BINA
Year:2009 | Volume:14 | Issue:2 (55)|Papers Count:21

Purpose: To report the efficacy of a single intravitreal injection of bevacizumab (IVB) alone or in combination with intravitreal triamcinolone acetonide (IVT) versus macular laser photocoagulation (MPC) as primary treatment for diabetic macular edema (DME).Methods: This randomized three-arm clinical trial included 103 eyes of 97 patients with clinically significant DME and no previous treatment. The eyes were randomly assigned to one of the three study arms: the IVB group received 1.25 mg IVB (37 eyes), the IVB/IVT group received 1.25 mg IVB together with 2 mg IVT (33 eyes), and the MPC group underwent focal or modified grid laser photocoagulation (33 eyes). Primary outcome measure was change in best-corrected visual acuity (BCVA).Results: Changes in BCVA (logMAR) at 12 weeks were -0.22±0.23,-0.13±0.31and +0.08±0.31in the IVB, IVB/IVT and MPC groups, respectively. The marginal regression model based on generalized estimating equation analysis demonstrated that changes in visual acuity was statistically significant in the IVB group at both 6 (P<0.001) and 12 (P=0.024) weeks but only at 6 weeks in the IVB/IVT group. Significant decrease in central macular thickness (CMT) was observed in the IVB and IVB/IVT groups at 6 weeks. Conclusion: Up to 12 weeks, IVB treatment in eyes with DME yielded better visual outcome than laser photocoagulation, although it was not associated with a significant decrease in CMT. IVT seemed to have no further beneficial effect in combination with IVB.

Purpose: To evaluate the results of Verteporfin photodynamic therapy (PDT) in vasoproliferative tumors (VPT) of the retina and retinal capillary hemangiomas (RCH).Methods: In a retrospective case series, 6 tumors in 5 eyes with VPT, and 3 RCH in 3 eyes underwent PDT which was performed using intravenous Verteporfin. Eyes were evaluated for tumor regression, final bestcorrected visual acuity (BCVA), and final retinal status.Results: Patients were followed for a mean period of 7.1±3.9 months. Mean number of PDT sessions for each tumor was 1.33 (range 1-2). Overall, mean BCVA improved from 1.7±1.06 to 0.88±0.8 logMAR (P=0.017). Tumor thickness decreased from 3.53±0.83 to 1.73±0.73 mm (P<0.001). Subgroup analysis revealed improvement in BCVA and tumor thickness in the VPT group (P=0.04). However, in the RCH group, there was no statistically significant improvement in BCVA (P=0.43) despite significant reduction in tumor thickness (P=0.024). A favorable outcome characterized by improved or unchanged visual acuity was achieved and the tumor regressed in all eyes. Subretinal fluid was absorbed in all eyes except for one eye with preoperative proliferative vitreoretinopathy.Conclusion: Vasoproliferative tumors and retinal capillary hemangiomas can be treated effectively by Verteporfin PDT and a favorable outcome can be expected.

Purpose: To evaluate the visual outcomes and complications of low power transpupillary thermotherapy (TTT) in patients with neovascular age-related macular degeneration (AMD). Methods: The study included 20 eyes of 17 patients. Diagnosis of exudative AMD was established on the basis of fundus examination and fluoresces in angiography (FA). TTT was performed using a diode laser at 810 nm wavelength, spot size of 2.5 to 4 mm and duration of 60 seconds for each spot with power settings between 300-600 mw (20% reduction). Follow-up visits were scheduled 1 and 6 weeks and 1,3 and 6 months after the procedure and yearly thereafter. Patients were followed for at least 6 months. Cases with persistent leakage from CNV in late frames of FA were referred for another treatment option.Results: Patients included 10 men (12 eyes) and 7 women (8 eyes) with mean age of 70.71±9.8 (range 50-84) years. Baseline best-corrected visual acuity (BCVA) ranged from 20/50 to 20/1300. Post-TIT regression of leakage (clinically and angiographically), and improvement or stabilization of visual acuity, was not statistically significant (P=0.14). Post-TTT complications included sub retinal prepapillary hemorrhages in 2 eyes, vitreous hemorrhage in 2 eyes and macular infarction in one eye. At final follow-up, fibrosis of the CNV was detected in 7 (35%) eyes and flat chorioretinal atrophy with hypopigmentation was seen In 11 (55%) eyes. There was no significant difference between cases with flat atrophy and those with fibrous scars in terms of BCVA (P=0.91). Subgroup analysis showed that patients with better visual acuity ( ³20/60) had poorer visual outcomes after TTT (P=0.03). Conclusion: Overall, in spite of the low threshold, visual acuity remained unchanged or decreased. Although TTT can occlude choroidal neovascularization, it could not prevent retinal complications andoccurrence or progression of chorioretinal atrophy or sub retinal fibrosis.

