Journal of Ophthalmic and Vision Research
Year:2019 | Volume:14 | Issue:1|Papers Count:23

On the occasion of the New Year and the 14 th year of publication of Journal of Ophthalmic and Vision Research (JOVR), I take the opportunity to wish our readers, contributing authors, reviewers, editors and journal staff a very happy new year filled with health and prosperity. I extend my sincere gratitude to all of you who made the journal a successful venture. Without your contribution and ongoing support, we would never have been able to reach our current status.

Purpose: To assess the effect of a novel intense pulsed light (IPL) therapy on tear proteins and lipids in eyes with Meibomian gland dysfunction (MGD). Methods: Twenty‑ four eyes of 12 patients with MGD were recruited and received five overlapping flashes (565‑ 1400 nm) directed at the lower eyelid. The IPL parameters include intensity: 2. 5 to 6. 5 J/cm 2, voltage: 100 to 240 V, frequency: 50 to 60 Hz, input: 16 W, maximum optical energy: 23 J, pulse duration: <2. 0 ms, and repetition time: 1‑ 3. 5 s. Tear samples were evaluated immediately before and 2 weeks after IPL therapy and included measurements of protein concentration, electrophoretic mobility by using sodium dodecyl sulfate‑ polyacrylamide gel electrophoresis, lipid profile assessments, and thin‑ layer chromatography (TLC) for phospholipids. Results: Significant improvements were observed in tear protein concentrations and molecular weight after IPL therapy. The most pronounced effect was in the molecular weight of tear lysozyme, lactoferrin, and albumin. Tear lipids showed an improvement in the concentrations of total lipids, triglycerides, cholesterol, and phospholipids. On TLC, the tears in patients with MGD had significantly lower amounts of anionic phosphatidylethanolamine, phosphatidylinositol, and phosphatidylserine but amounts zwitterionic neutral phospholipid phosphatidylcholine were normal. These anionic phospholipids showed obvious recovery after IPL therapy. Conclusion: IPL therapy is effective in eyes with MGD. It improved tear protein and lipid content and composition. The anionic phospholipids were more responsive to IPL therapy than were the other zwitterionic phospholipids.

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.

Purpose: To evaluate the effects of donor graft thickness on postoperative best spectacle‑ corrected visual acuity (BSCVA), refractive outcomes, endothelial cell density (ECD) and function, intraocular pressure (IOP), and postoperative complications after Descemet stripping automated endothelial keratoplasty (DSAEK). Methods: This retrospective, interventional case series enrolled 77 eyes of 64 patients who underwent DSAEK with or without simultaneous cataract surgery. Clinical outcomes, including BSCVA, refraction, keratometric astigmatism, IOP, and ECD were assessed at the final follow‑ up examination. Univariate analyses were used to investigate the effects of postoperative donor graft thickness on clinical outcomes and complications. Results: The mean patient age was 62. 3 ± 15. 6 years, and the patients were followed for 26. 2 ± 20. 9 months postoperatively. The mean postoperative central graft thickness was 102. 4 ± 31. 6 µ m. In the univariate analysis, postoperative central graft thickness was significantly associated with postoperative IOP (P = 0. 005), central recipient thickness (P = 0. 002), and ECD (P = 0. 016). No significant association was found for central graft thickness with postoperative BSCVA (P = 0. 70), spherical equivalent refraction (P = 0. 33), keratometric astigmatism (P = 0. 27), graft detachment (P = 0. 16), graft decentration (P = 0. 17), high IOP (P = 0. 53), or endothelial rejection (P = 0. 88). Conclusion: This study failed to demonstrate any significant correlation between graft thickness and BSCVA. Attempting to minimize graft thickness might not have the desired outcome regarding endothelial cell density and function. Increased graft thickness could negatively impact the accuracy of IOP measurements after DSAEK.

