مجله چشم پزشکی بینا
سال بیست و دوم شماره 3 (بهار 1396)

To determine refractive state and corneal parameter changes after cycloplegia with cyclopentolate 1% using dual scheimpfluge imaging system.
Healthy volunteers between the ages of 10 and 40 years who were referred for ophthalmic evaluation in a 3-month period were included. Complete ophthalmic examination, auto-refraction and corneal imaging with the Gallilei dual scheimpfluge system was performed before and after 30 minutes of applying 1% cyclopentolate. Changes in refractive and corneal parameters were evaluated.
One hundred and six patients with mean age of 28±5 years or 212 eyes (201 myopic and 11 hyperopic) were evaluated. The mean spherical equivalent before cycloplegia was -3.4 ± 2.6 D (diopter), after cycloplegia the mean hyperopic shift was 0.4±0.5 D (P The refractive state, posterior corneal curvature and corneal thickness changed statistically and significantly after cycloplegia, so it is recommended not to measure these parameters in cycloplegic state for clinical judgment, in IOL power calculation and refractive surgery.

To compare the efficacy of inferior oblique myectomy and anterior transposition for correcting Inferior Oblique Over Action (IOOA) and DVD.
This retrospective study was carried out on patients with IOOA who had either myectomy or an­terior transposition of the inferior oblique muscle from 2010 to 2015. The authors compared pre-operative and post-operative inferior oblique muscle function grading (-4 to ) as the main outcome measure; vertical and horizontal deviation, dissociated vertical deviation (DVD), and A V-pattern between the two surgical groups as secondary outcomes.
A total of 99 eyes of 56 patients with a mean age of 5.9 ± 6.5 years were included (47 eyes in the myectomy group and 52 eyes in the anterior transposition group). There were no differences in pre-operative best corrected visual acuity, amblyopia, spherical equiva­lent, and primary versus secondary IOOA between the two groups. Both surgical procedures were effective in reducing IOOA and satisfactory results were similar be­tween the two groups: 61.7% and 67.3% in the myec­tomy and anterior transposition groups, respectively (P= 0.56). After adjustment for the pre-operative DVD, there was no statistically significant difference between the two groups post-operatively. The pre-operative hypertro­pia was 6 to 14 and 6 to 18 prism diopters (PD) in the myectomy and anterior transposition groups, respec­tively. After surgery, no patient had a vertical deviation greater than 5 PD.
Both the inferior oblique myectomy and anterior transposition procedures are effective in reducing IOOA with similar satisfactory results. DVD and hypertropia were also corrected similarly by these two surgical procedures.

The aim of the study was to investigate the effect of alternate occlusion on controlling intermittent exotropia in children between 3 and 8 years.
In this interventional before-after study, the ability of 28 children to control deviation at far and near was evaluated based on an office control scale, routinely used in eye clinics and the Holmes scale. Stereopsis and fusion were assessed using the Titmus and Worth 4-dot test in each assessment session, respectively. Patch therapy was used for children based on eye dominancy. Two-hour alternate daily occlusion was prescribed for children with no dominancy. For children with dominancy, 2-hour occlusion of the dominant eye for 5 days and the non-dominant eye for 2 days for up to 3 months in three consecutive 3-month periods was introduced. All measurements were repeated at 3 different times (3, 6, and 9 months) after treatment.
For all children with mean ages of 4.7±1.56 years, deviation controlling at far, improved significantly after 3 months of treatment by two scales, in comparison to the before of study(p=0.005 for the office control and p˂0.001 for Holmes score). Also there was an improvement in far deviation controlling in 6 and 9 months after treatment in comparison to the before of treatment (p=0.008 for the office control after 6 and 9 month and p˂0.001 after 6 and p=0.010 after 9 month for Holmes score). However there were no significant differences between the results of the 3 months and 6 months after treatment with each other, the 3 months and 9 months with each other and 6 months and 9 months with each other. Deviation controlling at near showed significant improvement in all three periods of treatment based on Holmes criteria in comparison to the before of study (p=0.007 for 3 months, p=0.004 for 6 months and p=0.014 for 9 months).
The near stereopsis was better at 9 months of treatment in comparison to the before of study (p=0.028) and 9 months after treatment compared to the 3 months of treatment, significantly improved (P = 0.043). Comparing 6 months rather than before treatment it was a sign of improved stereopsis; however, this improvement was not statistically significant (p=0.068) while there was no improvement in other courses. Measurements of fusion with Worth4-dot test did not show significant progress between all the periods.
The alternate occlusion is significantly effective in controlling intermittent exotropia. As a result, it can be used as a useful method in order to postpone the surgery or even eliminate the need for surgery in patients with intermittent exotropia.

To present a new surgical technique for excision of orbital cavernous hemangioma.
This retrospective study included patients with orbital cavernous hemangioma (CH) who were operated from 2001 to 2016 at our referral center. Epidemiologic data, symptoms, signs and images were reviewed from patients’ files with at least one year of follow up. Surgical results and complications were documented. We used “index finger decollation” technique without grasping the tumor for release of adhesions and its removal.
This study included 76 patients, of them 60 patients (79%) had orbital CH and 16 patients (21%) had periorbital CH. Orbital cases had mean age of 40±12.1 (9-66) years consisting of 36(60%) female and 24 (40%) male patients. In 30 (50%) patients the right eye and in 29 (48.3%) patients the left eye were affected, one (1.7%) patient had bilateral involvement. The main complaint was proptosis in 54 (90%) patients; average proptosis was 5.3±2 millimeters. In 35 (58.3%) patients, mean hyperopia of 1.1±1.8 (0.5 to 10) diopter as compared to other side was detected. The surgical approach was lateral orbitotomy in 49 (81.7%) patients, medial transcutaneous in 7 (11.7%) patients, inferior transconjunctival in 3 (5%) patients and in one (1.6%) patient simultaneous lateral and medial orbitotomy was performed. All tumors were removed intact; complications included proptosis in one case, lower lid retraction in one case and diplopia in two cases which all improved before 2 months. No optic nerve damage occurred. Periorbital cases had mean age of 31.6±15.1 years. 11 of them (68.8%) were female and 5 of them (31.2%) were male with equal involvement of the right and the left eye. In all cases, complaint was periorbital lump. All periorbital tumors were removed without complications.
“Index finger decollation” technique without grasping the tumor for excision of orbital cavernous hemangioma, via any external approach to the tumor is a safe technique with minimal complications.

