Journal of Current Ophthalmology
Volume:35 Issue: 3, Jul-Sep 2023

To look for causative genetic mutations in a series of Iranian families with strabismus. In addition, we systematically reviewed all the published articles regarding the role of genetic variations in primary and nonsyndromic comitant strabismus.

Four families with a history of multiple cases of primary and nonsyndromic comitant strabismus were enrolled in this study. Polymerase chain reaction and Sanger sequencing of exons 23, 11, and 3 of the Abelson helper integration site 1 (AHI1), nebulin (NEB), and paired box 3 (PAX3) genes were performed, respectively. One offspring of a consanguineous marriage underwent whole‑exome sequencing (WES) to look for possible causative variants. To conduct a systematic review, we thoroughly searched PubMed, Scopus, and ISI Web of Knowledge extracting relevant publications, released by April 2021.

We examined four Iranian strabismus pedigrees with multiple affected offspring in different generations. Among these 17 participants, 10 family members had strabismus and 7 were healthy. Sanger sequencing did not reveal a causative mutation. Therefore, to further investigate, one affected offspring was chosen for WES. The WES study demonstrated two possible variants in MYO5B and DHODH genes. These genetic variants showed high allele frequency in our population and are thought to be polymorphisms in our series of Iranian families.

We demonstrated that mutations in AHI1, NEB, and PAX3 genes were not common in a series of Iranian patients with familial strabismus. Moreover, by performing WES, we revealed that two variants of uncertain significance as possible causative variants for strabismus are not related to this disease in our population.

To review current eyedrop instillation techniques, common difficulties faced by patients instilling eyedrops, available eyedrop assistive devices, and patient education regarding eyedrop instillation.

PubMed, Embase, and Google Scholar were searched from conception until June 2022 for articles on eyedrop instillation difficulties, techniques, tools, and patient education.

Instillation involves pulling down the lower eyelids and placing drops on the corneal surface or conjunctival fornix, followed by closing of the eyelids for about 1 min. Examples of techniques include eyelid closure and nasolacrimal obstruction techniques. Patients encounter many difficulties when administering eyedrops, including but not limited to poor visibility, squeezing the dropper bottle, aiming the bottle, and accidentally blinking. However, devices are available that assist with aim and dropper compression-force reduction in eyedrop instillation. These can be particularly useful in patient demographics with diminished manual dexterity or the ability to generate force from their fingers. Furthermore, despite patient education in eyedrop instillation not being a common practice, it has been found that adequate patient education can lead to significant improvement in eyedrop instillation technique.

While many factors are associated with poor eyedrop instillation technique, there are many solutions available including assistive devices and proper instillation education.

To evaluate diagnostic performance of ganglion cell inner plexiform layer (GCIPL) and retinal nerve fiber layer (RNFL) parameters measured with Cirrus high‑definition optical coherence tomography (OCT) in patients with preperimetric glaucoma.

In this multicenter cross-sectional study, 150 eyes of 83 patients with preperimetric glaucoma were compared with 200 eyes of age and sex matched healthy subjects. All patients had visual field testing and OCT scanning of GCIPL and RNFL in all quadrants. The independent Samples t‑test was used to determine if a difference exists between the means of two independent groups on a continuous dependent variable. The area under the receiver operating characteristic (ROC) curve (AUC) of each parameter was calculated for discriminatory ability between normal controls and preperimetric glaucoma. The sensitivity and specificity were estimated by point coordinates on ROC curve.

The best parameters for distinguishing preperimetric glaucoma from healthy eyes were the combined average GCIPL + average RNFL, followed by average RNFL + GCIPL (inferotemporal), and average RNFL + GCIPL (minimum). The GCIPL parameters with the highest to lowest AUC (in decreasing order) were inferotemporal, followed by average, minimum, superior, inferior, superonasal, inferonasal, superotemporal, and quadrants. The RNFL parameters with the highest to lowest AUC (in decreasing order) were average, followed by nasal, temporal, superior, and inferior quadrants. The sensitivity of combined GCIPL + RNFL parameters ranged 85%–88% and the specificity ranged 76%–88%. The sensitivity for RNFL parameters ranged 80%–90% and the specificity ranged 64%–88%.