Purpose: To review the management outcomes of black diaphragm intraocular (BDI) lens implantation in Arab patients with aniridia. Methods: Patients with aniridia undergone BDI lens implantation at our institution between 2013 and 2014 were included. Uncorrected visual acuity (UCVA), manifest refraction, and best‑ corrected visual acuity (BCVA) were evaluated before and 6 months and yearly after BDI lens implant surgery until the last visit. Intra‑ and postoperative complications were noted. Results: Our series comprised 14 patients (8 males) with aniridia. The median duration of follow‑ up was 30 months (25% quartile). Ocular parameters, refractive status, and vison were all significantly improved at the last follow‑ up compared to the preoperative values (P < 0. 05 for all comparisons). All patients reported a significant decrease in photophobia and glare. Postoperatively, 11 eyes (78%) gained 2 or more lines of UCVA. At the last follow‑ up, BCVA increased by 2 or more lines in all cases. Early postoperative complications included main wound leakage (one eye) and anterior chamber hyphema (one eye). Late (≥ 6 months) complications included corneal decompensation (one eye), failed penetrating keratoplasty graft (2 eyes), and subluxation of a scleral fixated BDI lens (one eye). Surgical interventions performed to manage complications included penetrating keratoplasty in 2 eyes with corneal decompensation and failed graft (one each), and re‑ suturing of a subluxated intraocular lens (one eye). Conclusion: BDI lenses seem to be a safe and effective iris prosthetic with intraocular lens combination surgery for patients with congenital or traumatic aniridia. Periodic evaluation and prompt management of complications are recommended.

Purpose: To investigate a potential link between the incidence of malignant glaucoma after cataract surgery and seasonal variations in daylight. Methods: In total, 18, 374 uncomplicated cataract surgeries were performed between June 2008 and June 2013 at an ambulatory surgery center in Toronto. Toronto’ s average monthly daylight over that time period— in hours per day for each month— was determined. The number of malignant glaucoma cases that developed after cataract surgery performed in months with above average daylight was compared to the number of cases that developed after cataract surgery performed in months with below average daylight. Fisher’ s exact test was used to analyze the relationship between the development of malignant glaucoma and variation in daylight during the month of cataract surgery. Results: Malignant glaucoma developed in 16 eyes. Thirteen cases of malignant glaucoma developed in months with above average daylight and three cases developed in months with below average daylight (P = 0. 01). Eyes that developed malignant glaucoma in months with more daylight were slightly longer (21. 95 ± 1. 23 mm) than those that developed malignant glaucoma in months with less daylight (21. 55 ± 0. 88 mm). Conclusion: Light‑ induced choroidal expansion may play a major role in the development of malignant glaucoma following cataract surgery.

Purpose: To evaluate sensitivity and specificity of digital retinal image reading in the diagnosis of referral‑ warranted retinopathy of prematurity (ROP). Methods: Infants referred to the ROP clinic underwent fundus examination through indirect ophthalmoscopy. Fundus photographs were acquired using RetCam (shuttle 2; Clarity medical systems, Pleasanton, CA, USA). Four retinal specialists who were blind to patients’ information reviewed the RetCam fundus photographs. By comparing the results of photographs’ readings with that of indirect ophthalmoscopy as the gold standard, the sensitivity and specificity of telescreening was determined. Results: A total of 147 treatment‑ naï ve patients met the inclusion criteria and were enrolled in the study. Mean gestational age (GA) was 28. 6 ± 2. 0 weeks. Digital retinal imaging had sensitivity of 85% and specificity of 35% in detecting referral‑ warranted ROP in our study. Positive predictive value of digital photography was 80%, and negative predictive value was 43%. Conclusion: Digital photography for diagnosis of ROP may show good potential as a screening modality in developing countries. It can facilitate early diagnosis, prevent unnecessary referrals, and be implemented for investigational purpose. However, the overall study result did not provide evidence to propose digital photography as a substitute for indirect ophthalmoscopy in the diagnosis of ROP.

