Factors Predisposing to Amblyopia After Exotropia Surgery

Amblyopia (lazy eye) is one of the significant complications of strabismus surgery. It is the most important cause of unilateral visual impairment in both children and adults. The current investigation was achieved to determine the postoperative amblyopia rate and to identify factors predisposing to amblyopia following exotropia surgery among patients who had been referred to Imam Khomeini Hospital in Urmia, Iran. The present investigation is a retrospective study that was conducted over three years (2008-2010). The study consisted of sixty patients who underwent their first strabismus surgery for treatment of horizontal deviation. Patients were followed up for at least 24 months, and the rate of postoperative amblyopia was measured. The preoperative deviation, strabismus type (exotropia vs. esotropia), visual acuity, age at surgery , and the number of operated muscles were analyzed as determining factors of postoperative development of amblyopia. Amblyopia was observed in 50% of cases during the follow-up period. No statistically significant differences were observed between amblyopic and non-amblyopic eyes in terms of sex, age at surgery, strabismus type, and visual acuity. But amblyopic eyes showed higher deviation angles compared to nonamblyopic eyes (<0.001). The Cox hazard model analysis revealed a significant contribution of deviation angle to postoperative development of amblyopia. A larger deviation angle has been identified as a positive predictor of postoperative development of amblyopia in our investigated population. Due to such a high rate of postoperative amblyopia, it seems better to initiate and complete amblyopia therapy before strabismus surgery.

Serum concentrations of 25-hydroxyvitamin D and different subtypes of age-related cataract; a case-control study

Introduction: Age-related cataract (ARC) is the principal causes of low vision and also the most prevalent type of cataract among the elderly population, particularly women. Objectives: To evaluate the association between serum concentration of vitamin D and risk of different subtypes of senile cataract. Patients and Methods: A total of 200 controls and 1241 patients with newly recognized ARC attending the ophthalmology ward of a major teaching hospital in Urmia, Iran, were included in this investigation. All included subjects aged 40 to 85 years. Cataracts were classified as pure nuclear cataract (NC) (n=216), pure cortical cataract (CC) (n=336), pure posterior sub-capsular cataract (PSC) (n=140) and mixed cataracts (549). Serum concentration of 25-hydroxyvitamin D was obtained from blood samples. All participants were administered by a questionnaires to collect data on demographic variables and risk factors. Results: On multivariate analysis, a marked negative association (P < 0.05) was found between vitamin D serum levels and the risk of NC (OR = 0.20; 95% CI: 0.09-0.75) or CC (OR = 0.25; 95% CI: 0.12-0.96) in females only. Other significant predictors of pure NC in women were higher education (OR = 0.51) and serum calcium levels (OR = 0.35). Apart from serum concentrations of vitamin D, postmenopausal status (OR = 2.26) was the other predisposing factor for pure cortical opacity in women. Conclusion: Our finding does not endorse a role for vitamin D in cataractogenesis among men. In women, however, serum levels of 25(OH)D were only inversely associated with the risk of NC and CC and not with PSC or mixed cataract. Providing sufficient vitamin D is possibly helpful in preventing senile cataract formation in females.

Conjunctivitis and other ocular manifestation following COVID-19; updated information about transmission of COVID-19 by eye

Coronavirus disease 2019 (COVID-19) was reported in Wuhan, in late December 2019 and was became a pandemic health problem worldwide. In this review, the current evidence related to the ocular transmission of SARS-CoV-2 and its common manifestations was studied. According to this review, 7% to 69.4% of patients had at least an ocular symptom following COVID-19. Ocular symptom are bilateral or unilateral conjunctivitis, increased secretion, eye itching and foreign body sensation, epiphora, dry eye, conjunctival congestion, eye pink, conjunctival hyperemia, and chemosis. SARS-CoV-2 particles were found in tears and conjunctiva. Therefore, the transmission of COVID-19 by conjunctiva is possible. Then, it is essential to wear eye shield to protect against developing ocular involvement by COVID-19 because personal glasses and contact lenses cannot protect from COVID-19.

Sinonasal Anatomical Variations and Primary Acquired Nasolacrimal Duct Obstruction: A Single Centre, Case-Control Investigation

Objective

Primary acquired nasolacrimal duct obstruction (PANDO) is an idiopathic narrowing of the nasolacrimal duct caused by chronic inflammation and consecutive stenosis of the nasal tissue. In the current investigation, we aimed to study the etiopathogenic role of sinonasal anatomical abnormalities and paranasal inflammatory pathologies in PANDO.

Materials and Methods

Computed tomography (CT) findings of 459 patients who were diagnosed with unilateral PANDO between April 2009 and March 2017 were compared with that of a control group, which comprised 200 subjects without nasolacrimal duct obstruction who had been referred to the ear nose throat (ENT) clinic with the complaint of vertigo and headache. A radiologist (R. S.) masked to the clinical situation of participants retrospectively examined their CT findings.