GCIPL and RNFL have good discriminatory ability; the sensitivity and specificity increase when both parameters are combined for early detection of glaucoma.

To evaluate the effect of early posttrabeculectomy bleb leakage on trabeculectomy surgery outcomes and success rate.

The present prospective cohort study was conducted on 203 eyes of 203 patients who underwent trabeculectomy at Torfeh and Imam Hossein Medical Centers, Tehran, Iran, between 2016 and 2021. Patients were divided into two groups: those with early bleb leakage (within the 1st month of surgery) and those without bleb leakage. The success rate of surgery was compared 12, 18, and 24 months after surgery in the two groups. The average intraocular pressure (IOP) and the need for medications in patients 1, 3, 6, 9, 12, 18, and 24 months after the trabeculectomy were also compared.

Bleb leakage was detected in 33 eyes during the 1st month after a trabeculectomy (16.3%). The mean decrease in IOP in the group with leakage was significantly lower than in patients without leakage at 1, 6, 9, 12, 18, and 24 months after surgery (P < 0.05). The need for antiglaucoma medication was significantly higher among patients with bleb leakage at 3 months (P = 0.04) and 9 months (P = 0.047) after surgery (P < 0.05). The success rate at 12, 18, and 24 months after surgery was significantly lower in the group with leakage than the group without.

The results of our study suggest that early posttrabeculectomy bleb leakage negatively impacts surgery success. Furthermore, IOP reduction was lower in patients with early leakage.

To assess the risk factors and management of corneal plaques formed after keratoplasty.

In this retrospective study, medical records of all eyes with plaques formed on top of corneal grafts performed in the period between January 2014 and January 2022 were reviewed. The retrieved data included prekeratoplasty corneal pathology, ocular risk factors, operative data and complications, plaque management, and chemical composition of the plaques using infrared spectrometer.

Thirteen eyes were included in this study. Predisposing ocular comorbidities included ocular surface disorders with variable degrees of dry eye in nine patients, rheumatoid arthritis in three patients, history of herpetic keratitis in two eyes, and cicatrizing conjunctivitis in two patients. Surgical excision and amniotic membrane transplantation (AMT) were performed in 12 eyes. Postoperatively, five eyes showed recurrence after excision, two eyes developed graft vascularization and scarring, and one eye showed persistent epithelial defect and graft scarring, whereas four eyes showed complete epithelialization with mild haze. Rekeratoplasty and AMT were performed in two eyes with no plaque recurrence. Chemical analysis using infrared spectrometry showed that the plaques consisted of ammonium magnesium phosphate and calcium phosphate carbonate in 9 (75%) cases and pure mucus in 3 (25%) cases.

Postkeratoplasty corneal plaque formation is an underestimated complication of keratoplasty that may occur after persistent epithelial defects. Ocular surface disorders are the primary predisposing risk factors. In our experience, the prognosis after medical treatment or surgical scraping is guarded, and regrafting can be the only solution to restore graft clarity

To analyze the frequency of main keratotopographic patterns at the 1st, 2nd, and 3rd stages of keratoconus and investigate corneal biomechanical properties across different patterns.