Purpose: To evaluate the peripapillary choroidal thickness (CT) in children with unilateral amblyopia using spectral‑ domain optical coherence tomography (SD‑ OCT). Methods: One hundred and six eyes of 53 children with unilateral amblyopia and 20 eyes of 20 children with normal vision were involved in this study. Of the 53 children with unilateral amblyopia, 29 (54. 7%) had hyperopic anisometropic amblyopia and 24 (45. 3%) had strabismic amblyopia. Peripapillary CT was measured from 6 mm length radial B‑ scans at the optic nerve head using the enhanced depth imaging program of an SD‑ OCT (Heidelberg Engineering, Germany). Age, sex, refractive error, and best‑ corrected visual acuity were also recorded. Results: The average peripapillary CT was greater in amblyopic eyes than in the fellow eyes of the children with amblyopia (P = 0. 002), and control eyes (P < 0. 001). There was no significant difference between the fellow eyes of children with amblyopia and the control eyes (P = 0. 158). The average peripapillary CT was negatively correlated with axial length (AL) in amblyopic eyes (r = ‑ 0. 381; P = 0. 005) and fellow eyes (r = ‑ 0. 392; P = 0. 004) but not in control eyes (r = ‑ 0. 232; P = 0. 325). After adjustment for the possible effects of AL, the average peripapillary CT in amblyopic eyes was still greater than in fellow eyes (P = 0. 014) and control eyes (P = 0. 022). Conclusion: The peripapillary choroid of eyes with amblyopia was thicker than that of the fellow eyes and control eyes. No significant difference was observed between fellow eyes and control eyes.

Purpose: To assess the effect of experimental anisometropia and monovision on stereopsis using the Titmus, Randot, and TNO stereoacuity tests. Methods: Sixty adult volunteers were enrolled in the present study. Four different types of anisometropia— myopia, hyperopia, and astigmatism (both 90° and 45° )— were induced by placing trial lenses over the dominant eye (from 3 to 1 D). Stereoacuity was measured using the Titmus, Randot, and TNO tests. Results: In all the anisometropia types, stereopsis deteriorated with increase in anisometropia in the three stereoacuity tests performed (P < 0. 001). The largest decrease in stereopsis was attributed to 3 D myopic anisometropia— 6. 51 ± 2. 10, 6. 59 ± 2. 35, and 7. 36 ± 1. 89 arc seconds in Titmus circles, Randot circles, and TNO, respectively. Minimal change in stereopsis was observed in 1 D astigmatism of 45° . Conclusion: Any type of anisometropia may reduce stereoacuity; this reduction is most noticeable with myopic anisometropia, especially in the TNO test, probably due to the lack of monocular cues.

Purpose: To design a screening program for prevention of blindness at the community level in Iran. Methods: In this qualitative study, the components and properties of the screening program were identified using a participatory action research method with focus group meetings (FGMs) with relevant health care providers and authorities. A content analysis approach was used for data analysis. Results: In total, 18 stakeholders including six ophthalmologists with different sub‑ specialties participated in the five FGMs. The screening program aims to discover vision‑ threatening eye conditions in people aged 50 years and over. Primary health care workers deliver the program including vision tests and fundus imaging with the support of an ophthalmic technician. Retina specialists perform decision‑ making. Referral plans are interacted through an automated digital program. The screening environment, feedback, ethics and medical legal issues are other main components of the program. Conclusion: This study presents the initial concepts and components of a screening program for prevention of blindness in the adult population in Iran. The program has the potential to improve eye health at the community level and may potentially be replicated as a model for similar settings elsewhere.

