kourosh shahraki

Despite the common association between bilateral retinal hemorrhage and shaken baby syndrome (SBS), unilateral retinal hemorrhage does not necessarily exclude this diagnosis. This study used computational simulations to elucidate the biomechanical phenomena within the eye under asymmetrical shaking forces.

Finite element analysis (FEA) incorporating the vitreous, vitreoretinal interface, retinal layers, and retinal vessels was perform ed under asymmetrical shaking conditions. To assess the stress - strain response at the preretinal, intraretinal, and subretinal locations, we divided the retinal mesh into three equally spaced layers with an element height of 0.083 mm. The remaining space w ithin the retina was filled with the vitreous humor and attached to it via the main retinal vessels extracted from a standard fundus image. The resulting changes in shear stress and intraocular pressure (IOP) were quantified .

The FEA model demonst rated that increasing the rotational radius from 10 cm to 14 cm or 17 cm led to a significant increase in shear stress and IOP across the vitreoretinal interface and within the retinal layers. Specifically, shear stress in the preretinal layer increased by 70.2% (8.0 kPa vs. 4.7 kPa), in the intraretinal layer by 20.0% (5.4 kPa vs. 4.5 kPa), and in the subretinal layer by 6.1% (3.5 kPa vs. 3.3 kPa). Simultaneously, IOP in the central region increased by 157.5% (39.4 mmHg vs. 15.3 mmHg) and in the posterior region by 162.3% (41.7 mmHg vs. 15.9 mmHg) when the rotational radius was increased to 17 cm from 10 cm. Increasing the rotational radius to 17 cm led to more pronounced changes in peak IOPs, with the central region showing a change of 39.4 mmHg and the po sterior region a change of 41.7 mmHg. These results indicate a direct correlation between the rotational radius and the magnitude of IOP changes in the vitreous .

These findings highlight the critical impact of rotational radius on the biomecha nical forces exerted within the eye during asymmetrical shaking events, leading to variations in shear stress and IOP that could contribute to unilateral retinal hemorrhage in SBS. These insights reveal the complexity of diagnosing SBS and emphasize the ne ed for careful consideration of the biomechanical evidence in patients presenting with asymmetrical or unilateral retinal hemorrhage .

Esotropia resulting from sixth cranial nerve palsy can substantially impact an individual’s visual acuity and overall quality of life. If the condition does not resolve in 6–10 months, surgical intervention may be necessary. Various muscle surgeries may be considered, with vertical rectus muscle transposition emerging as the primary option for treatment of complete palsy. However, this technique carries the risk of anterior segment ischemia and post-surgery deviations. Herein, we present a successful treatment of chronic complete sixth nerve palsy using a modified Nishida procedure, without splitting or tenotomy, and an adjunct botulinum toxin A (BTA) injection in the ipsilateral medial rectus muscle.

A 59-year-old woman with a history of traumatic sixth nerve palsy had previously undergone horizontal muscle strabismus surgeries. Following multiple left medial rectus recessions, lateral rectus resection, and BTA injections, esotropia persisted. The worsening of her condition led to emotional distress and impaired social interaction. Initial examination revealed marked esotropia and limited left eye abduction. Magnetic resonance imaging (SIGNA MR750w, GE Healthcare, Waukesha, WI, USA) of the left eye revealed a contracted medial rectus muscle and substantial atrophy of the left lateral rectus muscle. A modified Nishida procedure was performed with an injection of 3 units of BTA into the ipsilateral medial rectus muscle, resulting in improved ocular alignment and stable findings after nine postoperative months. Furthermore, we supported our successful outcome with a summary of similar reported cases of sixth nerve palsy managed using the modified Nishida procedure with or without adjunctive procedures.

Following the modified Nishida procedure, the patient experienced a reduction in diplopia, improved ocular alignment and stability, and an increased binocular diplopia-free field. This case underscores the importance of an individualized approach to complex strabismus cases and highlights the modified Nishida procedure as a valuable tool in such circumstances. In the future, strabismus management will focus on refining personalized treatment and exploring innovative techniques for complex cases. Our success in using a combination of Nishida procedure and BTA injection should be further investigated in large-scale studies.

Diabetic macular edema (DME) affects approximately 10% of patients with diabetes mellitus. This condition can cause blurred or distorted vision, which significantly affects the quality of life of these patients. We evaluated the therapeutic effects of intravitreal methotrexate (MTX) injections on persistent DME.