The study comprised two stages. The first stage was computational‑experimental, where we utilized COMSOL Multiphysics® software (COMSOL AB, Stockholm, Sweden) to mathematically model corneal mechanical behavior under intraocular pressure and pulsed air jet action in both normal and keratoconic conditions. The second stage was the clinical phase, during which we retrospectively analyzed the examination results of both healthy subjects and patients with keratoconus. In total, the study included 256 eyes (256 subjects). Among them, 174 eyes (174 healthy individuals) had normal corneas with different refractions, and 82 eyes (82 individuals) had stages 1, 2, and 3 of keratoconus based on Amsler–Krumeich classification. The keratotopographic characteristics of the participants were assessed using Sirius(Schwind, Germany) and Pentacam AXL(OCULUS Optikgeräte GmbH, Germany) keratotomographs, while the corneal biomechanical properties were studied using noncontact tonometry with the Corvis ST device (OCULUS Optikgeräte GmbH, Germany). The study focused on evaluating corneal stiffness index values in the central optical zone under various keratotopographic patterns. In addition, it compared the elastic coefficient values c1 , c2 , and c3 for the model of hyperelastic behavior of corneal material outside the keratoconus zone. Furthermore, the study examined the values of reduced stiffness zone characteristics, including the stiffness reduction factor ψmax, effective radius Rk , and the ratio of maximum and minimum strain intensity in keratoconus of different stages.

The mean age of the patients in the study was 30.16 ± 8.31 years, with 166 men and 90 women participating. The study revealed typical keratotopographic patterns in the examined keratoconus stages, as well as their occurrence frequency. In the 1st stage of keratoconus, the pattern of asymmetric astigmatism was noted more frequently (in 75% of cases). In the 2nd stage, the pattern with an ectasia zone in the lower cornea was observed in 80% of cases, and in the 3rd stage, a centrally located keratotopographic ectasia pattern was found in 42% of cases. Comparative analysis showed that the greatest decrease in stiffness parameter (SpA1) and stress–strain index occurred in the central pattern (by 64% and 46%, respectively), while the least decrease was observed in local corneal radius reduction in the lower cornea (by 42% and 33%, respectively).

The decrease in strength properties in keratoconus occurs in a local area, the size and degree of which are determined by the disease stage. The indicated biomechanical parameters are consistent regardless of the shape and localization of keratotopographic patterns but are relevant to diagnostic specifications using the Corvis ST pneumotonometer, which assesses corneal properties in the apical zone.

To compare the surgical and clinical outcomes of 27-gauge vitrectomy and 23-gauge vitrectomy.

We conducted a single‑center, prospective, randomized study. Fifty‑three patients affected by vitreoretinal interface disorders (epiretinal membranes and macular holes) were randomly scheduled to undergo 27-gauge (28 patients) or 23-gauge (25 patients) pars plana vitrectomy. The presence of any potential factor of increased baseline inflammation or eye anatomy influencing the surgery was criteria for exclusion. The time of surgery, postoperative intraocular pressure (IOP), state of sclerotomy wounds, rate of complications, postoperative pain, and indicators of inflammation were studied. We also introduced a new parameter to compare intraocular inflammation after surgery, given by the change in the number of intraretinal hyperreflective foci (HRF).

The 27-gauge vitrectomy was 1.28 min longer than 23-gauge vitrectomy (P < 0.05). The day after surgery, the mean IOP value was significantly higher in the 27‑gauge group (16.12 mmHg versus 13.04 mmHg in the 23‑gauge group, P < 0.05), but this difference disappeared in successive follow-ups and the sclerotomy wounds closed after 2 weeks in the both groups. The rate of postoperative hypotony did not significantly differ in the two groups (10.71% in the 27‑gauge group and 8% in the 23‑gauge group the day after the surgery, P = 0.94). Less postoperative eye redness was seen in 27-gauge eyes (value 1 on the scale) compared to 23-gauge (value 2 on the scale) (P < 0.05), but there was no significant difference in intraocular inflammation (cells, Tyndall, and number of HRF, P > 0.05 for all).

The 27-gauge vitrectomy may have better outcomes in terms of IOP maintenance and cause less redness after the surgery but with a slightly prolonged surgery time and no other differences under other parameters (inflammation, rate of complications, postoperative pain, visual gain, and closure of the sclerotomy wounds).

To assess the efficacy of autologous platelet‑rich plasma (PRP) injections in suprachoroidal space and subtenon space in cases of retinitis pigmentosa, which is a genetic disease, leading to gradual loss of vision. Till date, no treatment is available.

