Journal of Current Ophthalmology
Volume:30 Issue: 4, Dec 2018

In choroiditis, fundoscopic examination is very limited. Only the choroidal foci of sufficient importance causing yellow-white discoloration can be visible through the retinal pigment epithelium (RPE). This is the reason why several inflammatory choroidal entities, with different pathophysiologic mechanisms, were grouped under the general term “white dot syndromes”.1 With the advent of indocyanine green angiography (ICGA), we gained access to the choroidal compartment which allowed the differentiation between the two main mechanisms at the origin of choroidal inflammatory pathology: choriocapillaris diseases (inflammatory choriocapillaropathies/choriocapillaritis) and stromal diseases (stromal choroiditis). Primary inflammatory choriocapillaropathies include multiple evanescent white dot syndrome (MEWDS), acute posterior multifocal placoid pigment epitheliopathy (APMPPE), idiopathic multifocal choroiditis (MFC), serpiginous choroiditis as well as acute macular neuroretinopathy such as acute zonal occult outer retinopathy (AZOOR).2, 3 In these conditions, ICGA shows patchy or geographic hypofluorescent areas of variable sizes more clearly visible on the late frames. These areas correspond to areas of hypo or non-perfusion of the choriocapillaris. Recently, optical coherence tomography angiography (OCT-A), a new imaging technique which allows visualization of the retinal and choroidal vasculature, was developed. It has the advantage of being fast and easy to acquire, non-invasive, and depth-selective.4 OCT-A of active lesions of APMPPE and serpiginous choroiditis revealed areas of non-perfused choriocapillaris which corresponded topographically to hypofluorescent areas in ICGA,5, 6 supporting the theory of choriocapillaris hypo and/or non-perfusion as the origin of these diseases. However, a recent study by Pichi et al.7 has created doubt about choriocapillaritis being the origin of the morphological and functional alterations in MEWDS,7 as OCT-A seems not to show any alterations in choriocapillaris circulation. We present in detail the reasons why choriocapillaritis should not be discarded as the origin of the pathological lesions in MEWDS.
Arguments in favor of MEWDS being a primary choriocapillaritis
Choriocapillaritis entities belong to the same nosological group
Numerous reports indicate that primary choriocapillaritis entities (i.e., MEWDS, APMPPE, MFC, serpiginous choroiditis, and intermediary forms) belong to the same nosological group.8, 9, 10, 11 These are young patients who present with uniform symptoms described as blurred vision, photopsias, and visual field disturbances12, 13, 14 probably caused by ischemic damage to photoreceptor outer segments due to inflammatory non-perfusion of the choriocapillaris. In more than 50% of primary choriocapillaritis patients, a viral flu-like episode precedes the onset of the disease.8, 11 MEWDS patients conform perfectly to all points of this nosological ensemble. For more than two decades, this group has also been united by ICG angiographic findings showing diverse patterns of hypofluorescence depending on the level and importance of choriocapillaris involvement. Most reports for nearly three decades have interpreted these ICGA signs as choriocapillaris non-perfusion. Therefore, it is very unlikely that these ICGA findings are suddenly attributed to a new, questionable mechanism solely for MEWDS and not other choriocapillaritis entities.
Different choriocapillaritis entities can occur in the same patient In addition to similar nosological characteristics, indicating a similar physiopathological process and the involvement of a similar structure, namely the choriocapillaris, numerous reports have shown that more than one type of choriocapillaritis can occur in the same patient,15, 16, 17, 18, 19, 20 underlining the unitarian character of this group of disorders. MEWDS patients that have evolved to MFC have been described, supporting the hypothesis of a common mechanism. Fig. 1 shows an overlapping case of MEWDS with MFC.

