BINA
Year:2003 | Volume:8 | Issue:4 (32)|Papers Count:14

Purpose: To compare the prevalence of open-angle glaucoma (OAG), glaucoma suspect (GS), and ocular hypertension (OHT) among patients with Graves' orbitopathy (GO) admitted to a private endocrinology clinic and a control group.Methods: This analytic study with convenience sampling was conducted on patients with GO verified by complete systemic and paraclinic examinations by an endocrinologist (A.F.), and a matched control group from companions of patients admitted to the general ophthalmology clinic of Imam Hossein Hospital without any history of documented thyroid disease or orbitopathy and with negative systemic and paraclinic examinations at the time of study. Complete ophthalmologic examinations and intraocular pressure (IOP) measurements in primary position of gaze were performed at least at two different times of day. In case of any type of optic nerve defect or dysfunction, visual field testing by Humphery automated achromatic static perimetry and to rule out compressive optic neuropathy (CON), CT-scan or MRI were performed. OAG, OHT, and (GS) were diagnosed based on characteristic findings and after ruling out the other causes. Classification of Graves' orbitopathy was performed by NOSPECS system and phases of disease activity. Fisher's exact test or chi-square test for qualitative and ANOVA or Hest for quantitative data were used in statistical analysis.Result: We assessed 233 eyes of 117 patients with GO and 240 eyes of 120 persons in the control group. Mean age ± SD was 39.9±13.4years and 39±14.2years in GO group and control group, respectively. OAG was diagnosed in 6 eyes (2.5%), GS in 5 eyes (2.1%), and OHT in 20 (8.5%) eyes of GO group. From the control group, 2 eyes (0.8%) had OAG. Prevalence of OAG was not statistically different between the two groups, but prevalence of OAG and GS altogether was statistically more in GO than control group (P< 0.02). Prevalence of ocular hypertension with or without optic nerve damage also was statistically more in GO than control group (p<0.001). In GO group, 10 eyes (4.3%) had CON, of these, 5 (2.1%) had also OHT. All OAG and GS eyes were in class 3 or higher of NOSPECS classification. Active phase of GO was observed more in eyes with OHT (p< 0.001), but not for eyes with OAG or GS in GO group.Conclusion: The prevalence of OAG, GS, and OHT in Graves' orbitopathy is more than the general population. Also the results of this study suggest routine and periodic ophthalmologic examination in patients with GO especially in higher classes of NOSPECS classification and/or active phase of disease.

Purpose: To evaluate the efficacy of contact diode laser in hypotony maculopathy following trabeculectomy with mitomycin C in glaucoma patients.Methods: This interventional case serieswas performed on patients with hypotony (IOP< 6 mmHg) associated with decreased vision and/or ophthalmic signs ofmaculopathy such as macular folds and choroidal detachment following trabeculectomy with mitomycin C. They were evaluated after one month and were scheduled for laser therapy if the signs and symptoms had not mproved. Laser therapy was performed with G-probe around or directly over the bleb in the operating room under sterile condition with retrobulbar anesthesia. Success indicator was IOP≥6 mmHg and improvement or no worsening in maculopathy after 2 months of follow up. Results: Eight patients (6 males and 2 females) were treated. Mean IOP before therapy was 4±1.3 mmHg (1-5 mmHg) and two months after the therapy reached 10.12±3.5mmHg (4-16 mmHg). Funduscopic findings did not change after therapy. Laser therapy was successful in 87.5% of the cases (CI95%:65-100%). In no patient leakage of the bleb, cataract, or bleb perforation was seen. In one patient, IOP increased so timolol drop 0.5% twice daily was begun. Conclusion: Contact diode laser treatment of thin-walled blebs is probably an effective measure to elevate IOP. Further studies are recommended for evaluation of this treatment modality.