Seventy-eight eyes of 39 patients of retinitis pigmentosa having visual acuity ranging from reading of Early Treatment Diabetic Retinopathy Study (ETDRS) chart from 1 m onward to patients who were not able to read the ETDRS chart but whose visual acuity ranged from finger count close to face to <1 m were included in the study. The left and right eyes of each patient were randomized as the intervention eye and control eye. 0.2 mL of autologous PRP was injected in suprachoroidal space and 0.5 mL of PRP was injected in subtenon space of the intervention eye taking aseptic precautions. Injections were repeated at 15-day intervals up to 3 injections.

Majority of patients were in the age group of 18–30 years(20 cases) followed by 31–45 years(13 cases) and more than 45 years(6 cases). Intervention eyes showed a statistically significant improvement in visual acuity and multifocal electroretinography (mfERG). Improvement was noted in amplitude density latency and in ring ratio of mfERG. There was a significant improvement in best-corrected visual acuity (BCVA). However, no improvement in mfERG or BCVA was observed in the control group.

Gene therapy may be the ultimate cure for retinitis pigmentosa, but it is unaffordable for many patients due to its high cost. PRP may be recognized as a modality to improve vision and stop further deterioration, especially in cases where functional vision is preserved. Negligible treatment costs and affordability will give power to economically disadvantaged patients.

To assess the effect of oral dextrose versus acetaminophen versus placebo in pain relief in retinopathy of prematurity (ROP) examination.

In this prospective randomized, double-blind controlled clinical trial study performed in the ophthalmology clinic of Shafa Hospital (referral hospital for eye disease), Kerman, Iran, 105 premature neonates with birth weight ≤2000 g and gestational age between 28 and 34 weeks were studied. Pain score measurement with Premature Infant Pain Profile‑Revised (PIPP‑R) during ROP examination in three intervention groups, acetaminophen group (15 mg/kg oral acetaminophen), dextrose group (one cc of oral dextrose 50%), and placebo group (one cc of distilled water), was done.

Out of 105 infants, 33 infants received acetaminophen drops, 35 infants received dextrose drops, and 37 infants received placebo. The mean pain score of the group receiving acetaminophen was 11.39, dextrose 12.17, and placebo 11.54. The acetaminophen group had a lower average PIPP‑R score. This difference was not significant between the three groups (P = 0.38).

Acetaminophen and dextrose in comparison with distilled water did not show a significant difference in reducing neonatal pain during ROP examinations. However, the PIPP-R score in the acetaminophen group was lower compared to the other groups.

To study the prevalence of musculoskeletal disorder(MSD) and the associated occupational risk factors among Indian ophthalmologists, including residents and fellows.

A cross-sectional survey was conducted among ophthalmologists in India using a semi-structured questionnaire in a web-based survey. The questionnaire was prepared in English after extensive literature research and consulting with subject experts. It was pretested on ten ophthalmologists and after confirming that there were no ambiguities, the questionnaire was circulated. After providing informed consent online and ensuring the confidentiality of information, respondents could fill out the questionnaire containing questions to assess demographic details, risk factors, and musculoskeletal symptoms.

We received 551 valid responses, out of which 74.77% reported musculoskeletal symptoms since starting practice in ophthalmology. We found a statistically significant association of work‑related MSD with greater hours of practice, a higher number of hours of surgery, and a larger patient load. The self-reported symptoms were maximum in lower back (56.55%), followed by neck (49.03%), upper back (38.59%), and shoulder (23.79%). As a remedial measure, 58.98% resorted to rest while only 8.98% consulted orthopedist. Only 46% were aware of good ergonomic practices. Surgery (74.5%), indirect ophthalmoscopy (51.69%), and slit-lamp examination (50.73%) were reported as the major culprits. Respondents declared an interference with personal life (39.56%), with work (33.74%) as well as having caused psychological stress (43.2%) due to work-related MSD.

A vast majority of our respondents reported work-related MSD. Major risk factors were hours of practice, hours of surgery, higher body mass index, sedentary lifestyle, and higher patient load. The awareness of ergonomic practices was low.