This prospective interventional case series included patients with confirmed persistent DME that was unresponsive to previous standard treatments. The patients underwent comprehensive eye examinations and macular imaging with optical coherence tomography (OCT). A single intravitreal MTX injection (400 μg MTX in 0.16 mL solution) was administered, followed by patient assessments at 1, 3, and 6 months after injection. Best-corrected distance visual acuity (BCDVA), intraocular pressure (IOP), macular thickness (MT), and central subfield thickness (CST) were measured at baseline and post-injection to evaluate treatment efficacy.

We included 33 eyes of 30 patients with a mean (standard deviation [SD], range) age of 62.7 (8.3, 44 to 77) years, of whom 17 (56.7%) were men and 13 (43.3%) were women. All participants had type 2 diabetes mellitus, with a mean (SD, range) duration of 17.0 (6.8, 10 to 31) years. Most participants (n = 27 eyes, 81.8%) had non-proliferative diabetic retinopathy, and six eyes (18.2%) had regressed proliferative diabetic retinopathy. Four eyes (12.1%) had undergone prior macular laser photocoagulation. The mean (SD) number of prior intravitreal bevacizumab injections was 3.4 (0.8), and 29 eyes (87.8%) had received one intravitreal triamcinolone injection. During the study period, a statistically significant difference was observed in CST (P < 0.05); however, no statistically significant differences were observed in BCDVA, MT, or IOP (P > 0.05). Pairwise comparison revealed a significant decrease in CST at 6 months post-injection compared to the baseline value (P < 0.05). During the investigation period, no side effects of MTX, such as macular edema, retinal tears, vitreous hemorrhage, endophthalmitis, or vision loss, were observed.

A single intravitreal MTX injection significantly reduced CST in patients with persistent DME, without relevant safety concerns. However, no significant improvement in functional outcomes was observed. Therefore, there is no strong evidence to recommend its use as a treatment for pDME. Further studies, preferably randomized clinical trials with long-term follow-ups, are warranted to assess the long-term efficacy, safety, and potential benefits of intravitreal MTX for the treatment of persistent DME.

 The study aims to determine the age- and sex-adjusted prevalence of refractive errors and its related factors among the adult population of southeastern Iran.

 The current study included 9280 individuals aged 35 to 70 years using a multistage random sample method from October 2015 to January 2019 as a part of a Persian cohort study in Zahedan. Uncorrected and corrected vision, objective noncycloplegic, and subjective refraction were measured, with all participants undergoing ophthalmoscopy, slit-lamp biomicroscopy, fundoscopy, refraction, and retinoscopy. Data were analyzed using SPSS version 23.0 statistic software and described as percentage, odds ratio, and 95% confidence interval. Comparisons between groups and relationships among risk factors and refractive errors were performed with chi-square, nominal, and multiple regression analysis.

 The prevalence of low and moderate myopia, high myopia, low and moderate hyperopia, high hyperopia, low and moderate astigmatism, and high astigmatism was 24.2 (95% CI: 22.40 - 25.90), 1.5(95% CI: 0.00 - 3.53), 16.1(95% CI: 14.20 - 17.90), 1.3(95% CI: 0.00 - 3.30), 35.6 (95% CI: 33.90 - 37.30), and 3.8 (95% CI: 1.80 - 5.70) percent, respectively. The prevalence of refractive errors significantly varied across different age groups overall and by sex (P = 0.01). The proportion of refractive errors also significantly differed by education (P = < 0.001). The prevalence of against the rule, with the rule, and oblique astigmatism was 32.8 % (95% CI: 31.10 - 34.20), 42.1% (40.50 - 43.60), and 24.9% (23.10 - 26.60), respectively. The risk of astigmatism was significantly lower in men than in women (OR = 0.75; 95 % CI: 0.60 - 0.90). Based on multiple regression, the risk of myopia (OR = 2.07; 95 % CI: 1.60 - 2.60) and hyperopia (OR = 25.38; 95 % CI: 18.70 - 34.3) was higher in the age group 65 to 75 years compared to the younger group.

 The present study provided valuable information on the prevalence of refractive errors in the adult population in south-eastern Iran. The findings underscore the need for comprehensive eye care services, particularly for older individuals and those with lower education levels. Further prospective research is warranted to explore the factors contributing to refractive errors and to develop effective strategies for its prevention and management.

To report the study protocol, methodology and latest enrollment data of a large epidemiological multi-central eye cohort named PERSIAN Eye Cohort Study (PECS), originating from the ongoing PERSIAN Cohort Study, to investigate the distribution of ophthalmic disorders in different regions and ethnicities of Iran, and determine their associations with various exposures of ophthalmic and non-ophthalmic nature.