Purpose: To compare ipsilateral and contralateral carotid wall thickness in patients with acute unilateral non-arteritic anterior ischemic optic neuropathy (NAION).Methods: This prospective case series included 17 (10 male and 7 female) patients with unilateral NAION of less than 8 weeks' duration who underwent B-mode ultrasonography to measure intima-media thickness (IMT) in the common carotid and internal carotid arteries. IMT values of the affected side were compared with those on the contralateral side.Results: Mean patient age was 59.6±10.8 (range 45-74) years. Mean interval between onset of NAION and measurements was 27.6±13.2 (range 10-45) days. Mean IMT of both common and internal carotid arteries on the affected side (1.19±0.14 and 1.41±0.29 mm, respectively) was significantly (P<0.001) higher than the noninvolved side (0.92±0.11 and 0.83±0.2, respectively).Conclusion: NAION may be accompanied by increased carotid wall thickness. Carotid wall thickness measurement using ultrasound in patients with NAION may be useful to identify concomitant carotid artery disease.

Purpose: To report the outcomes of surgical and non-surgical treatment for sixth nerve palsy and paresis in our center.Methods: Hospital records of 33 patients (35 eyes) with sixth nerve dysfunction who were referred to Labbafinejad Medical Center from September 1996 to September 2006 and underwent surgical procedures or botulinum toxin injection were reviewed.Results: Patients were divided into three groups: Group A had muscle surgery without transposition; group B had transposition procedures and group C had botulinum toxin injection. The deviation improved from 50.3±16.8 to 6±9.8 prism diopter (PD) after the first operation and to 2.5±5 PD after the second operation in group A; from 56.9±24.3 to 5.5±16 PD after the first operation and to almost zero following the second operation in group B; and from 44.3±10.5 to 15±20 PD 6 months following botulinum toxin injection. Head posture and limitations of motility also improved significantly in all three groups. The overall reoperation rate was 18.2%.Conclusion: Various procedures are effective for sixth nerve dysfunction; all improve ocular deviation, head turn and abductive capacity of the eye. The rate of reoperation is not high if treatment is selected appropriately according to the patient's condition.

Purpose: To determine the effect of occluding a normal eye on visual acuity, contrast sensitivity and stereopsis in amblyopic school children.Methods: Amblyopic children from primary schools of region 2 in Mashhad were identified and referred to Optometry Clinics of Mashhad Medical University through a screening program. Informed consent was obtained from the parents. All subjects underwent an ophthalmologic examination including visual acuity, subjective refractive error, biomicroscopy and funduscopy. Best-corrected visual acuity (BCYA), contrast sensitivity and stereopsis were measured by Snellen E chart, Cambridge low contrast chart and Titmus stereotest, respectively. All tests were repeated 2 weeks, 1 month and 3 months after initial examination.Results: Of 1,947 children, 289 (14.8%) were amblyopic of whom 62 subjects were eventually enrolled for the study. BCYA in the amblyopic eye was less than 3/10 in 25.8% of subjects before treatment however all children had BCYA of 3/10 or better afterwards. Mean BCYA in amblyopic eyes significantly increased from 0.53±0.26 logMAR to 0.24±0.23 logMAR after 2 months of treatment (P<0.001). Mean contrast sensitivity in amblyopic eyes was 68.3 before treatment which improved to 152.5, 138.2 and 198 after 2 weeks, 1 month and 2 months of treatment, respectively (P<0.001).Conclusion: Contrast sensitivity may provide better assessment of visual function as compared to visual acuity. Changes in contrast sensitivity are more sensitive to occlusion therapy as compared to visual acuity. Therefore, contrast sensitivity may yield better evaluation of subclinical changes not detectable by testing visual acuity.

Purpose: To compare general anesthesia (GA) with local anesthesia (LA) in terms of safety and patient satisfaction.Methods: In this interventional case series, 928 consecutive patients who underwent vitreoretinal surgery were included. Data for analysis were type of anesthesia and operation, patient compliance, operating conditions and pain scores. General anesthesia was provided with a standard method and local anesthesia was performed through peribulbar or retrobulbar routes. Selection of the type of anesthesia was determined by patient age and co-morbidities based on the surgeon's opinion.Results: Patients were operated under local anesthesia in 343 (36.9%) and general anesthesia in 585 (63.1%) cases. Mean age was 68.8±7.3 (range 51-78) years in the LA group and 55.9±6.5 (range 43-70) years in the GA group (P= 0.041). ASA (American Society of Anesthetics) physical status score in the LA group was higher than GA group. Patients were in appropriate condition in 96.4% and operating conditions were good or excellent in 98.8%. The majority of patients (97%) said they would choose local anesthesia for their next vitreoretinal procedures.Conclusion: Local anesthesia is a useful and flexible method of anesthesia for vitreoretinal surgery, with excellent patient tolerance, especially in old patients and those who suffer from concurrent diseases.