Purpose: To compare the levels of gene expression for enzymes involved in production and elimination of reactive oxygen/nitrogen species (ROS/RNS) in normal human corneal cells (NL cells) with those in human corneal cells with keratoconus (KC cells) in vitro. Methods: Primary NL and KC stromal fibroblast cultures were incubated with apocynin (an inhibitor of NADPH oxidase) or N‑ nitro‑ L‑ arginine (N‑ LLA; an inhibitor of nitric oxide synthase). ROS/RNS levels were measured using an H2 DCFDA fluorescent assay. The RT2 Profiler™ PCR Array for Oxidative Stress and Antioxidant Defense was used for initial screening of the NL and KC cultures. Transcription levels for genes related to production or elimination of ROS/RNS were analyzed using quantitative PCR. Immunohistochemistry was performed on 10 intact human corneas using antibodies against SCARA3 and CPSF3. Results: Array screening of 84 antioxidant-related genes identified 12 genes that were differentially expressed between NL and KC cultures. Compared with NL cells, quantitative PCR showed that KC cells had decreased expression of antioxidant genes SCARA3 isoform 2 (0. 59‑ fold, P = 0. 02) and FOXM1 isoform 1 (0. 61‑ fold, P = 0. 03). KC cells also had downregulation of the antioxidant genes SOD1 (0. 4‑ fold, P = 0. 0001) and SOD3 (0. 37‑ fold, P = 0. 02) but increased expression of SOD2 (3. 3‑ fold, P < 0. 0001), PRDX6 (1. 47‑ fold, P = 0. 01), and CPSF3 (1. 44‑ fold, P = 0. 02). Conclusion: The difference in expression of antioxidant enzymes between KC and NL suggests that the oxidative stress imbalances found in KC are caused by defects in ROS/RNS removal rather than increased ROS/RNS production.

Marfan syndrome is an autosomal dominant genetic connective tissue disorder that results from mutations in the fibrillin‑ 1 gene located on chromosome band 15q15– 21. Fibrillin, a glycoprotein, is widely expressed throughout the body and contributes to the elasticity and force‑ bearing capacity of connective tissue. In the eye, fibrillin is a key constituent of the ciliary zonules, which suspend the crystalline lens in place. The zonular defect leads to ectopia lentis, which is a hallmark of Marfan ocular abnormalities and occurs in 60% to 80% of cases. Other less common ocular features of Marfan syndrome are increased axial length, astigmatism, and flat cornea. Visual function in Marfan syndrome could be affected in several ways: ectopia lentis, refractive error, amblyopia, retinal detachment, cataract, and glaucoma. Management of a subluxated lens starts with the correction of refractive error with eyeglasses in mild cases. In more severe cases, especially when the lens bisects the pupil, complete correction of refractive error is impossible without removing the subluxated lens. The best method for visual rehabilitation after lens extraction is still debated. Aphakic Artisan lens implantation at the time of subluxated lens removal results in good visual outcomes with an acceptable safety profile. Studies with longer term follow‑ up and larger sample populations are needed to evaluate the safety of this procedure in patients with Marfan syndrome.

Age‑ related macular degeneration (AMD) is a major cause of vision loss in the developed world and its pathogenesis is a topic of active research. To date, much study has been focused on the role of the retinal pigment epithelium (RPE) and Bruch’ s membrane (BrM) in AMD pathogenesis, but the role of the choroid has also been investigated. In this review, we focus on recent advancements in research in the role of the choroid in AMD, beginning with an exploration of the histopathologic, cellular and molecular changes that occur in the choroid in AMD and concluding by discussing new choroidal imaging techniques and patterns seen on fluorescein angiography, indocyanine green angiography, spectral‑ domain optical coherence tomography and optical coherence tomography angiography. Exploring these domains will lead to a better understanding of the factors at play beyond the outer retina in this important disease.

Two questions that clinicians should answer as they attempt to apply the results of clinical trials to clinical practice are: (1) will statistically significant results be reproduced in their clinical practice; and (2) if nothing goes wrong in a clinical trial, is everything alright? Regarding the first question, when considering the results of a randomized, multicenter, prospective, controlled clinical trial, two questions that cannot be addressed by simply by reading the trial results and that only the practicing clinician can answer are: (1) is the study population representative of the patient about to be treated; and (2) is the totality of evidence outside the trial (including the clinician’ s own extensive experience) consistent with the trial result? Regarding the second question, clinicians are advised to recognize that most studies, even Phase 3 trials, are underpowered to accurately assess the risk of low frequency events.