Results

The prevalence of deviated nasal septum was found to be strongly associated with PANDO incidence (55.3% on PANDO side of patients vs. 28.3% among controls; p<0.001). Significant increases, albeit of smaller magnitude, were also observed in the relative frequency of Agger nasi cells and maxillary sinusitis on the PANDO side of the subjects (14.6% and 27.0%, respectively) compared to controls (9.5% and 20.6%, respectively) (p=0.023 and p=0.038, respectively). Unilateral PANDO was also found to be robustly associated with an ipsilateral deviated nasal septum (p<0.001). The odds of septal deviation occurrence were 3.037 times (95% Confidence Interval (CI): 2.303-3.990; p<0.001) more on the PANDO than the non-PANDO side of the studied cases.

Conclusion

Ipsilaterally deviated nasal septum appears to have a role in the development of unilateral primary acquired obstructive disease of the lacrimal drainage system. The incidence of PANDO might also be affected by Agger nasi cells and maxillary sinusitis. Multicenter studies are essential to further elucidate the interaction between type, severity, extent, and dimensions of different pathologies with nasolacrimal duct obstruction.

Intravitreal Bevacizumab with or without Triamcinolone for Wet Age-related Macular Degeneration: Twelve-month Results of a Prospective, Randomized Investigation

PURPOSE:

The purpose of this study is to compare the long-term outcomes of intravitreal bevacizumab (IVB) with a combination therapy including IVB/intravitreal triamcinolone acetonide (IVB/IVTA) in neovascular age-related macular degeneration (AMD).

MATERIALS AND METHODS:

This prospective, randomized clinical trial was conducted on 136 eyes of 136 patients with neovascular AMD. Eyes were randomly assigned to receive IVB alone (71 eyes) or in combination with IVTA (65 eyes). In the IVB group, three consecutive injections of 1.25 mg/0.05 ml of bevacizumab were administered 1 month apart, whereas in the IVB/IVTA group, 4 mg/0.05 mL of triamcinolone acetonide was added to bevacizumab in the first injection. Additional IVB injections were administered in eyes demonstrating active choroidal neovascularization. Best-corrected visual acuity (BCVA) and optical coherence tomography were performed at baseline as well as at all follow-up visits.

RESULTS:

No differences were seen between the patients receiving IVB and those receiving IVB/IVTA in terms of baseline BCVA (P = 0.97) and baseline central macular thickness (CMT) (P = 0.77). BCVA improved, and CMT reduced significantly in both study arms at almost all follow-up intervals. IVB/IVTA intervention, compared with IVB, was statistically more effective in improving BCVA (P = 0.01) and in reducing CMT (P = 0.02) after 12 months. The average number of reinjections was 1.25 ± 0.92 in the IVB group and 1.06 ± 1.01 in the IVB/IVTA group (P = 0.44).

CONCLUSION:

Our results suggest that the synergistic effect of intravitreal triamcinolone and IVB for treatment of neovascular AMD shows itself most apparently after 8 months of follow-up.

Risk factors for pterygium recurrence after limbal-conjunctival autografting: a retrospective, single-centre investigation

PURPOSE

To determine the risk factors related to recurrence of pterygium after pterygium excision with limbal-conjunctival autograft.

STUDY DESIGN

Retrospective, observational case series.

METHODS

The current study included 310 patients who underwent surgical removal of pterygium using limbal-conjunctival autografting. All surgery was performed by the same surgeon at a single Hospital from 2006 to 2011. Preoperative and postoperative patient data were collected. The patients were summoned to follow-up examinations. Procedures with at least 12 months of follow-up were included in the final analysis. Potential risk factors for pterygium recurrence were determined by Cox proportional-hazard linear analysis and recurrence-free survival time was evaluated using Kaplan-Meier method.

RESULTS

The overall recurrence rate was 5.2% during an average follow-up time of 20.1±8.6 months (range, 12-37 months). According to Kaplan-Meier evaluation, the estimated time to recurrence was 34.2 ± 0.5 months (95% confidence interval 33.3-35.0 months) for the whole population. Multivariate analysis showed that age < 45 years old (RR = 3.582, 95% CI 1.984-13.044, P = 0.047), recurrent type of pterygia (RR = 4.856, 95% CI 1.794-13.142, P = 0.002), and vertical size of pterygium > 6.7 mm (RR = 2.529, 95% CI 1.053-6.075, P = 0.038) were significantly associated with increased risk of recurrence.

CONCLUSION

Our findings suggest that young age, recurrent type of pterygia, and larger pterygial tissue are risk factors for pterygium recurrence after surgical excision. Hence, early excision of pterygium is recommended to decrease the recurrence rate.