To present potential benefits as well as limitations of premium intraocular lens (IOL) use, and provide insight in future of premium cataract surgery. Bibliographic research was performed in PubMed/Medline database, and the most recently updated papers were evaluated. Keywords used were: premium intraocular lens, multifocal intraocular lens, toric intraocular lens, toric multifocal intraocular lens, accommodative intraocular lens, and the respective brand names. Multifocal IOLs provide uncorrected distance visual acuity (UDVA) of 0.03 logMAR in 82.3%–95.7% of patients and overall spectacle independence in 81%–85% of patients. Toric IOLs provide UDVA of 0.3 logMAR in 70%–95% of patients, residual astigmatism of 1 D or less is noted in 67%–88% of patients, and spectacle independence is reported in 60%–85% of patients. Toric multifocal IOLs provide UDVA of 0.3 logMAR in 92%–97% of patients, and spectacle independence is reported in 79%–90% of patients. Accommodative IOLs represent intensively developing field in ophthalmology, and the results are still variable depending on the IOL model. Premium IOL technology and advanced surgical techniques have significantly improved postoperative visual outcomes. Future developments will potentiate development of new premium IOL designs that will provide spectacle independence and excellent visual outcomes after cataract surgery.

To review and highlight important practical aspects of deep anterior lamellar keratoplasty (DALK) surgery and provide some useful tips for surgeons wishing to convert to this procedure from the conventional penetrating keratoplasty (PK) technique. In this narrative review, the procedure of DALK is described in detail. Important pre, intra, and postoperative considerations are discussed with illustrative examples for better understanding. A comprehensive literature review was conducted in PubMed/Medline from January 1995 to July 2017 to identify original studies in English language regarding DALK. The primary endpoint of this review was the narrative description of surgical steps for DALK, its pitfalls, and management of common intraoperative complications. A standard DALK procedure can be successfully performed taking into consideration factors such as age, ophthalmic co-morbidities, status of the crystalline lens, retina, and intraocular pressure. Careful trephination and dissection of the host cornea employing appropriate technique (such as big bubble technique, manual dissection, visco-dissection, etc.) suitable for the specific case is important to achieve good postoperative outcomes. Prompt identification of intraoperative complications such as double bubble, micro and macroperforations, etc. are vital to change the management strategies. Although there is a steep learning curve for DALK procedure, considering details and having insight into the management of intraoperative issues facilitates learning and reduces complication rates.

To determine the rate of excimer laser refractive surgery in Iran and its trend during 2010–2014, and the number of surgeries per ophthalmologist. Twelve provinces were considered for the study; 4 major referral provinces of Tehran, Fars, Isfahan, and Khorasan, and 8 others which were selected randomly. Then a number of excimer laser centers were chosen from each province. In the timeframe between 2010 and 2014, one week per season was randomly selected for each center, and the number of surgeries conducted in these 20 weeks was determined by trained personnel. In the 12 surveyed provinces, 28 of the 57 active surgical centers were selected. The rate of excimer laser refractive surgery in 2010 in Iran was 2764 per million population which reached 3744 per million by 2012 and took a slightly decreasing trend to 3582 until 2014. Based on the number of ophthalmologists and the number of surgeries in 2014, the average number of surgeries per ophthalmologist was 103 surgeries. This is the first study to report the rate of excimer laser refractive surgery in Iran.

This study aimed to evaluate the anatomical, therapeutic, and functional outcome of therapeutic penetrating keratoplasty (TPK) in terms of success and failure. In this retrospective study 57 eyes of 57 patients were reviewed. They had undergone TPK from December 2012 to June 2017. Data analyzed included the baseline demographic features and characteristics, preoperative diagnosis, and postoperative outcomes. The baseline characteristics included age, gender, laterality, indications of TPK, lens status, size of the recipient, grade of the graft, organisms identified, preoperative best corrected visual acuity (BCVA), secondary procedures, adjunctive surgical procedure, postoperative BCVA at last follow-up, intraocular pressure (IOP), and long-term complications of TPK. The ultimate outcome of TPK was observed in terms of anatomical, therapeutic, and functional outcome which indicated the success and failure. A total of 57 eyes of 57 with an age range of 2–76-year-old patients who underwent TPK were included in the study. Perforated corneal ulcer was a major indication of TPK in 32 (56.1%) cases. Anatomical success was obtained overall in 49 (85.96%) cases. Indications of TPK and preoperative visual acuity, complications of TPK, and ultimate graft clarity showed significant impact on the anatomical outcome (P = 0.03, P = 0.00, P = 0.00, and P = 0.05), respectively. The therapeutic and functional success was observed in 51 (89.47%) and 40 (70.17%) cases, respectively. Perforated corneal ulcers was the major indication for TPK. Indications and complications significantly affect the anatomical, therapeutic, and functional outcome.

