfusion intervals.

Visual outcome and contrast sensitivity after photorefractive keratectomy in low to moderate myopia: wavefront-optimized versus conventional methods

PURPOSE

To compare visual outcomes and contrast sensitivity after wavefront-optimized or conventional photorefractive keratectomy (PRK) in myopic patients with or without astigmatism.

SETTING

Vanak Eye Surgery Center, Tehran, Iran.

DESIGN

Comparative case series.

METHODS

Patients with low to moderate myopia with or without astigmatism were allocated into 2 groups. The study group was treated with wavefront-optimized PRK (Allegretto Wave Eye-Q software version 2.020 default treatment) and the control group, with conventional PRK (Technolas 217z). In all cases, treatments were bilateral and performed with the same device. Baseline and 3-month postoperative measures were uncorrected and corrected distance visual acuities, manifest refraction, and contrast sensitivity.

RESULTS

Each group comprised 66 eyes. The mean preoperative spherical equivalent refraction improved from -2.99 diopters (D) ± 1.02 (SD) preoperatively to -0.08 ± 0.26 D 3 months postoperatively in the study group and from -2.66 ± 0.95 D to 0.01 ± 0.30 D, respectively, in the control group. In both groups, the postoperative mesopic and photopic contrast sensitivity decreased significantly at most spatial frequencies. The postoperative decrease in contrast sensitivity in both groups was comparable except at spatial frequencies of 3 cycles per degree (cpd) under mesopic conditions and 12 cpd under photopic conditions, frequencies at which the control group had a greater reduction.

CONCLUSIONS

Visual acuity and refractive error outcomes were similar in both treatment groups. After 3 months, mesopic and photopic contrast sensitivity were significantly decreased in both groups; the reduction in the 2 groups was almost comparable.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Nodal monocytoid B-cell lymphoma (nodal marginal-zone B-cell lymphoma)

Benign monocytoid B cells are seen in lymph nodes in different types of lymphadenitis and they occur in the form of clusters within and around sinuses and in the interfollicular areas, but rarely completely surround benign follicles to produce a marginal-zone pattern. The cytologic hallmark of these cells is the presence of abundant pale to clear cytoplasm; these cells usually are of medium size, and they have a rather bland-appearing, irregular nuclei with inconspicuous nucleoli. Malignant monocytoid B-cell proliferations in a lymph node have been classified as monocytoid B-cell lymphomas (MBCL), which are now called nodal marginal-zone B-cell lymphoma (MZL) in the World Health Organization (WHO) classification. In the recently published clinical evaluation of the International Lymphoma Study Group classification of non-Hodgkin's lymphoma, 25 of 1,378 cases (1.8%) were classified as primary MZL, whereas four times as many cases (105 or 7.6%) were classified as low-grade mucosa-associated lymphoid tissue (MALT)-type lymphoma. Transformation to large-cell lymphoma at the time of diagnosis was seen in five of 25 (20%) cases of nodal MZL and in 32 of 105 (30%) cases of MALT-type lymphoma. Comparison of the clinical findings at presentation and the survival results indicate that nodal MZL is more aggressive clinically than low-grade MALT-type lymphoma. For example, patients with nodal MZL had a significantly higher incidence of advanced-stage disease, including peripheral and paraaortic lymphadenopathy, than those with MALT-type lymphoma. Moreover, patients with nodal MZL had lower 5-year overall survival and failure-free survival than patients with MALT type lymphoma. When analysis was restricted to those patients with zero to three adverse risk factors in the International Prognostic Index, patients with nodal MZL still had a significantly lower overall and failure-free survival at 5 years than patients with MALT-type lymphoma. We conclude that nodal MZL is a distinctive disease entity and is similar to other low-grade nodal lymphomas, such as the follicular or small lymphocytic lymphomas, but different than MALT-type lymphoma.