To investigate the effect of intravenous erythropoietin (EPO) in adjunction to intravenous steroid and conventional treatment protocol in patients with MTON.
In this non-randomized prospective interventional comparative case series, eleven patients diagnosed with MTON, received intravenous EPO (10000 IU twice a day) for 3 days combined with intravenous methylprednisolone (500 mg twice a day for 5 days) followed by oral prednisolone 1mg/kg for two weeks, and vitamin B12, B6 and folic acid (EPO group). These patients were compared with a historical control group who had received similar treatment except EPO. Our main outcome measures were Best-Corrected Visual Acuity (BCVA), Peripapillary Retinal Nerve Fiber Layer Thickness (PRNFLT), and visual field Mean Deviation (MD).
Patients in both groups had better final BCVA at the third month. Mean BCVA improved significantly from 2.93±0.55 to 1.75±1.16 LogMAR at month 3 (p Intravenous EPO in combination with systemic steroid appears to be an effective treatment in patients with MTON. This combinational therapy may supplement additional benefits to the systemic steroid regimen.

To compare the visual outcome between wavefront-optimized (WFO) and topography-guided customized ablation (T-CAT) for compound myopic astigmatism.
This double blind, prospective clinical trial study comprised 40 eyes (21 patients) with compound myopic astigmatism. Myopia was considered between 1 to 8 diopters and astigmatism was considered between 1 to 3 diopters. Patients were randomly divided into two groups: 1) the wavefront optimized group and 2) the topography-guided group. All surgeries were done with Allegretto WaveLight® EX500laser eximer. Visual acuity, refractive error, corneal aberrations, ocular high order aberrations and corneal asphericity were measured before and 6 months after surgery. The results were compared between the two groups.
Six months after surgery, the best corrected visual acuity was similar in two groups. Mean spherical equivalent refraction was -4.33 ± 1.7D and -4.13 ± 1.61 D (P=0.528) to -0.06 ± 0.14 D and -0.04 ± 0.09D (P=0.586) in wavefront optimized and topography-guided groups after surgery. Less stromal tissue was ablated in the topography-guided group than in the wavefront optimized group (P = 0.969). There was no significant difference between the 3rd and 4th grade corneal aberrations between the two groups before and after the surgery (P>0.05). Corneal spherical aberration was increased in both groups. This increase was higher in the WFO group (P = 0.798). Higher order aberrations increased from 0.35 ± 0.14 μm and 0.35 ± 0.11 μm (P=0.496) to 0.52 ± 0.15μm and 0.49 ± 0.16 μm (P=0.786) in the WFO and T-CAT groups, respectively. Corneal asphericity increased in group two, which was higher in the WFO group (P=0.679).
The results of topography-guided and wavefront optimized treatments with Allegretto eximer laser were similar in the correction of compound myopic astigmatism, but TCAT induced fewer HOAs.

To describe a patient with mesenchymal chondrosarcoma of the orbit, review clinical, imaging and pathologic findings as well as treatment modalities.
Case Report: A 59-year-old woman presented with a 2-month history of progressive proptosis. CT revealed a clearly outlined heterogeneous mass with calcified foci, whereas MRI showed an isointense signal to gray matter on T1 and T2-weighted images with gadolinium enhancement. Tumor excision was performed via lateral orbitotomy and pathologic examination showed mesenchymal chondrosarcoma of the orbit. After surgery, radiotherapy and exentration were suggested to the patient, she refused the recommendations due to good visual acuity. After 10 months of follow up there was no local recurrence or metastasis in examinatons.
When we encounter calcified tumor, the orbit mesenchymal chondrosarcoma must be considered in differential diagnosis.

To describe the clinical features, management, and visual outcome in a case of stromal rejection with a rare and unusual presentation after deep anterior lamellar keratoplasty (DALK).
Case report: A 25-year-old healthy man with advanced keratoconus underwent DALK using the standard big bubble technique in his right eye. Five months after surgery, the patient involved in red eye, decreased vision, acute epithelial edema, acute and diffuse stromal edema, fine diffuse keratic precipitates (KPs) in the graft location and AC (anterior chamber) inflammation with cells and flair without any vascularization in the graft and recipient bed, and any infiltration or loosening of the sutures. Management with topical and systemic steroids, and topical antibiotic lead to complete resolution of stromal edema, KPs and AC inflammation. Nine months after the first episode, the patient was referred due to the same clinical presentation and similar findings on examination. Recurrence was treated successfully with the same prior medications and clear graft was achieved.
Although there is no endothelial immune reaction after DALK for keratoconus, stromal graft rejection after DALK can be presented with the same features as endothelial graft rejection and should be differentiated from herpes simplex virus (HSV) keratouveitis.