To evaluate the association between subjective dry eye symptoms and the results of the clinical examinations. The study was a clinical-based survey involving 215 first-year students selected consecutively during a regular ocular health examination at the University of Cape Coast Optometry Clinic. The data collection process spanned for a period of four months. Out of the 215 students, 212 returned their completed questionnaires and were subsequently included in the study. Dry eye tests including meibomian gland assessment, tear break up time, fluorescein staining, Schirmer test, and blink rate assessment, were performed on each subject after completion of the Ocular Surface Disease Index (OSDI) questionnaire. Shapiro–Wilk test was used to determine the normality of the clinical tests, and Spearman's correlations co-efficient was used to determine the correlations between the clinical test results and dry eye symptoms. Statistically significant associations were found between OSDI scores and blink rate (rs = 0.140; P < 0.042), and associations between OSDI scores and contrast sensitivity scores (rs = 0.263; P < 0001). However, the results of corneal staining (rs = −0.006; P < 0.926), Schirmer test (rs = −0.033; P = 0.628), tear break up time (rs = −0.121; P < 0.078), meibomian gland expressibility (rs = 0.093; P < 0.180), and meibomian gland quality (rs = 0.080; P < 0.244) showed no significant association with OSDI. The correlation coefficients range from −0.006 to 0.263 showed low to moderate correlation between dry eye symptoms and the results of clinical test. Associations between dry eye symptoms and clinical examinations are low and inconsistent, which may have implications for the diagnoses and treatment of dry eye disease.

To determine the effect of isotretinoin on corneal sensitivity in acne patients. Fifty patients (13 men and 37 women) with a mean age of 23.24 ± 3.4 years were selected among patients receiving isotretinoin (1.0 mg/kg) for acne according to inclusion criteria. The Cochet-Bonnet esthesiometer was used to measure corneal sensitivity (in mm filament length) two times (the measurements were done immediately before starting the medication, then 3 months after that), including 3 measurements each time, between 11 a.m. and 1 p.m. by an experienced operator. The average of the 3 measurements in each time was recorded as the final value. One-way analysis of variance and Chi square were used for quantitative and qualitative comparison of corneal sensitivity before and after isotretinoin use, respectively. The mean corneal sensitivity was 5.54 ± 0.05 before medication consumption which decreased to 5.41 ± 0.05 after isotretinoin treatment for 3 months (P < 0.005). After controlling the effect of age and sex, the decrease of corneal sensitivity was markedly significant (P = 0.003) as decreased corneal sensitivity was more pronounced at higher ages and in female gender. In non-parametric evaluation, corneal sensitivity was categorized as substantial (5.5–6 mm), intermediate (4.5–5.5 mm), and low (3.5–4.5). About 72% of the participants had substantial corneal sensitivity before drug consumption, which decreased to 60% after 3 months of treatment. According to the results of this study, corneal sensitivity decreases after three months of treatment with isotretinoin. This decrease is more pronounced at higher ages and in women.

To determine the effect of corneal cross-linking (CXL) on retinal structure and function. The current study was conducted on 42 eyes of 21 patients with keratoconus (KCN) who were candidates for CXL due to disease progression. The Optovue optical coherence tomography (OCT) (Optovue Inc., Fremont, USA) from macula and multifocal electroretinography (mERG) were performed on all patients prior to surgery and at 1- and 6- month follow-up. Structural and functional parameters of macula including retinal thickness in OCT, and amplitude and latency of electroretinogram were compared between eyes that underwent surgery and control fellow eyes during the study period. A statistically significant increase in central foveal, foveal, parafoveal, and perifoveal thickness was observed at 1-month follow-up. The changes were non-significant at 6 months. Although a statistically significant reduction in amplitude and increase in latency in both rings 2 and 3 were observed at 1 month in mERG, only amplitude changes in ring 2 remained significant at 6 months. Transient anatomical and functional alterations following CXL were observed in the current study.