Purpose: To present a case of bilateral peripheral ulcerative keratitis (PUK) caused by primary herpes simplex virus‑ 1 (HSV‑ 1) infection resulting in corneal perforation. Case Report: A 24‑ year‑ old man presented at the eye casualty of our clinic, with a 20‑ day history of severe pain, redness, photophobia, and tearing in both of his eyes. Slit‑ lamp examination revealed bilateral superior corneal perforation. A laboratory work‑ up that included immunological testing for infectious and autoimmune factors showed primary HSV infection. Positive PCR analysis of corneal scrapings for HSV confirmed initial end‑ organ ocular infection. Because the patient showed progressive HSV‑ 1‑ related PUK resulting in bilateral superior corneal perforation with iris prolapse, he was prescribed both systemic and topical acyclovir and prednisone. He then underwent bilateral surgical intervention, namely eccentric penetrating keratoplasty in one eye and a two step procedure in the other, whereby two corneal patch grafts and an amniotic membrane transplant were initially used, followed 1 month later by a large diameter penetrating keratoplasty. Conclusion: In cases of PUK, differential diagnosis should include infectious and autoimmune diseases. Primary HSV should also be considered as a potential cause of this form of keratitis, which, if left untreated, can lead to devastating outcomes. To our knowledge, this is the first published case of bilateral PUK caused by primary HSV‑ 1 infection.

Purpose: To report the unusual case of an immunocompetent individual with herpes zoster ophthalmicus who developed central retinal artery occlusion and subsequent neovascular glaucoma. Case Report: A 40‑ year‑ old, immunocompetent patient was diagnosed with herpes zoster ophthalmicus and central retinal artery occlusion on initial presentation. Subsequently, he developed neovascular glaucoma. Conclusion: There are a few case reports of central retinal artery occlusion developing after varicella zoster virus infection. However, a literature search found no reports of neovascular glaucoma following central retinal artery occlusion secondary to varicella zoster virus infection. The present case report indicates that neovascular glaucoma is a possible complication in such a scenario.

Purpose: To report visual rehabilitation with a native Pintucci keratoprosthesis (KPro) after a severe ocular surface chemical burn in a male patient. Case Report: A 41‑ year‑ old man experienced a bilateral severe chemical burn 5 years previously. Earlier penetrating keratoplasty and keratolimbal allografts were unsuccessful in both eyes, and neither of the eyes had vision better than light perception. Both corneas were opaque and conjunctivalized. Because of severe dry eye and total limbal stem cell deficiency, the left eye was considered for a Pintucci‑ type KPro. In the first stage, the ocular surface was reconstructed with an oral mucus membrane graft, and a KPro was placed under the skin and orbicularis oculi muscle. Three months later, the KPro was removed and implanted in the left eye. During seven months after the KPro implantation, the anatomical position was acceptable, and his best corrected visual acuity was 2/10. Conclusion: Bearing in mind the successful results of the native Pintucci KPro in this case of severe acid burn, using this type of keratoprosthesis in patients with total limbal stem cell deficiency and severe dry eye is recommended.

Purpose: To report 2 cases of optic nerve head (ONH) granuloma, with raised serum angiotensin‑ converting enzyme (ACE) levels not fitting into the existing criteria for ocular sarcoidosis (OS). Case Report: Fundus photography, ultrasonography, fluorescein angiography, and optical coherence tomography were performed for both patients. Systemic workup was performed for granulomatous disorders, including sarcoidosis, tuberculosis, and syphilis. Both patients had ONH granulomas and elevated ACE levels, with one of the patients also presenting retinal vasculitis. No other focus of systemic sarcoidosis was localized. Both patients were treated with oral steroids, following which they showed a marked, rapid clinical improvement. Both patients remained stable for at least one year. Conclusion: The current accepted criterion for diagnosis of OS may need changes to include such borderline cases due to lack of correlation between clinical and investigative findings.