Comparison of treatment response to intravitreal injection of triamcinolone, bevacizumab and combined form in patients with central retinal vein occlusion: A randomized clinical trial

BACKGROUND

Central retinal vein occlusion (CRVO), is the second-most common disorder after diabetic retinopathy that threatens the vision related to retinal vessels. One of the main reasons of vision loss is CRVO in acute and chronic forms.

OBJECTIVE

The aim of this study was to investigate the response to intravitreal injection of triamcinolone, bevacizumab, and a combined form in patients with CRVO.

METHODS

This study was a double-blinded randomized clinical trial conducted on patients with CRVO who were referred to the ophthalmology clinic of Urmia Imam Khomeini Hospital from May 2015 to May 2016. In total, ninety patients were divided into three groups using random numbers table. The first group received intravitreal triamcinolone acetonide (IVT) for treatment of macular edema due to CRVO, the second group received intravitreal bevacizumab (IVB) and the third group received a combination of IVT and IVB. The best corrected visual acuity (BCVA) and central macular thickness (CMT) were recorded and analyzed using optical coherence tomography system.

RESULTS

In this study a total of 90 eyes were studied, 41 case (45.55%) were male and 49 cases (54.44%) were female. The mean age of patients was 68.41±8.32 years. The mean score of final visual acuity was 0.293±0.11 in the IVT group, 0.25±0.10 in the IVB group and 0.48±0.15 in the IVB+IVT group. The differences between groups considering final visual acuity was significant (p<0.001). The mean thickness of final macular was 383.33±97.70 micrometer in IVT group, 386.33±136.79 micrometers in IVB group and 307.33±110.79 micrometers in IVT+IVB group which were significant (p=0.014).

CONCLUSION

Using a combination of bevacizumab and triamcinolone in the treatment of central retinal vein occlusion compared with using each of them separately, had a better result and can be used as a solution in this disease.

TRIAL REGISTRATION

The trial was registered at the Thai Registry of Clinical Trials (http://www.clinicaltrials.in.th) with the TCTR ID: TCTR20170612005.

FUNDING

The authors received no financial support for the research, authorship, and/or publication of this article.

Optimal Glycemic and Hemoglobin A1c Thresholds for Diagnosing Diabetes Based on Prevalence of Retinopathy in an Iranian Population

Background

The use of glycemic thresholds for diabetes diagnosis is controversial. However, no information is available regarding glycemic and glycated hemoglobin (HbA1c) thresholds for detecting diabetic retinopathy (DR) in the Iranian population.

Objectives

The main purpose of the current investigation was to examine the association of fasting plasma glucose (FPG) and HbA1c levels with diabetic retinopathy (DR), and to determine the relevant cut-off levels in an Iranian population.

Patients and Methods

This cross-sectional, population-based study was performed during 2012-2013 in Urmia, the capital of West Azerbaijan province, Iran. The subjects were 3,010 Iranians aged 40-81 years. The FPG levels were determined using the glucose oxidase method whereas, the HbA1c values were measured using a standardized assay by high performance liquid chromatography. DR was evaluated by an examination of the fundus photograph of each eye. The photographs were graded according to the international clinical diabetic retinopathy disease severity scale by photograph graders who were masked to the clinical information.

Results

Of the subjects, 59 had DR. The prevalence of DR increased steeply between the ninth and the tenth deciles for both variables. The ROC curve analysis showed overall glycemic thresholds for DR of 6.5 mmol/L (117 mg/dL) for FPG and 6.2% (44 mmol/mol) for HbA1c. The sensitivities and specificities were 78.0% and 87.1% for FPG and 89.8% and 89.5% for HbA1c, respectively. The areas under the ROC curves indicated that HbA1c was a stronger discriminator of retinopathy: the area under curve was 0.880 for FPG and 0.946 for HbA1c P < 0.001). However, the thresholds for detecting DR for the two measures showed no significant differences after excluding individuals receiving anti-hyperglycemic medication.

Conclusions

These findings suggest that the HbA1c and FPG thresholds for detecting diabetes in the Iranian population are lower than the current diagnostic criteria.