This study was designed to assess the functional and anatomic outcomes of intravitreal aflibercept injection in patients with wet age-related macular degeneration (AMD) refractory to intravitreal bevacizumab or ranibizumab therapy. This retrospective study included 43 eyes of 43 patients resistant to treatment with at least 6 injections of bevacizumab or ranibizumab. Persistent intraretinal and subretinal fluid (IRF and SRF) on optical coherence tomography (OCT), no improvement in best corrected visual acuity (BCVA), and a central macular thickness (CMT) increase of more than 100 μm due to SRF and/or IRF compared to baseline for at least 6 monthly intravitreal bevacizumab or ranibizumab injections were defined as resistant to bevacizumab/ranibizumab therapy. BCVA, intraocular pressure (IOP), CMT, maximum retinal thickness (MRT), and maximum pigment epithelial detachment (PED) height (MPEDH) were evaluated before and after aflibercept injections. After initiating aflibercept treatment, the mean final BCVA logarithm of the minimum angle of resolution or recognition (logMAR) improved to 0.84 ± 0.59 which was statistically significant compared to baseline (1.14 ± 0.51), (P < 0.001). After aflibercept injection, statistically significant reduction was noted in mean CMT (402.6 ± 196.7 μm vs 264.2 ± 52.85 μm, P < 0.05), MRT (435.3 ± 195.2 μm vs 282.2 ± 31.8 μm, P < 0.05), and MPEDH (154.2 ± 86.0 μm vs 68.3 ± 70.6 μm, P < 0.05). There was no correlation between the total number of previous injections and the increase of BCVA (r = −0.10, P = 0.265). The decrease of mean IOP was statistically significant under aflibercept treatment (P < 0.001). The present study showed the efficacy of aflibercept treatment in eyes with persistent retinal or SRF under bevacizumab or ranibizumab therapy. A significant anatomical and functional improvement was noted.

This study aimed to evaluate two psychophysical contrast sensitivity testing methods in amblyopic patients. Thirty-three adults with anisometropic amblyopia participated in this study. Psychophysical contrast sensitivity was measured for both amblyopic and fellow eyes of the participants at 1, 3, and 5 cycles per degree (cpd) spatial frequencies by Freiburg visual acuity and contrast test (FrACT) and Metrovision contrast sensitivity test, which employ sine-wave gratings for measurement of contrast sensitivity. We evaluated the correlation between the two tests and used Bland–Altman analysis to measure the agreement between the two methods. Except for 1 cpd in amblyopic eyes, FrACT showed significantly higher contrast sensitivity measurements than Metrovision at all spatial frequencies both in normal and amblyopic eyes (P < 0.01). The difference between the two methods increased with an increase in spatial frequency. There was a significant correlation between the two tests at most of the spatial frequencies. While the difference between the results of the two tests increased with an increase in contrast sensitivity in amblyopic eyes, we found an inter-test agreement in normal eyes. Although both FrACT and Metrovision employ sine-wave gratings to measure contrast sensitivity, there are some differences between them, and their results can not be used interchangeably.