Purpose: To compare the efficacy and safety of Ahmed Glaucoma Valve (AGV) implantation in the superior versus inferior quadrants.Methods: This prospective parallel cohort study was performed on 106 eyes of 106 patients with refractory glaucoma. Main outcome measures included intraocular pressure (IOP) and rate of complications. Other outcome measures included best-corrected visual acuity (BCVA), number of glaucoma medications and success rate (defined as at least 30% IOP reduction and 5<IOP<22 mmHg with or without medications). Criteria for failure included implant removal, additional glaucoma surgery, phthisis bulbi or loss of light perception.Results: AGV was implanted in the superior quadrants in 58 eyes and in the inferior quadrants in 48 eyes. Baseline characteristics were comparable in the study groups, except for preoperative lOP which was higher in the superior group (P=0.01). Patients were followed for a mean period of 10.6±8.5 and 10.6±6.8 months in the superior and inferior groups, respectively (P=0.48). BCVA was comparable between the groups at all postoperative visits. After one year, statistically significant but comparable lOP reduction from baseline (P<0.001) was achieved in both groups (47.0±27.2% and 43.0±24.5% reduction for the superior and inferior groups respectively, P=0.725). Mean number of glaucoma medications was comparable after one year (1.3±1.2 versus 1.9±0.8 for superior and inferior implants respectively, P=0.256). Success rates were also similar after one year: 27 eyes (81.8%) versus 20 eyes (95.2%) for superior and inferior implants, respectively (P=0.227). However, the overall rate of complications such as implant exposure necessitating removal, cosmetically unappealing appearance and endophthalmitis was higher in the inferior group: 25% versus 5.2% (P=0.004).Conclusions: Superior and inferior AGV implants have comparable intermediate efficacy in terms of IOP reduction, decrease in number of glaucoma medications and preservation of vision. However, the inferior quadrants entail significantly more complications. It may be prudent to avoid AGV implantation in the inferior quadrants if the superior quadrants have no contraindications to surgery.

Purpose: To investigate the association between acute corneal hydrops in patients with keratoconus (KCN) and mitral valve prolapse (MVP).Methods: This case-control study included KCN patients with corneal hydrops who were referred to Labbafinejad Medical Center or a collaborating private clinic from March 2006 to March 2008 as the case group. The control group included age- and sex-matched individuals who were selected from patients without any ophthalmic diseases among clients of the same medical centers. Patients with history of eye trauma, corneal degenerative diseases, rheumatic fever, Madan syndrome, rheumatoid arthritis, and systemic lupus erythematous were excluded. The size of the control group was four times that of the case group to increase the power of the study. All subjects were referred for cardiac examination and underwent two-dimensional M-mode and color Doppler echocardiography. Proloff's criteria were used for diagnosis of MVP. Fisher exact test and logistic regression were used to compare these two groups. Results: Overall, 160 patients (32 cases and 128 controls) with mean age of 31.0±13.2 were studied. Prevalence of MVP was 65.6% in the case group and 9% in controls (P<0.001). Patients with hydrops had an odds ratio of 26.7 for having MVP (95% confidence interval, 9.5-75.2). Age- and sex-adjusted analysis revealed a higher correlation between the two conditions in the case group.Conclusion: There seems to be a correlation between corneal hydrops secondary to KCN and MVP suggesting the need for cardiovascular evaluation in these patients to assess mitral valve status.

Purpose: To report 3 cases of nocardia keratitis following photorefractive keratectomy (PRK). Report of Outbreak: Four eyes of 3 patients (2 female and one male) who had undergone PRK by a single surgeon at a single center developed nocardia keartitis 3 to 6 weeks postoperatively. Mean age was 25 (range 23-28) years and mean onset of corneal manifestations was 29 (range 21-40) days after PRK. Corneal smear and culture and confocal scan were performed in all eyes. Two eyes from the first two patients required lamellar keratectomy to debulk the involved stroma and to obtain specimens for microbiologic and histopathologic evaluation. Light microscopic examination disclosed gram-positive and acid-fast filaments of nocardia which were confirmed by the microbiologic results. Diagnosis of nocardia keratitis in the third case was not as challenging as the first two cases because of a high index of suspicion. Confocal scan in all cases disclosed hyperreflective and slender fibril-like structures in the corneal stroma. All eyes responded favourably to topical amikacin and the infection resolved without recurrence. Conclusion: Nocardia is a rare cause of keratitis following PRK. Clinical suspicion along with microbiologic, histopathologic and confocal scanning help to establish the correct diagnosis. The most probable cause of the outbreak was inadequate attention to sterility during surgery.