Purpose: To compare the efficacy of the standard treatment of ocular toxoplasmosis (pyrimethamine, sulfadiazine, and predinsolone) with a regimen consisting of trimethoprim sulfamethoxazole (TMP/SMX) plus predinsolone.Methods: In a prospective randomized single-blind clinical trial, 59 patients were randomly assigned to treatment groups: 29 in the pyrimethamine/ sulfadiazine group and 30 patients to the TMP/SMX group. Treatment consisted of six weeks of antibiotics plus steroids, and patients were followed weekly with measurements of visual acuity and examination of the anterior vitreous and fundus for signs of inflammation ELISA measurements of anti- toxoplasmosis antibodies (IgM and IgG) were undertaken. The main outcome measure consisted of change in size of the retinochoroidal lesion on fundus photography, obtained at initiation and completion of treatment.Results: No significant difference was found in the amount of decrease in retinochoroidal lesion between the two treatment groups (61% reduction in the classic treatment group ND 59% in the TMP/SMX regimen, P = 0.69). Similarly no significant difference was found in visual acuity after treatment between the two groups (mean visual acuity after treatment 0.11 Log MAR in both groups, P = 0.41). Adverse treatment effects were similar in both groups, with one patient in each suffering from any significant drug side effects. The rate of recurrence with an average of 14 months follow up was 6.8% with no significant difference between treatment groups (P = 0.48). Conclusions: The efficacy in terms of decrease in retinal lesion and improvement in visual acuity was similar between a regimen of TMP/SMX plus steroid and the standard treatment of ocular toxoplasmosis with pyrimethamine and sulfadiazine plus steroids. Therapy with TMP/SMX appears to be an acceptable alternative for the treatment of ocular toxoplasmosis. A prospective randomized clinical trial, which would match patients in terms of size of retinal lesions, is recommended for stronger conclusion.

Purpose: To evaluate the efficacy of subtenon injection of carboplatin in the management of intraocular retinoblastoma in patients referred to Farabi Eye Hospital.Methods: The study was a randomized double blind matched clinical trial. Definite diagnosis of intraocular retinoblastoma was made based on clinical examination, ultrasonography, and orbit CT-scanning. A comprehensive ocular examination was performed with the patient under anesthesia. The greatest basal diameter and the thickness (elevation) of the turners were estimated through indirect ophthalmoscopy in disc diameter (DD). After excluding extraocular spreading of the tumor, each eye was assigned to one of 10 blocks based on tumor stage (Reese-Ellsworth classification) and randomly received either systemic chemotherapy alone (control group) or systemic chemotherapy with subtenon carboplatin (case group). During follow up examinations, the size of tumor was checked. Adjuvant treatment or enucleation was performed if needed.Results: The study included 35 tumors in 17 eyes of 13 patients including 19 tumors in 8 eyes in the control group and 16turners in 9 eyes in the case group. At final examination there was a 46.92% decrease in tumor thickness at funduscopy in the control group versus 63.12% in case group (P=0.12). The decrease in greatest tumor diameter in the control group (47.32%) was not significantly different from that in the case group (38.80%). The decrease in thickness on echography in the control group (57.22%) did not differ significantly from that in the case group (61.73%). One eye (12.5%) in the control group and 3 eyes (33.3%) in the case group were  enucleated. Conclusion: Subtenon carboplatin does not seem to increase the efficacy of  systemicchemotherapy for the treatment of intraocular retinoblastoma.