Detection of Hydroxychloroquine Retinal Toxicity by Automated Perimetry in 60 Rheumatoid Arthritis Patients with Normal Fundoscopic Findings

Hydroxychloroquine (HCQ) is an antimalarial drug used extensively in treatment of autoimmune diseases such as rheumatoid arthritis. Retinal toxicity is the most important side effects of this drug. Even after the drug is discontinued, retinal degeneration from HCQ can continue to progress. Consequently, multiple ophthalmic screening tests have been developed to detect early retinopathy. The aim of the current study was to evaluate the value of central 2-10 perimetry method in early detection of retinal toxicity. This prospective cross-sectional investigation was carried out on 60 rheumatoid arthritis patients, who had been receiving HCQ for at least 6 months and still were on their medication (HCQ intake) at the time of enrollment. An ophthalmologist examined participants using direct and indirect ophthalmoscopy. Visual field testing with automated perimetry technique (central 2-10 perimetry with red target) was performed on all included subjects twice in 6 months interval: The first one at the time of enrollment and the second one 6 months later. Males and females did not show any significant difference in terms of age, duration of therapy, daily and cumulative HCQ dose, anterior or posterior segment abnormalities, hypertension, body mass index, and best corrected visual acuity. Anterior segment was abnormal in 9 individuals including 3 subjects with macular pigmentary changes, 4 individuals with cataract and 2 cases with dry eyes. Moreover, 12 subjects had retinal pigmented epithelium (RPE) in their posterior segments. After 6 months, depressive changes appeared in 12 subjects. Additionally, HCQ therapy worsened significantly the perimetric results of 5 (55.6%) patients with abnormal anterior segment. A same trend was observed in perimetric results of 6 (50.0%) subjects with abnormal posterior segments (P=0.009). The daily dose of HCQ (P=0.035) as well as the cumulative dose of hydroxychloroquine (P=0.021) displayed statistically significant associations with perimetric results. Central 2-10 perimetry is a useful method for early detection of HCQ retinal toxicity, but more comprehensive studies, with larger sample size, longer-term follow-up and more precise techniques are mandatory to confirm HCQ retinal toxicity.

Investigating the Association between Angiogenic Cytokines and Corneal Neovascularization in Sulfur Mustard Intoxicated Subjects 26 Years after Exposure

OBJECTIVES

This study aimed to evaluate the associations between the concentrations of three major angiogenic cytokines-vascular endothelial growth factor-A165 (VEGF-A165), basic fibroblast growth factor (bFGF), and platelet-derived growth factor-BB (PDGF-BB)-in the tear of sulfur mustard (SM)-exposed subjects and corneal neovascularization (CNV) 26 years after exposure.

MATERIALS AND METHODS

The concentrations of VEGF-A, bFGF, and PDGF-BB were measured by enzyme-linked immunosorbent assay (ELISA) in reflex tears of (i) SM-injured patients with CNV (positive case group including 18 individuals) and (ii) SM-injured patients without CNV (negative case group including 22 individuals). Then results were compared to corresponding values obtained from tears of 40 healthy control subjects.

RESULTS

The mean concentrations of all investigated growth factors, VEGF-A165, bFGF, and PDGF-BB, were significantly higher in positive cases than controls (P ≤ 0.001, P = 0.028, and P = 0.041, respectively). Whereas, VEGF-A165 was the only growth factor which displayed significantly elevated concentrations in negative case group compared to the healthy individuals (P = 0.030). Additionally, the mean level of VEGF-A165 was also higher in positive patient group than negative patients (P = 0.022). Subjects with increased concentrations of tear VEGF-A165 were more than 10 times more likely to suffer from CNV than normal individuals (odds ratio (OR) = 10.43, confidence interval (CI): 2.14-38.46, P = 0.001), while elevated levels of bFGF and PDGF-BB increased the risk of CNV by about twofold.

CONCLUSION

Although all investigated cytokines had increased in tears of positive patients, VEGF-A was the only one which showed a significant correlation with the severity of CNV, and thus played a crucial role in corneal angiogenesis.

Does hinge position affect dry eye after laser in situ keratomileusis?

PURPOSE

To evaluate the effect of corneal flap hinge position on dry eye after laser in situ keratomileusis (LASIK).

METHODS

In a prospective double-masked randomized controlled clinical trial, 212 consecutive eyes of 106 myopic patients underwent LASIK; in each patient, one eye was randomly assigned to the superior hinge and the other eye to the nasal hinge procedure. The patients were examined pre-operatively and 1 week, 1 month, 3 months and 6 months after surgery for visual acuity, fluorescein tear film breakup time and Schirmer's baseline tear secretion test; a subjective evaluation of dry eye symptoms was accomplished by the Ocular Surface Disease Index (OSDI) questionnaire at the 1-month, 3-month and 6-month postoperative visits.

RESULTS

Tear film breakup time was not significantly different with the nasal or superior hinge flap technique at the preoperative, 1-week, 1-month, 3-month and 6-month visits (p > 0.05 for all comparisons between two groups). No significant difference between the two groups was found for the amount of Schirmer's baseline tear secretion test at pre- and postoperative visits (p > 0.05 for all comparisons between two groups). Subjective evaluation of symptoms also showed no significant difference at the 1-month, 3-month and 6-month postoperative visits.

CONCLUSIONS

The nasal and superior hinge flap methods do not affect signs and symptoms of dry eye after LASIK. We recommend that selecting the hinge position should be done according to the surgeon's preference and ease.