Purpose: To report the results of photorefractive keratectomy (PRK) with mitomycin-C (MMC) to correct myopia and astigmatism in patients who had previously undergone penetrating keratoplasty (PKP).Methods: Thirty-eight eyes of 32 patients underwent PRK with MMC to correct astigmatism and myopia following PKP.Result: Mean spherical equivalent (5E) was -5.2±4.7 0 (diopter) and mean astigmatism was -2.4±3 0 preoperatively which reached -3.1±3.1 0 and -1.2±2.8 0 3 months after the operation respectively. The cornea was clear in 55.3%, had trace haze in 21.1%, moderate haze in 15.8% and severe haze in 7.9% of cases. Conclusion: PRK with MMC after PKP is a relatively safe and effective procedure. It reduces both the spherical error and the cylindrical component of the ametropia. Corneal haze is the major complication.

Purpose: To report a case of isolated eyelid pseudotumor.Case report: A 40-year-old man presented with swelling and erythema of the right upper eyelid of 4 months duration. Multiple topical and systemic antibiotics had been administrated without any response. Incisional biopsy and evaluation of the lesion disclosed a diagnosis of eyelid pseudotumor. Oral prednisolone was initiated and then tapered slowly on the basis of clinical response. After six months, the eyelid lesion disappeared totally.Conclusion: Isolated eyelid involvement is a rare presentation of inflammatory pseudotumor of the orbit and should be considered in the differential diagnosis of eyelid lesions.

Purpose: To present two patients with hydatid and alveolar cysts of the orbit and to present their clinical, imaging, pathologic and therapeutic features.Case Report: Two young children from rural areas were referred for progressive proptosis. Imaging showed intraorbital cysts. They were operated on with a clinical suspicion of hydatid and alveolar cysts. Pathologic evaluation confirmed the diagnoses in both instances.Conclusion: Clinical findings and imaging before the operation help the diagnosis of orbital echinococcosis. Knowing the nature of these lesions can prevent surgical complications. Alveolar cysts are much more invasive than hydatid cysts and their treatment is more difficult.

Purpose: To present a case of ocular toxocariasis in a young male subject from the north of Iran.Case Report: A 29-year-old man presented to our clinic with history of decreased vision in his left eye from 10 days before. He had a history of similar symptoms 2 years ago. Visual acuity in the left eye was counting fingers at 2 meters but relative afferent pupillary defect was negative. The right eye was normal on examination but the left eye showed mild anterior chamber reaction together with +3 to +4 cell in the anterior vitreous. Funduscopy in left eye disclosed posterior vitreous organization in the superonasal area of the retina. Serologic test study for toxocariasis was strongly positive.Conclusion: Ocular toxocariasis is a rare but severe cause of unilateral visual loss in young healthy persons.

Purpose: To report the clinical and histopathological features of recurrent atypical fibrous histiocytoma of the comeo-sclerallimbus followed by intra-epithelial squamous neoplasia.Case Report: A 25-year-old female patient presented with a recurrent vascularized gelatinous mass in the left nasal limbus. The preliminary histopathological diagnosis of the previously excised lesion was an amelanotic malignant melanoma at a private general pathology center. The lesion had recurred after one year and the histopathologic diagnosis was a poorly differentiated malignant melanoma at another pathology center. The lesion recurred again and the specimen was sent to a third histopathologic center where the histopathologic diagnosis revealed spindle cell growth with moderate atypia. A pannus-like lesion occurred in the nasal limbus 3 years later which was excised and sent to the Eye Bank Pathology Laboratory. Reviewing the slides related to the first recurrent lesion and the histopathologic examination of the recently excised specimen disclosed a final diagnosis of atypical fibrous histiocytoma and intra-epithelial squamous neoplasia, respectively.Conclusion: Fibrous histiocytoma is a rare limbal tumor that may have atypical features and can be misdiagnosed as an amelanotic melanoma. This is also a rare report on the occurrence of intraepithelial squamous neoplasia following excision of recurrent fibrous histiocytoma.