Purpose: To define the characteristics of patients who experienced postoperative uveitis following cataract surgery and its related morbidities. Methods: In this prospective descriptive study, 126 patients who experienced postoperative uveitis following cataract surgery were examined. Of them, 110 patients had follow up examinations from 3 to 30 months (mean 11.7 months). Associated systemic and ocular disorders, type of surgery, type of intraocular lens and viscoelastic, final best corrected visual acuity, and early and late morbidities were studied. Results: The patients included 64 (50.8%) males and 62 (49.2%) females aged 58±14.9years. The surgery was phacoemulsification and posterior chamber intraocular lens implantation (PE+PCIOL) in 72 cases (57.1%), extracapsular cataract extraction and PCIOL (ECCE+PCIOL) in 51 cases (40.5%), and lensectomy + PCIOL in 3 cases (2.4%). Among 110 patients who committed follow up examinations, 56 cases (51%) were female and 54 cases (49%) were male. Late complications were posterior capsular opacity (PCO) in 38 cases (34.5%) and cystoid macular edema (CSME) in 4 cases (3.6%). Symptoms of uveitis occurred during 2 weeks after surgery in most of the patients (69.8%). and all patients responded well to topical or systemic steroids. Final best corrected visual acuity (BCVA) was 20/30 or better in 76 cases (69%), between 20/40 and 20/80 in 24 cases (22%), and less than 20/80 in 10 cases (9%). All cases with BCVA less than 20/80 had ocular disease such as choroidal neovascularization scar or age-related macular degeneration, advanced glaucoma, or corneal opacity.Conclusion: Postoperative uveitis following cataract surgery has no serious late complications and final corrected visual acuity of the patients is satisfactory.

Purpose: To evaluate corneal topographic changes and induced corneal astigmatism after scleral buckling surgery. Methods: As an interventional case series, patients referred to us from February to November 2002, with rhegmatogenous retinal detachment were scheduled for scleral buckling surgery. The exclusion criteria were: history of pervious scleral buckling, any corneal disease visible on slit lamp biomicroscopy, and any ophthalmic operation in the previous 6 months. According to the extent of surgery, the patients were divided into 4 groups: A) 3600 encircling band + buckling, B) segmental buckling + encircling band, C) radial buckling, and D) local circumferential buckling. Videokeratography was done for all patients before, and then one and 3 months after scleral buckling. Corneal astigmatism, mean keratometry, SRI (surface regulatory index), SAl (surface asymmetry index), PVA (potential visual acuity) were evaluated at each visit. Results: From 56 patients enrolled in this study, 39 patients completed follow up. There were 29 (74.4%) males and 10 (25.6%) females with mean age of 50.35±20years. The patients consisted of 3 (7.65%) in group A, 30 (76.92%) in group B, 4 (10.25%) in group C, and 2 (10.25%) in group D. Statistically significant differences regarding SRI, SAl, PVA (in Log MAR) from baseline measurements were observed in all patients at one and 3 months postoperatively. In spite of increasing corneal astigmatism, there were no statistically significant differences in mean keratometry after scleral buckling surgery. In group B, the results were the same as overall results. In groups A, C, and D the above variables were increased postoperatively. Conclusion: Irregular astigmatism is induced after scleral buckling surgery that remains up to 3 months. It is one of the important causes of decreased visual acuity postoperatively.

Purpose: To evaluate the efficacy of preoperative oral clonidine (5 µg/kg) in preventing ocular hypertension in the early period after cataract surgery with posterior chamber intraocular lens implantation under general anesthesia.Methods: This randomized double-masked clinical trial comprised 62 eyes of 62 patients with senile cataract who underwent cataract extraction and posterior chamber intraocular lens implantation without any viscoelastic use. They were randomly assigned into two groups of preoperative oral clonidine (5 µg/kg) and placebo. Intraocular pressure (lOP) was measured preoperatively and 6, 12, and 24 hours postoperatively. Results: There was less increase in mean lOP in the clonidine group at 6 hours (+0.41±4.55, P=0.6) and 12 hours (0.06±3.62, P=0.9) compared to the placebo group (5.77±4.25, P=<0.001 and 4.70±3.19,P<0.001,respectively) after surgery. There was no statistically significant difference between the two groups in mean lOP 24 hours post operatively (clonidine group 15.41±3.96, placebo group 16.00±341) but compared to preoperative lOP, less increase in mean lOP was seen in the clonidine group (1.38±4.64, P=0.1 as compared to the placebo group (+3.80±2.92, P<0.001).Conclusion: A single dose of oral clonidine (5 µg/kg) preoperatively can produce a significant lOP-lowering effect in the early period after cataract surgery, especially in the first 12 hours.