A central committee designed the study and equipped six chosen centers (Khameneh, Some’e Sara, Hoveizeh, Yazd, Rafsanjan and Zahedan). A focal point in each center conducted the study under close supervision of the central committee.

This ongoing study was launched in 2014. Out of 65,580 eligible participants of the PERSIAN Cohort, 48,618 individuals aged 35-70 have been enrolled in the PECS (response rate: 74.13%) until June 2021. Slit lamp and fundus photography were performed for 28,702 (59.03%) and 27,437 (56.43%) individuals, respectively.

This large epidemiological multi-central eye cohort can improve our epidemiological knowledge of the prevalent ophthalmic disorders in different regions and ethnicities of Iran, and determine their associations with various exposures of ophthalmic and non-ophthalmic nature. This will be very useful for future planned nationwide and global interventions.

There are limited studies on the normal values of eye protrusion in Iran. Systematic efforts to provide acceptable normal exophthalmometry values for Iranian population are required for a proper approach to orbital diseases. English and Farsi language publications in PubMed, the ISI Web of Knowledge database, Iranian SID, and Iran Medex were searched using the following keywords: “proptosis”, “eye protrusion”, “exophthalmous”, “Hertel exophthalmometer” and “Iran”. Four articles from 1995 to 2010 were found and included in the meta-analysis. Statistical analysis was performed using the Metan command within Stata 15.0 software. It included 3,696 subjects in whom the average eye protrusion was 16.5 mm (95% CI: 15.1–17.8) in men and 16.2 mm (95% CI: 14.6–17.7) in women (P = 0.5). Mean left and right eye protrusion were 16.3 (95% CI: 14.7–18.1) and 16.4 mm (95% CI: 14.8–17.7), (P = 0.3), respectively. While Iranian teenagers (13–19 years old) showed a mean value of 17.1 mm (95% CI: 15.0–19.1), older age group (≥20 years) showed a lower mean eye protrusion of 16.3 mm (95% CI: 14.8– 17.7). Considering the two standard deviations, the highest normal value of eye protrusion in Iranian population is 20.1 mm. In conclusion, Iranian normal eye protrusion values were higher than Asians and lower than Caucasians

To investigate the relation between serum level of vitamin D and dry eye disease.

  In this cross-sectional case-control study, 40 patients with dry eye disease were enrolled.  Dry eye was diagnosed based on the slit lamp examination, tear meniscus height, tear break up time test, ocular surface disease index, and the results of Schirmer test. Forty age- and sex-matched healthy individuals served as controls. The serum level of vitamin D was measured and compared between patients with dry eye disease and controls.

 The mean age was 44.92  ± 11.4 and 44.07  ± 11.29 years in the case and control groups, respectively (P = 0.739). The mean serum level of vitamin D was 21.18  ± 11.83 ng/dl in the case group and 20.54 ± 9.98 ng/dl in the control group (P = 0.793). Ocular surface disease index had a positive correlation with age (r = + 0.363, P < 0.0001), but a negative correlation with the serum level of vitamin D (r = - 0.480, P = 0.002). Other investigated variables failed to demonstrate association with the serum level of vitamin D and dry eye.

According to the present study results, no significant association between vitamin D deficiency and dry eye was detected. However, due to relatively small sample size in the present study further studies are recommended to better investigate this subject.

Eyes are very sensitive to Sulfur Mustard gas (SM) because they have wet surfaces. Considering the late complications of eye due to mustard gas exposure in warfare patients, the present study was conducted to evaluate the late complications of the eye.

In the current descriptive study, we evaluated 300 male patients aged between 40-75 years old whose mustard gas injury period was about 27-32 years before. A complete eye examination by an ophthalmologist was done. The complications were divided in 4 grades: normal, mild, moderate, and severe. The results were reported as x2 and relative frequencies.

Out of 300 warfare patients, 37.5% were aged 46-50 years old, 79% were injured with mustard gas once, 13.4% twice, 6.6% three times, and 1% more than 3 times, 42% had hospitalization, and 77.6% used drugs. The most common symptoms were itching (42.3%), burning (38.3%), and dryness (37%) and the most prevalent complication of the lid was MGD (39.4%). Also, the most prevalent complication of Conjunctiva was vascular anomalies (46.6%), the most common complication of limbus was ischemia (12%), and the most common complication of cornea was epithelial defect (13.4%). Among the prevalent ocular surgeries were punctual occlusion (19.4%), penetrating keratoplasty (PK) (0.33%), tarsoraphy (0.66%), conj.flap (1%), amniotic membrane transplantation (0%), stem cell graft (2.66%), and lamellar keratoplasty (LK) (0.66%), in the order of frequency. The degrees of complications were 53.34% for normal, 33.33% for mild, 9.33% for moderate, and 4% for severe cases.

