فهرست مطالب حشمت الله قنبری

Neurofibromatosis is one of the phacomatosis syndromes that affects different organs in the body and is divided into two types. Neurofibromatosis type 1 can cause eye involvement in various forms, including eyelid, conjunctiva, iris or optic nerve involvement. Involvement of retinal vessels in the form of retinal ischemia is rare in this disease and usually occurs in the second or third decades of life and is controlled by laser treatment or surgery.

Case Report:

 In this report, we introduce a 3-year-old girl with neurofibromatosis type 1 who suffered severe retinal ischemia. This child suffered unilateral retinal involvement in the form of ischemic retinopathy with retinal and vitreous hemorrhage in her left eye, and despite two vitrectomy and retinal laser surgery in the left eye, the retinal involvement progressed and eventually the vision in the left eye was lost.

This report shows for the first-time retinal involvement at a young age in a patient with neurofibromatosis type 1 and its resistant nature.

Mesenchymal stem cells and their secretions contain various factors that have anti-inflammatory properties. The aim of this study was to evaluate the effect of environment derived from stem cell from apical papilla (SCAP) on H2O2-induced retinal toxicity in rats.

Twenty healthy rats were selected for this study, all of which underwent intravitreal H2O2 injection in days 1 and 2 of the right eye. They were then randomly divided into two groups: no other intervention was performed in the first group, but in the second group, on the fifth day, the conditioned medium adjacent to the stem cell of apex of the dental papilla were injected into the vitreous of the right eye. The left eye was considered as the control. After two weeks, all rats were euthanized and histological evaluation was performed.

Retinal thickness in the second group (236.8 ± 20.8 microns) was closer to the control group compared to the first group (199.9 ± 65.3 microns) which was statistically significant.

This study showed that the Conditioned medium adjacent to SCAP contains secretory factors that can have a protective effect on damaged retinal cells and reduce the rate of retinal atrophy.

The aim of this study was to determine the effectiveness of diode MicroPulse laser for improving visual acuity in patients with acute central serous retinopathy. In this clinical trial study, 26 patients with acute central serous retinopathy were selected and divided into two groups of 13; the first group was treated with diode MicroPulse laser; and in the second group, no intervention was performed. Patients in both groups were followed for three months, and visual acuity and recovery were compared between the two groups. The visual acuity (logMAR) before the start of treatment and at the 4th and 12th week of treatment did not show a significant difference between the two groups. In intragroup examination, visual acuity (logMAR) in both groups was significantly different (P < 0.01), but there was no significant difference between the two groups in the intergroup analysis (P = 0.82). Although the results of this study indicate that diode MicroPulse laser improves clinical and anatomical results in patients with acute central serous retinopathy, there is no statistically significant difference compared with spontaneous improvement of these patients.

The aim of this study was to evaluate the epidemiological characteristics of deep vitrectomy surgery at the Feiz Ophthalmology center in Isfahan, Iran.
This was a retrospective descriptive study on patients underwent deep vitrectomy in Feiz Medical Center during 2011 to 2015. Reviewing patient's medical records and information including demographic data was done and the data were analyzed.
Findings: In this study, 2437 patients undergoing deep vitrectomy were reviewed, with a mean age of 54.25 ± 17.40 years, of them, 56.4% were men. 35.2% and 37.2% of patients had visual acuity of hand motion and counting fingers, respectively. Vitrectomy was performed in right eye in 49.2% of the patients. The most common cause of vitrectomy was proliferative diabetic retinopathy (35.3%), followed by retinal detachment (29.3%). 7.5% of patients had a history of previous vitrectomy.
Deep vitrectomy surgery is common in ophthalmology centers and is more common in men, and in the age category of 50-70 years. Generally, proliferative diabetic retinopathy and retinal detachment were the most common causes of deep vitrectomy in this study.