Purpose: To present a case of suspected Leber’ s hereditary optic neuropathy (LHON) with MRI and OCT findings compatible with pseudotumor cerebri responsive to acetazolamide therapy. Case Report: A five‑ year‑ old boy referred to our clinic with optic atrophy and low vision was originally diagnosed with LHON. Laboratory tests were negative for LHON, while OCT and MRI were consistent with pseudotumor cerebri. Acetazolamide therapy resulted in dramatic improvement of visual acuity. Conclusion: Some cases of previously labeled hereditary optic neuropathies with clinical signs of idiopathic intracranial hypertension could respond to intracranial pressure lowering treatment.

PRESENTATION We report a 51‑ year old male patient with advanced keratoconus who presented to our clinic. He was diagnosed with keratoconus in 1986 and registered severely sight‑ impaired in 2006. His medical history included hay fever and asthma. He had no family history of keratoconus and rubbed his eyes excessively for many years. The patient was wearing scleral contact lenses and managing well. His contact lens‑ corrected visual acuity was 6/30 in the right eye (OD) and 6/30 in the left eye (OS). On slit‑ lamp examination, we observed advanced keratoconus (OD>>OS) with extreme corneal thinning and marked Munson’ s sign OD [Figure 1]. Corneal topography found advanced keratoconus bilaterally with a maximum keratometry of 112. 7 diopters OD and 70. 9 diopters OS [Figure 2a]. The thinnest point corneal thickness was 184 microns OD and 280 microns OS, as measured using ocular coherence tomography‑ assisted corneal pachymetry [Figure 2b]. Despite the extremely advanced keratoconus, particularly OD, there was no evident corneal scarring and the patient had no episodes of acute corneal hydrops (ACH)....

PRESENTATION An 88‑ year‑ old female with pseudoexfoliation syndrome presented with sudden vision loss and was found to have a dislocated one piece intraocular lens (IOL) that was resting on the retina. She underwent 23‑ gauge pars plana vitrectomy, IOL explantation, and anterior chamber IOL insertion. Intraoperative optical coherence tomography (EnFocus iOCT; Leica, Wetzlar, Germany) was used to assess the position and vault of the IOL on the retinal surface [Figure 1a]. Utilization of iOCT enabled the surgeon to safely grasp the IOL with forceps in the location with the greatest vault in order to minimize any potential trauma to the retina [Figure 1b]...

PRESENTATION A 78 year old patient presented to the glaucoma clinic due to the detection of narrow angles and elevated IOP. The corrected visual acuity and intraocular pressure were 20/25 and 18 mm Hg in both eyes with two anti-glaucoma eye drops, respectively. The laser iridotomies were patent OU. Funduscopy showed a cup/ disc ratio of 0. 5 OU and her baseline optical coherence tomography was within normal limits in both eyes. The left eye visual field reliability indices were within normal limits, however her pattern deviation plot illustrated greater defects than her total deviation plot [Figure 1]. Closer evaluation of the raw data showed exceptionally high peripheral sensitivities compared to her central thresholds. Her visual field defects did not correspond with the exam and optical coherence tomography.

Glaucoma is a neuropathic disorder that causes structural and functional damage to the optic nerve head and leads to visual field loss. [1] It is the leading cause of irreversible blindness and the second leading cause of blindness after cataract. [2, 3] It is the cause of blindness in 2. 5 million people worldwide (6. 6% of the world’ s blind population). [4] Despite the serious implications of glaucoma, there is a limited level of public awareness regarding it. Nearly 90% of Iranian patients with glaucoma are unaware of their disease, reflecting the low level of public awareness. [5] Raising public awareness and educating people, particularly glaucoma patients, plays an important role in glaucoma prevention and treatment.