Conjunctival vascular abnormalities and epithelial defect were the most significant signs among the sulfur mustard chemical war victims. Having reached the mentioned conclusions, it can be stated that mild complications were more than moderate and severe ones.

This study performed to compare the therapeutic effect between topically Na-hyaluronate1% and hydroxy propyl methylcellulose in the treatment of alkaline epithelial corneal defect.
Alkali burn was produced in 30 corneas from 30 New Zealand rabbits, using a corneal trephine 7.5mm. Three groups were randomly divided. Two groups (A, B groups) were treated with topically 4 times a day with Na-hyaluronate1%; hydroxy propyl methylcellulose. The saline-treated group served as a control. The healing of the epithelial defect was followed on a slit-lamp biomicroscope regarding its size everyday up to 17days with fluorescein staining.
Topically Na-hyaluronate1% significantly accelerated the corneal wound healing process compared with physiologic saline solutions & especially compared with hydroxy propyl methylcellulose. topically Na-hyaluronate1% could be used as an effective corneal wound healing adjuvant in alkaline corneal epithelial defect to accelerate the wound healing process and hydroxy propyl methylcellulose is not helpful for corneal epithelial defect treatment.

To compare the outcomes of surgical procedures in the treatment of inferior oblique muscle overaction (IOOA) as a common disorder of ocular motility. This retrospective study was performed on patients with primary and secondary IOOA who underwent three surgical treatment procedures including disinsertion, myectomy and anterior transposition, between 2001 and 2011. Type of strabismus, ocular alignment, presence of pre‑and post‑operative dissociated vertical deviation (DVD), pre‑ and post‑operative degree of IOOA were obtained using specified checklist. A total of 122 eyes of 74 patients with mean age of 13 ± 11.7 (range, 1‑51) years were included in this study. Disinsertion was performed on 12 eyes (9.8%), myectomy in 91 eyes (74.6%) and anterior transposition in 19 (15.6%). Preoperative V‑pattern and DVD existed in 67 and 17 eyes; after surgery they remained in only 10 and 8 eyes, respectively. The success rate (IOOA <+1), in disinsertion, myectomy and anterior transposition groups were 91.7%, 97.8%, and 89.5%, respectively and these measures did not change after 6 months. Overall, 53.3% (n = 65) and 38.5% (n = 47) of eyes had preoperative esotropia and exotropia. Preoperative hypertropia and hypotropia were observed in 16.4% (n = 20) and 3.3% (n = 4) of eyes, respectively. After surgery there were no cases of additional strabismus. However, residual hypertropia was seen in 9 eyes, while preoperative hypotropia increased in one patient who underwent anterior transposition surgery. Esotropia and exotropia were not observed in any surgical treatment groups postoperatively. We conclude that all these three procedures are effective for treatment of primary or secondary IOOA with minimum side‑effects.

To identify the postoperative surgical outcomes and the changes in deviation in patients treated by bilateral medial rectus (BMR) recession for small to large angle esotropia with a minimum follow-up of two years In this retrospective and consecutive case series, we reviewed medical records of 130 patients who had recession surgery for correction of esotropia between 2001-2011 in a tertiary center in Tehran. Patients were excluded if neurological abnormalities or developmental delays were documented and if structural eye abnormalities were present. One month after operation (n=109), there were 85 successful cases (orthophoria or deviation less than 10 prism diopter), 18 cases of undercorrection, and six cases of overcorrection. The success rate at two years after surgery (n=82) was 78.2% with 13.3.% undercorrection and 8.5% over correction. The preoperative angle of esodeviation and patients’ age are found to significantly influence the response to the surgery. Surgery was effective because of high success rate and acceptable alignment after two years follow-up. Dose response increased in patients with larger angle of preoperative deviation, and was lower for patients who were older at the time of the surgery.