Nonarteritic anterior ischemic optic neuropathy (NA-AION) is a disease with serious complications that already does not have any standard treatment. Some studies and experiences had shown that intravitreal erythropoietin injection has a neuroprotective effect. But there are some different and inconsistent results in those studies. So, the aim of this study was determining the effect of intravitreal injection of erythropoietin in treatment of the disease.
In a clinical trial study, 40 eyes (from 38 patients) were selected and randomly divided in two groups. In the first group, 2000 IU erythropoietin was injected in vitreous and the second group did not receive erythropoietin. Visual acuity and visual field were measured before and three months after the treatment and compared between the two groups.
Findings: The mean visual acuity was improved in the treatment group (P Intravitreal injection of erythropoietin in patients with nonarteritic anterior ischemic optic neuropathy leads to remarkable and significant improvement of visual acuity and field 3 months after the injection. So, this treatment strategy is advised in patients with suitable condition and without any contraindication by ophthalmologists. To evaluate the long-term effects, further studies are recommended.

The retinal laser photocoagulation is the gold standard treatment of the proliferative diabetic retinopathy. Nowadays, we can perform panretinal photocoagulation with single spot or pattern scan laser methods. This study aimed to compare the retinal ischemic changes and the retinal neovascularization regression between these two techniques. In a prospective clinical trial study, 146 eyes of 73 patients with proliferative diabetic retinopathy was enrolled. One eye of patients was treated with single spot laser photocoagulation randomly and other eye was preserved for pattern scan laser photocoagulation. The changes of retinal ischemia on the basis of noncapillary perfusion and the regression of neovascularization on the basis of amount of leakage on fluorescein angiography were compared between the two groups after 6 months. There was no significant difference in the retinal neovascularization regression of disc and elsewhere in eyes treated with pattern scan (P = 0.26) or single spot laser (P = 0.31). While the areas of the retinal ischemia progression was significantly higher (9 cases) in group treated with pattern scan in comparison to other group (2 cases) (P = 0.02). The areas of retinal ischemia progression were higher after treatment with pattern scan laser compared to single spot laser. Future researches are recommended to find a better modality than the pattern scan to induce regression of the retinal ischemia similar to the single spot laser technique.

To analyze the clinical patterns and etiologies of uveitis in Isfahan. The records of 2016 patients with uveitis who had been referred to the Feiz tertiary eye care center, Isfahan, between 1999 and 2013 were classified and analyzed with respect to demographic, clinical, anatomical, and etiological characteristics. At the onset of uveitis, the mean patient age was 33.76 years. Female to male ratio was 1.2/1.0. Anterior uveitis was the most common diagnosis (42.9%) followed by posterior uveitis 21.42%), intermediate uveitis (19.3%), and pan uveitis (16.31%) in descending order. Overall, non-infectious causes were more frequent etiology of uveitis (76.5%) as compared to infectious causes. Up to 43.89% of the patients had no identified etiologies. The most common known etiology was toxoplasmosis, followed by Behcet disease and Fuchs’ heterochromic iridocyclitis (FHIC). The most common etiology was idiopathic 50%) and FHIC (32.8%) in anterior uveitis, toxoplasmosis (91.1%) in posterior uveitis, idiopathic (81.5%) in intermediate uveitis, and Behcet disease (48%) and idiopathic (32%) in posterior uveitis. In 15.62% of cases, a systemic disease was diagnosed which included Behcet disease (the most common non-infectious systemic disease) and toxoplasmosis (the most common infectious systemic disease). Considering the course of uveitis, 49.6% were chronic. In 87.5%, uveitis was non-granulomatous. Significant differences were seen in the clinical and etiologic pattern of uveitis in Isfahan. For example, a higher frequency of uveitis caused by Toxoplasmosis, Behcet and FHI was observed. Environmental, genetic and geographical factors may contribute to this observed difference.

To report a case of endogenous Klebsiella endophthalmitis associated with liver abscess in Iran.Case report: A 79 year old man was referred with chief complaint of left eye pain and visual loss. The patient had conjunctival hyperemia, corneal edema, hypopyon and severe vitreous cellular reaction in the left eye and yellowish conjunctival discoloration which was apparent in the right eye. Abdominal CT scan revealed a right liver lobe abscess that underwent percutaneous liver biopsy under sonography guide. Blood, vitreous and liver mass cultures revealed Klebsiella Pneumonia growth. The patient was diagnosed as a case of endogenous Klebsiella endophthalmitis secondary to bacteremia associated with liver abscess.