The aim of this study was to investigate the aerobic conjunctival flora of neonates and the effects of delivery type on conjunctival flora development in neonates who were born with normal spontaneous vaginal delivery (SVD) or elective caesarean section (C/S) and who were not given prophylactic antibiotic eye drops after birth. This cross-sectional study included 95 healthy newborns. One day after the delivery, conjunctival samples were taken from newborns who were born with normal SVD or elective C/S, and not given prophylactic antibiotic eye drops after birth. Newborns with conjunctival hyperemia and discharge were excluded from study. Samples were plated in blood agar, EMB, and chocolate agar. These cultures were incubated at 37 °C for 24–48 h. Antibiotic sensitivity was evaluated using Kirby-Bauer disc diffusion method. Staphylococcus aureus (S.aureus) growth was observed in 7 (70%) and coagulase negative staphylococcus (CNS) growth in 2 (20%) out of 10 eyes with bacterial growth in 9 culture positive newborns born with C/S. Two S.aureus strains were resistant to methicillin. On the other hand, CNS growth was observed in the conjunctival cultures of 17 out of 19 eyes with bacterial growth in 16 culture positive newborns born with SVD. In 2 eyes with CNS growth, there was also S.aureus growth. The positive cultures for S.aureus were significantly higher in the conjunctival cultures of neonates born with C/S compared to neonates born with SVD, where CNS growth was significantly lower (P = 0.002). All isolates were susceptible to vancomycin, teicoplanin, and gatifloxacin. Two isolates were resistant to methicillin. In deliveries with C/S, the newborn does not contact the vagina. This may result in changes of bacterial characteristic of the flora. Culture positivity for S.aureus was higher in C/S compared to SVD, which may be important in case neonatal conjunctivitis develops.

This study was conducted to determine the demographics, clinical features, severity, and activity of thyroid eye disease (TED) in patients of a referral center in the north of Iran. Patients with TED who were referred to Amir-Almomenin Hospital, Rasht, Iran from March 2012 to March 2014 were enrolled in this cross-sectional study. The measurements of proptosis, lid width, lagophthalmos, extraocular muscle function, and visual acuity were recorded. The activity of ophthalmopathy was scored according to the clinical activity score (CAS). TED was diagnosed in 103 patients with a mean age of 42.1 ± 13.91 years. Of those patients, 52.4% were women, and 80% had hyperthyroidism. The mean duration of TED was 36.5 ± 53.12 months. Extraocular muscle involvement (98%) and eyelid retraction (88.3%) were the most common manifestations. Per the CAS results, 86 (83.5%) patients were at stage 0, and there was a significant difference in CAS scores between male and female patients, P = 0.02. The characteristics of TED in patients of the studied referral center during a two-year period, including common signs and symptoms, disease duration, treatment, an activity of disease were determined. Notably, many patients in this study had orbital squeal of TED meaning that they had inactive TED. Proper management of this serious complication requires close cooperation between endocrinologists and ophthalmologists to ensure timely referrals for appropriate care.

This study aimed to demonstrate the value of the chief compliant and patient history to accurately diagnose patient pathology without requiring ocular examination or imaging in an outpatient neuro-ophthalmology clinic. We prospectively evaluated 115 consecutive patients at our institution from January to April 2009. The attending neuro-ophthalmologist committed to a single most likely diagnosis while solely being exposed to patient demographic information (age, gender, race) and chief complaint, but was otherwise blinded to ocular examination or imaging. The validity of the initial diagnosis was assessed by further acquiring subjective and objective findings and the percentage of correct diagnoses was determined. Patient cases were categorized based on the neuro-ophthalmologic localization of the final diagnoses: afferent nervous system, central nervous system (CNS), efferent nervous system, orbital system, and pupillary system. Correct diagnoses by chief complaint and patient history were 84%, 100%, 86%, 80%, 50% and 100% for afferent, central, efferent, orbit, pupil, and other neuro-ophthalmic diseases, respectively. Over half the cases were correctly diagnosed by chief complaint alone, which improved to 88% when combined with the patient history. A simple combination of patient history and chief complaint predicts an overall diagnostic accuracy in approximately 90% of cases. Our study demonstrates the remarkable diagnostic value of patient history in neuro-ophthalmologic clinic practice.

To examine the risk of developing Parkinson's Disease (PD) in patients who are newly diagnosed with neovascular age-related macular degeneration (nAMD). This was a cohort study using the British Columbia (BC) Retinal Disease Database. Data from 2009 to 2013 was accessed. Rates of PD in patients prior to the diagnosis of nAMD were computed and compared to the rates of patients newly diagnosed with PD after the diagnosis of nAMD. The rate of PD prior to the diagnosis of nAMD was 1.42 per 100,000 person-years. The rate of PD after the diagnosis of nAMD was 2.88/100,000 person-years. The rate ratio was 2.03 (95% CI; 1.31–3.16). The findings suggest that patients who are diagnosed with nAMD are at a significantly higher risk of developing PD later in life. More studies are needed to identify the pathological mechanism between the two diseases.