Pleural tuberculosis occurs in 4% of newly diagnosed cases of tuberculosis. T-cells have an important role on the immunity against mycobacterial infections and as a result, the level of soluble interleukin 2 receptors (SIL-2R) as a marker of T-cell activation is elevated in patients with tuberculous pleural effusion. In this cross sectional study, the diagnostic accuracy of SIL-2R level was assessed in separating tuberculous from non- tuberculous effusions in Zahedan, Iran. From 112 patients fulfilled entrance criteria for exudative pleural effusion, 88 patients were included and underwent diagnostic procedures to identify the origin of pleural effusion. The SIL-2R was evaluated at various cut-off levels by nonparametric receiver operating characteristic (ROC) curve, and values affording greatest diagnostic accuracy were selected. SIL-2R level in TB group was 9147±3573 while this level in non-TB group was 2724±1326 and the difference was statistically significant (p=0.001). The cut-off point in our study was 4200 U/ml and the area under curve was 0.930 with 95% CI: 0.881–0.979 (p=0.001). The sensitivity and specificity for this level is 86 and 89%. Several factors lead to the variation in the level and cut-off point of SIL-2R in different regions. Our cut-off point was lower than other studies. The level of SIL-2R in patients with tuberculosis is significantly higher than parapneumonic effusions. We suggest that measuring the SIL-2R level in pleural fluid of tuberculous patients is a useful diagnostic tool in diagnosing tuberculous pleural effusion.

To report clinical and pathologic result of a young patient with isolated cavernous hemangioma of conjunctiva Case report: A 26-year-old man who presented with smooth، red، lobular surface mass was seen in the bulbar conjunctiva in temporal side with engorged episcleral and conjunctival vessels around the lesion. Excisional biopsy was performed. Pathologist confirmed the diagnosis of cavernous hemangioma of bulbar conjunctiva. Patient was followed-up for 18 months without recurrence and cosmetic feature was acceptable. Ocular surface is an uncommon site of cavernous hemangioma and isolated conjunctival cavernous hemangioma is rare، but this tumor is considered as a differential diagnosis of conjunctival vascular tumors.

Cardiac troponin I was found to be a sensitive and high specific marker of myocardial injury even in the pediatric population. This study aimed to elucidate the value of serum cardiac troponin I level after cardio-pulmonary bypass and effect of the time of aortic clamp duration on troponin I level. In this descriptive cross-sectional study, serum troponin I level measured before, 0.5 and 24 hours after open heart surgery in one hundred pediatric patients (58 female and 42 male) with mean age of 4.5 years old (15 month to 19 years) undergoing elective open heart surgery for congenital heart disease in Tehran Shahid Rajaei cardiovascular hospital. Patients’ demographic data, surgical procedure, length of intensive care unit stay, inotropic support requirement and their duration of endotracheal intubations and aortic cross clamping time on the troponin level were recorded. Baseline serum troponin level's were less than 0.1 mg/mm, stay of intensive care unit was significantly higher in patients with high troponin I level at 0.5 and 24 hour after surgery (P = 0.005, r = 0.275 and P = 0.001, r = 0.543, respectively). Troponin I level 0.5 and 24 hour after surgery was strongly related to intubation time (P = 0.004, r = 0.258 and P = 0.001, r = 0.473, respectively). Only Troponin I level's in 24 hour after surgery remained significantly predicative of need to Inotropic Agents (P = 0.001, r = 0.637). There was strongly relation between time of cardio pulmonary by-pass and troponin levels 0.5 and 24 hour after surgery (P = 0.001, r = 0.320 and P = 0.019, r = 0.235, respectively). However, aortic cross clamping time affect to troponin I level only 0.5 hour after surgery (P = 0.001, r = 0.402). Evaluation of the cardiac troponin I level in patient undergone open heart surgery represent acute myocardial damage, allows further stratification of risk when combined with standard measures. Post operative troponin I level predicts length of intensive care unit stay, need for inotropic agents, and length of need for inotropic agents and intubation time.

Wandering spleen is a rare condition characterized by increased splenic mobility due to the absence or laxity of its suspensory ligaments that may present as acute abdomen when it is twisted on its pedicle. Herein we report a case of torsion of a wandering spleen in a 24- year-old female patient without any history of trauma. The patient was admitted to emergency ward at February 2008 with clinical findings of acute abdomen. Laparotomy was performed and the infarcted spleen was removed. Although wandering spleen is a rare clinical entity, the possibility of torsion should be kept in mind in the differential diagnosis of acute abdomen to avoid serious complications.

Lichen sclerosus et atrophicus is a chronic skin disease with multiple clinical presentations. It affects women, and less frequently men and children. The disease is usually located in the anal and genital regions. It has a strong association with autoimmune diseases; besides, and immunogenetic studies have demonstrated it's association with HLA DQ7. The disease rarely affects extra-genital regions. The authors report two cases of lichen sclerosus et atrophicus in atypical locations (extra-genital), in which different management was used. High potency topical corticosteroid therapy is reported, with risks, however. Topical immunomodulating agents are described, obtaining favorable clinical responses and decreased risk of atrophy. In this study, we report 52 years old women with extra genital and guttate LSA that was treated with corticosteroid.