This report suggests that rather than being confined to Far East, endogenous endophthalmitis secondary to liver abscess due to Klebsiella pneumonia may be a global problem.

To report a case of acute retinal necrosis following herpetic encephalitis.Case Report: A 25-year-old male presented with pain and visual loss in his left eye. He had herpetic encephalitis 1 month prior to the visual symptoms. Ophthalmologic examination and paraclinical evaluation disclosed acute retinal necrosis. Herpetic encephalitis may be a risk factor for acute retinal necrosis. The virus may reach the eye by transaxonal route.

To evaluate ophthalmologists’ sitting position during ocular examination and surgery and to evaluate any correlation between musculoskeletal disorders and mean work time.

This cross-sectional study was performed on ophthalmologists in Isfahan, Iran in different occupational positions including the office, during slitlamp examination and in the operating room. The evaluation included neck angle, lumbar lordosis, pelvic angle and the position of lower leg and foot. Ophthalmologists were asked about spinal and shoulder pains and mean work time in the office and operating room.

Among 73 studied ophthalmologists (including 60 male and 13 female subjects), there were malpositions in neck angle in 43 (58.9%), lumbar lordosis in 36 (49.3%), hip angle in 9 (12.3%), lower leg in 49 (67.1%) and foot in 31 (42.4%) cases. Among 62 ophthalmologists who performed surgery there were malpositions in neck angle in 38 (61.3%), lumbar lordosis in 38 (61.3%), hip angle in 2 (37.1%), knee angle in 43 (69.4%) and foot in 44 (71.0%) cases. There was a significant correlation between spinal pains and mean work time in the office (P=0.02) and operating room (P=0.01).

According to the correlation between spinal pains and work time, it is necessary to educate ophthalmologists for correct sitting position during work.

To report treatment with intravitreal triamcinolone acetonide (IVTA) in a patient with cystoid macular edema (CME) secondary to retinitis pigmentosa (RP).Case Report: A 22-year-old male patient with RP presented with progressive visual loss. Visual acuity was 9/10 in the right eye and 10/10 in the left eye without refractive error. Examination revealed CME in the right eye. After failure of treatment with oral acetazolamide and reduction of visual acuity to 6/10, intravitreal injection of 4 mg triamcinolone acetonide was performed in the right eye. Six weeks later, macular edema resorbed and visual acuity improved to 10/10.

IVTA may be useful for selected cases of CME related to retinitis pigmentosa. Further study on a larger number of patients is warranted to assess the efficacy of this treatment.

To compare the efficacy of treatment with fortified cefazolin-gentamicin versus fortified vancomycin-ceftazidime eye drops for treatment of bacterial corneal ulcers. A double-blind clinical trial was performed on 89 patients with bacterial corneal ulcers who were referred to Feiz Hospital, Isfahan, Iran from 2004 to 2005. Patients were randomly assigned to two groups: one group included 41 patients who received fortified cefazolin-gentamicin eye drops and the other group included 48 patients who received fortified vancomycin-ceftazidime eye drops. Patients were evaluated in terms of time for re-epithelization, reduction of stromal infiltration and reduction in anterior chamber inflammation as well as culture results and drug complications. The patients included 57 (64%) male and 32 (36%) female subjects. Cultures were negative in 46%. Re-epithelization time was 13.2±3.1 days in the cefazolin-gentamicin group and 9.6±2.7 days in the vancomycin-ceftazidime group (P=0.01). Time for reduction of stromal infiltration and corneal ulcer treatment was 17.7±4.3 days in the cefazolin-gentamicin group vs 13.8±3.6 days in the vancomycin-ceftazidime group (P=0.04). The most common complaint of patients was eye burning in 73.1% of cases in the cefazolin-gentamicin group and 62.9% of cases in the vancomycin-ceftazidime group (P=0.007). Fortified vancomycin-ceftazidime eye drops are more effective than fortified cefazolin-gentamicin eye drops for the treatment of bacterial corneal ulcers and seem to entail fewer adverse effects.