Purpose: To evaluate the efficacy of oral metoclopramide in reducing patients' discomfort due to nausea and vomiting and to ensure completion of the investigation.Methods: Through a double-blind randomized placebo-controlled clinical trial, 400 patients (200 as treatment group and 200 as placebo group) suffering from retinal disorders were assessed. All patients were NPO for 6 hours and received 10 mg oral metoc1opramideor placebo 1 hour before intravenous injection of 5 ml of fluorescein 10%. The injection was performed during 4-6 seconds. Patients were observed for nausea or vomiting for 30 minutes after the injection. Results: All patients completed the study. The patients were aged from 12-95 years (51.7±14.1 years) including 60% males and 40% females. Vomiting occurred in two patients of metoclopromide group (1%) and 10 cases of placebo group (5%) (RR= 5.21, P= 0.01). Nausea occurred in 19 patients of treatment group (9.5%) and 30 cases of placebo group (15%) (P= 0.09). Conclusion: Metoclopramide may be indicated for prophylaxis in patients undergoing Fain order to prevent or control emesis, improve patient comfort, and ensure a successful outcome to investigation.

Purpose: To introduce a patient with bilateral optic neuritis due to brucellosis. Patient and findings: A 21-year-old female was referred to us due to severe bilateral visual loss 3 weeks after a diagnosis of brucellosis. On examination she had bilateral optic neuritis, preretinal hemorrhage and retinal vacuities. The patient developed bilateral optic atrophy and severe visual loss despite full medical treatment.Conclusion: Brucellosis can produce various types of eye involvement including vacuities, optic neuritis and retinal hemorrhage; therefore a detailed ocular examination including funduscopy should be performed in all patients with brucellosis. This disease should be included in the differential diagnosis of the etiologies of above mentioned ocular signs.

Purpose: To report a patient with orbital lymphoma masquerading as chronic conjunctivitis with retrobulbar involvement. Patient and findings: A 55-year-old man was referred to an ophthalmologist due to, redness and swelling of the right conjunctiva from 8 months before. The patient was treated with a diagnosis of chronic conjunctivitis but was referred to Imam Hossein Hospital because of no response to medial treatment and enlargement of the lesion and decrease in visual acuity. On funduscopy, we noticed the compression effect of a retrobulbar mass. Low grade B cell lymphoma was documented by biopsy. The patient was referred to a radiotherapist for treatment. Conclusion: Conjunctival lymphoma should be included in the differential diagnosis of chronic conjunctivitis. Persisting signs and symptoms of conjunctivitis not responding to standard treatment should prompt biopsy.

Purpose: To report a case of concurrent congenital superior oblique palsy and Axenfeld Rieger syndrome.Patient and findings: A 28-year-old man was referred for head tilt since early childhood. On physical examination, there was right hypertropia that increased with gaze to left and head tilt to right. Examination of the anterior segment showed prominent and anteriorly displaced Schwalbe's ring to which multiple peripheral iris strands adhered. Corectopia was present in the right eye. The diagnosis was congenital right superior oblique palsy and Axenfeld Rieger syndrome. Conclusion: Since neural crest cells eventually differentiate to produce tendons and sheaths of extra ocular muscles and Axenfeld Rieger syndrome is due to abnormalities of these cells in the embryonic period, the hypothesis that one common factor may have induced both entities in the patient is strongly suggested.

Purpose: To report a case of choroidal malignant melanoma metastasis to the contralateral orbit five years after enucleation. Patient and findings: A 70-year-old man with symptom of proptosis and decreased visual acuity came to our clinic. He had history of choroidal malignant melanoma in his left eye 5 years ago and the eye was enucleated at that time. Biopsy from his right orbit showed malignant melanoma. Radiotherapy was recommended but he refused further treatment. After six months he came to the clinic with severe proptosis and pain. Vision was NLP. He underwent radiotherapy and the proptosis was cured and his pain resolved.Conclusion: Orbital involvement after enucleation due to malignant melanoma is rare but possible even after many years therefore carefully and regularly examination of the fellow eye after enucleation is mandatory.