To report a case of multiple bilateral retinal pigment epithelial detachments(PEDs) in a woman with systemic lupus erythematosus(SLE).

Case Report.

A 28-year-old female with mild blurred bilateral vision in both eyes (OU) without pain or any other symptom was admitted to the hospital due to worsening renal function and uncontrolled high blood pressure (HBP). Best-corrected visual acuity (BCVA) was 20/30 and 20/40, right and left eyes, respectively. She had SLE, glucose‑6‑phosphate dehydrogenase deficiency, and immune thrombocytopenic purpura. BP was over 150/90 mmHg for more than 1.5 years, and she used corticosteroids at varying doses for more than 4 years. During hospitalization, she was taking prednisone 60 mg daily as ClassIV lupus nephritis was diagnosed. On fundoscopy, she had a lacy retinal pattern, remarkably on the macula in OU. Spectral-domain optical coherence tomography revealed multiple bilateral serous PEDs and pachychoroid. Angiofluoresceinography displayed multiple pooling hyperfluorescence areas. Six months afterward, while she was on prednisolone 10 mg daily, and antihypertensive medications, BCVA was improved to 20/25 OU. Nevertheless, she had no retinal or choroidal changes. Her findings could be related to SLE choroidopathy, central serous chorioretinopathy-like disease, and/or hypertensive choroidopathy.

Ocular involvement affects nearly one‑third of SLE patients. The findings are variable and can include nearly any part of the eyeball. Multiple bilateral PEDs have been described in the literature; however, in this case, it is probably multifactorial and not only related to SLE.

To describe a case of lamellar cataract in a child with a history of neonatal hypoglycemia and illustrate the importance of meticulous history-taking in children with cataracts, especially before planning surgery.

A single case report.

A 7-year-old girl with a history of neonatal hypoglycemia and ketoacidosis with high suspicion of a primary defect in ketone body utilization who presented with bilateral progressive blurred vision. Her best-corrected visual acuity (BCVA) was 20/200 in her right eye (OD) and 20/400 in her left eye (OS). Slit-lamp examination showed the presence of bilateral dense lamellar cataract. Fundus examination was unremarkable in both eyes(OU). She underwent cataract surgery with intraocular lens implantation under general anesthesia without prolonged fasting. Final BCVA was 20/82 in OD and 20/63 in OS.

Our aim through this case is to emphasize the importance to screen for episodes of hypoglycemic attacks in children with infantile cataracts.

To describe a rare case of hypotony and anterior uveitis following dual therapy with nivolumab and ipilimumab for metastatic melanoma.

Case report.

Here, we present the case of a 64-year-old man taking nivolumab and ipilimumab dual therapy for BRAF+ (v-raf murine sarcoma viral oncogene homolog B1) metastatic melanoma. After treatment for 3 months, he presented to the ophthalmology clinic with bilateral intraocular pressures of 1 mmHg, bilateral keratic precipitates, cataracts, posterior synechiae, and anterior chamber inflammation. He improved with topical medications and the cessation of immunotherapy.

Immunotherapies are a novel class of chemotherapy that has increased in prevalence for the treatment of numerous malignancies. There are many rare complications from these medications that are sparsely reported. Knowledge of ocular hypotony as a potential consequence of nivolumab and ipilimumab is important, particularly as it may arise months after treatment initiation and necessitate immunotherapy cessation.

To evaluate the safety and histological findings of intravitreal injection of ketamine in rats.

Each rat received a total volume of 0.1 ml of ketamine 0.01 mol/L (5 rats as ketamine group) or a total of 0.1 ml of normal saline 0.9% (5 rats as control group) under general anesthesia in a sterile condition. A histology assessment was performed 1 month after the intravitreal injection.

Lens opacity, necrosis, and atrophy of retinal layers and optic disc were not seen in five specimens in the ketamine group and five in the normal saline group. There was no inflammation in the vitreous, retinal layers, choroid, optic disc, and optic nerve in both groups.

Intravitreal injection of ketamine in a special dose has no obvious adverse effect on diverse intraocular tissue.