To evaluate the specifity and sensitivity of ocular sonography in the diagnosis of retinal detachment in the presence of vitreous hemorrhage. This cross-sectional study included 47 (23 right eyes and 24 left eyes) eyes of 47 patients (18 male and 29 female subjects) with vitreous hemorrhage suspected of retinal detachment requiring surgery. Preoperative ocular sonography was compared with intraoperative findings to determine the sensitivity and specifity of ocular sonography. Mean age of the patients was 43.8+23.1 years (range 4 months to 81 years). Causes of vitreous hemorrhage included trauma in 20 eyes (42.6%), diabetes mellitus in 9 eyes (19.1%), hypertension in 6 eyes (12.8%), following cataract surgery in 3 eyes (6.4%), following penetrating keratoplasty in one eye (2.1%) and unknown in 8 eyes (17.1%). Visual acuity was counting fingers in 2 (4%), hand motion in 12 (27%) and light perception in 31 (69%) eyes. The diagnostic data of sonography were as follows: sensitivity 87.5%, specifity 64.5%, accuracy 72.4%, positive predictive value 56% and negative predictive value 90.9%. Ocular sonography is a useful diagnostic tool for evaluation of retinal detachment in patients with vitreous hemorrhage.

To report tonic pupil in a patient with ocular siderosis.Case Report: A 12-year-old male patient presented with over-sized right pupil from two weeks before. Visual acuity (VA) was 10/10 in both eyes without afferent pupillary defect. Anisocoria was present with the right and left pupils, measuring 5 and 3 mm in diameter, respectively. Anisocoria was greater in bright light and there was a good constriction of right pupil in response to 0.1% pilocarpine. A metallic foreign body was found on funduscopy and orbital X-Ray. The patient was lost to follow up. Two months later he returned with VA of 6/10 in the right eye. Tonic pupil was still present and pigmetary changes were seen on fundus examination. A foreign body measuring 1.5×1.5 mm in size was extracted with deep vitrectomy. Anisocoria and signs of tonic pupil resolved completely six months after surgery but a faint posterior subcapsular cataract was detected. Best-corrected visual acuity was 7/10 at final follow-up. Ocular siderosis can present with a tonic pupil and should be considered in the differential diagnosis of this condition.

To evaluate the efficacy of pretreatment with diclofenac sodium 1% eye drop for prevention of post-cataract surgery ocular inflammation.

A double blind clinical trial was performed on 111 patients who were scheduled for phacoemulsification and intraocular lens implantation (PE+IOL) at Feiz Hospital, Isfahan-Iran. Cases with traumatic cataract and complicated surgery were excluded. Patients were randomly assigned to three groups: (1) controls; (2) treatment with one drop of diclofenac sodium 1% QID one day before surgery; and (3) treatment with one drop of diclofenac sodium 1% QID for three days preoperatively. All eyes received topical steroid and antibiotic, postoperatively. Postoperative anterior chamber (AC) reaction, ocular pain, burning, red eye, atonic mydriasis and intraocular pressure were evaluated on days 1, 3, 14 and 30.

The study included 70 male and 41 female subjects with mean age of 61.03+8.35 years. Ocular pain was significantly more prevalent and severe in controls compared to other groups on postoperative days 1, 3 and 14. AC reaction was also more prevalent and severe in controls than the other two groups only on the first postoperative day. The prevalence and severity of red eye on days 1, 14 and 30 postoperatively were higher in controls compared to the two other groups without any difference by the third postoperative day. Eye burning was more prevalent in the control group than the other two groups only on days 1 and 3. The active treatment groups had no difference in terms of the above-mentioned characteristics at any stage; except for AC reaction on the first postoperative day which was more severe in the one-day treatment group compared to the three-day group. There was no significant difference between the three groups regarding relative miosis intraoperatively. Postoperative changes in intraocular pressure were within normal limits in all groups.

Pretreatment with diclofenac sodium 1% can reduces the incidence and severity of post-cataract surgery AC reaction, eye burning, red eye and ocular pain, particularly during the first postoperative week.