To present a rare manifestation of macular telangiectasia type 2 (MacTel type 2) followed up for over six years. A 61-year-old woman with one year history of blurred vision of her left eye was referred. Whereas the funduscopy, spectral-domain optical coherence tomography (SD-OCT), fluorescein angiography (FA), and fundus autofluorescence (FAF) were normal in the right eye, they revealed noticeable findings typical of MacTel type 2 in the left eye. After over six years follow-up, OCT-angiography (OCTA) showed no remarkable difference between the two eyes, and en face OCT showed subtle abnormal change in the right eye as well as typical pathological changes in the left eye. MacTel type 2 can present unilaterally and remain so for a long time. The role of multimodal imaging in diagnosis and follow-up is of utmost importance.

Deep sunken superior sulcus of the upper eyelid can result from aging, genetic, prostaglandin use, and prior aggressive upper blepharoplasty. If severe, it can cause exposure keratopathy, lagophthalmos, and giant fornix syndrome. We herein report on another milder manifestation of deep superior sulcus and its treatments. Methods Case report Results: Deep sunken superior sulcus syndrome caused to soft contact lens displacement and wear intolerance and was treated with upper eyelid suclus hyaluronic acid gel injection. Contact lens wear intolerance is likely more common in patients with deep sunken superior sulcus syndrome and can potentially be treated with superior sulcus hyaluronic acid gel injection.

To report a rare and complicated case of acanthamoeba keratitis (AK) presented with total necrosis and dislodgment of cornea, iris, and crystalline lens with exposure of vitreous hyaloids face. Case report of 28-year-old female referred to the Farabi Eye Hospital with a history of known left eye AK since 4 months earlier. She also had a history of soft contact lens wear for two years and topical steroid use before proper diagnosis. Slit-lamp examination of the left eye revealed ring infiltration and stromal edema with haziness. The patient was prescribed anti-acanthamoeba treatment. She returned after 2 weeks with increasing ring infiltration and slight vision loss. Slit-lamp examination showed spontaneous total necrosis of cornea, iris, and crystalline lens with vitreous exposure to the air. The patient underwent an urgent operation consisting of total debridement of necrotic tissues including a 1 mm rim of the sclera, anterior vitrectomy, tectonic penetrating keratoplasty, and amniotic membrane transplantation (AMT) with temporary lateral tarsorrhaphy. The graft was clear within the 4 years of follow-up. At the last examination, the left eye was pthysic due to ciliary shut down and visual acuity remained light perception. Early suspicion to AK, especially in contact lens wearers, and applying diagnostic modalities like confocal microscopy and early appropriate management with cysticide agents such as polyhexamethylene biguanide may prevent these untoward complications.

To report a case of autoimmune keratitis in a patient with mycobacterium tuberculosis (MBT). An 84-year-old male with pulmonary tuberculosis (TB) was admitted with chronic, non-healing bilateral ulcerations of the inferior peripheral cornea associated with stromal and subconjunctival nodules. Clinical examination revealed circumscribed peripheral corneal ulceration with whitish nodules in adjacent stromal and subconjunctival tissue. Microbiological cultures of the corneal tissue were negative for MBT and other microbial pathogens; however, enzyme-linked immunosorbent assay (ELISA) of blood and corneal samples showed significantly elevated levels of IgM and IgA against MBT. In addition to systemic anti-tuberculosis therapy, the patient was treated topically with Polyspectran® eye drops, Dexamethasone eye drops, and Bepanthen® ointment, for 2 weeks. Both eyes showed dramatic improvement after 2 weeks. The present report demonstrates that MBT is able to initiate delayed autoimmune response within the corneal tissue during an intensive phase of anti-tuberculosis treatment.