To evaluate the efficacy of silicone oil injection after deep vitrectomy in infectious endophthalmitis regarding visual acuity. This single-blind randomized clinical trial was performed on 50 cases of infectious endophthalmitis undergoing deep vitrectomy. Patients were randomly assigned to two groups: in one group silicone oil was injected into the eye at the end of the operation (silicone group) and in the second group the eye was formed with balanced salt solution (non-silicone group). All patients were followed for more than six months. The underlying cause of endophthalmitis was cataract surgery in 23 patients (46%د), trauma in 20 patients (40%), bleb-associated endophthalmitis in 3 patients (6%), corneal graft in 2 patients (4%) and endogenous in 2 patients (4%). Mean visual acuity was 2. 1 LogMAR in the silicone group and 4. 0 LogMAR in the non-silicone group (P< 0. 0001). Silicone oil injection may be beneficial in terms of visual outcomes in deep vitrectomy for infectious endophthalmitis.

To determine whether angiotensin II levels in aqueous humor is related to diabetes mellitus and to evaluate the effect of captopril.

In a case-control study, aqueous humor samples were obtained during cataract surgery from 58 eyes of 58 patients, of which 37 were diabetic. From these latter subjects, 16 had taken captopril (captopril group) and 21 had not taken any angiotensin converting enzyme (ACE) inhibitor (non-captopril group). Angiotensin level was assessed by radioimmunoassay. Severity of macular edema was evaluated by clinical examination after surgery. Mann Whitney U test was used to assess the statistical difference of mean angiotensin II and Hb A1C levels between the groups and Spearman's rank-order correlation coefficient was used to evaluate the correlation between aqueous levels of angiotensin II and severity of macular edema.

The aqueous level of angiotensin II was significantly higher in diabetic patients (31.07.3 pg/ml) compared to non-diabetics (6.282.8 pg/ml). (P<0.0001) Aqueous concentration of angiotensin II in the captopril group (16.36.5 g/ml) was significantly lower than in the non-captopril group (75.739.36). (P<0.0003) Severity of macular edema was significantly lower in the captopril group as compared to the non-captopril group such that 68.75% of the captopril group vs 33.3% of the non-captopril group had no macular edema (P<0.005).

These findings suggest that the aqueous level of angiotensin II is significantly correlated with the severity of macular edema and may have a role in pathogenesis of macular edema in diabetic patients. It seems that modulation of the renin-angiotensin system may become a very important target for medical treatment in patients with diabetic macular edema.

To report complications involving the posterior segment after laser assisted in situ keratomileusis (LASIK) in 5 myopic patients ranging in age from 26 to 38 years. Patients and Case one developed bilateral cilioretinal artery obstruction in association with ischemic optic neuropathy. Case two presented with nonsimultaneous bilateral delayed-onset optic neuropathy. In case three, aggravation of the symptoms and signs of Stargardt's maculopathy was noticed. Case four showed rapid progression and worsening of diabetic retinopathy in both her eyes. In case five, early onset unilateral macular hemorrhage was observed. The increased intraocular pressure during LASIK surgery may disturb blood flow in posterior ciliary arteries and choroid. The deleterious effect of LASIK on ocular circulation may result in sight threatening complications in predisposed patients.

Cataract surgery is common and one of the most common surgery techniques is extra capsular cataract extraction (ECCE). The most important factor in recovery of visual acuity after cataract surgery is postoperative astigmatism. In this study the resulted astigmatism of cataract surgery sutured by two methods of running and separate was compared. Patients were operated as ECCE and most of them with Pc Iol implantation and then all of them were sutured with Nylon 10.0. Corneal sutures of 104 cases were running and of 53 cases were separated. 39% of patients were women and 61% were men. The mean of preoperative astigmatism was 0.11 diopter. The mean of postoperative astigmatism one day after operation was 5.19 diopter (running: 4.7; separated: 5.7), and 3 months after operation was 1.58 diopter (running: 1.12; separated: 2.05). From the fourth week after surgery the difference between the two methods was significant. According to above data, running sutures are better tolerated by patients and induce less postoperative astigmatism.