مجله چشم پزشکی بینا
سال دوازدهم شماره 4 (تابستان 1386)

To determine the frequency and severity of retinopathy of prematurity (ROP) among singleton and multiple-birth neonates referred to Farabi Eye Hospital, Tehran-Iran. We reviewed the records of 99 consecutive neonates from multiple-gestation pregnancies including 68 twins, 26 triplets and 5 quadruplets who were screened for ROP during 2002-2004. The frequency, severity and risk factors of ROP were determined. The results were compared with a group of singletons who did not differ from the multiple-birth group regarding birth weight, gestational age, oxygen therapy, respiratory distress syndrome, transfusion, sepsis, phototherapy and gender. ROP was present in 12.1% of multiple-birth neonates compared to 15.1% in singletons (P=0.53). Threshold ROP was present in 6.1% of multiple-birth neonates and 7.1% of singletons (P=0.62). ROP was detected in 60% of quadruplets vs 9.6% of twins and triplets with threshold disease in 40% of quadruplets compared to 4.2% in twins and triplets. Logistic regression analysis revealed no statistically significant differences in frequency and severity of ROP among subgroups of multiple-gestation pregnancies (P= 0.79). The higher frequency of ROP among multiple-birth neonates is due to lower birth weight and gestational age but there is no significant difference between multiple-births and singletons in terms of frequency and stages of ROP. Screening for ROP in multiple pregnancy births may be conducted according to the same standard protocols as for singletons.

To determine the incidence of retinopathy of prematurity (ROP) and to evaluate the possible neonatal risk factors for ROP. This cross-sectional study included all premature infants born at hospitals affiliated to Tehran Medical University, Tehran-Iran who were referred within 4-6 weeks after delivery to Farabi Eye Hospital from 2004 to 2005. Inclusion criteria were birth weight (BW) < 1500 g or gestational age (GA) ≤ 32 weeks. One-hundred and forty-seven infants (74 male, 73 female) were included in this study. ROP was present in 44 (29.9%) newborns (8.8% in prethreshold and 21.1% in threshold stage). Mean GA was 30.30±2.33 wk and mean BW was 1385.82±355.91 g. A significant association existed between the incidence of ROP and low gestational age (P< 0.001), low birth weight (P< 0.001), oxygen therapy (P= 0.033), bronchopulmonary dysplasia (P= 0.001), respiratory distress syndrome (P= 0.00 1) and blood transfusion (P= 0.013). There was no significant association between ROP and sex, multiple gestations, mechanical ventilation, intraventricular hemorrhage, sepsis and phototherapy. In multivariate logistic regression analysis, only gestational age (P=0.002), bronchopulmonary dysplasia (P=0.006) and phototherapy (P=0.031) remained significant risk factors for ROP. The incidence of ROP in this study is higher than previous studies in our center. This may be due to advances in Neonatal Intensive Care Unit equipment and surveillance. Suitable criteria for ROP screening seem to be GA < 32 wk or BW < 1500 g. Newborns with 1500 g < BW < 2000 g or GA> 32 wk who may be at high risk for ROP should also be screened.

To evaluate the analgesic effect of topical sodium diclofenac 0.1% during pan-retinal photocoagulation (PRP) in patients with proliferative diabetic retinopathy (PDR). Two-hundred informed patients (102 male, 98 female) with PDR were enrolled in this randomized controlled double-masked clinical trial. The treatment group received sodium diclofenac 0.1% eye drops and controls received artificial tear 30, 60 or 90 minutes before laser therapy in a masked and random fashion. Pain level was evaluated immediately after PRP using the Scott’s visual analogue scale. Mean patient age was 53.6±14.2 (range 20-82) years. Average pain level was 46% in the treatment group vs 77% in controls (P<0.0001, t-test). Average pain level was 42% in female vs 46% in male subjects in the treatment group (P=0.014, t-test). There was no correlation in either group between pain level and age, number of laser spots, time interval from application of the drops to laser treatment (30, 60 or 90 minutes) and using daily aspirin. Using topical sodium diclofenac 0.1% before PRP in patients with PDR is a useful method for pain reduction.

To evaluate the histopathologic features of optic neurotomy with microvitreoretinal (MVR) blade and excimer laser in cadaver eyes. Optic neurotomy was performed in 11 cadaver eyes using 20-gauge MVR blade and in three cadaver eyes with pulsed xenon chloride (XeCl) excimer laser (308 nm) via monofile light-conducting fiber with a core diameter of 200 microns. After tissue processing, hematoxylin and eosin stained slides were used to evaluate the posterior segment of the globes, including the optic nerve head. None of the cases in the MVR neurotomy group had scleral macro- or micro-perforation and no injury was induced to the central retinal vein or artery. In 10 cases, the distance between the neurotomy site and the central retinal vessels ranged from 50 to 500  at all histologic levels. In one remaining case this distance was approximately 10 on two histologic sections and about 200  at a third level. Intra-neural hemorrhage was found in 18% of cases. Neurotomy was successfully induced in two of three cases attempted with the excimer laser. In one case, due to cloudy media, it was not apparent whether the laser successfully induced the neurotomy and no neurotomy was evident on sectioning. MVR induced optic neurotomy is an effective procedure to create scleral outlet relaxation, without significant surgical complications such as scleral perforation or central retinal vascular injury. This preliminary study also demonstrates that the XeCl excimer laser can make non-mechanical cuts with relative ease and reliability.

To determine hearing thresholds at sound frequencies important for speech comprehension in subjects with ocular pseudoexfoliation (PXF) and to compare them with that of controls without PXF. Eighty-three subjects with ocular PXF and 83 age and sex matched controls without PXF were enrolled in this case-control study. Pure tone audiometry (bone conduction) was performed at 1, 2 and 3 kilohertz (KHz) in all subjects. Thresholds were compared to an age and sex stratified standard (ISO7029) and between study groups. Hearing loss was defined as sum of tested hearing thresholds (HTL-1,2,3) lower than the ISO7029 standard median. The study included 60 male and 23 female subjects in each group. Hearing loss was present in 147 of 166 (88.6%) examined ears in the case group vs 89 of 166 (53.6%) ears in the control group (P<0.001; odds ratio [OR] = 6.69; 95% confidence interval [CI], 3.49-11.79). Overall 78 subjects (94.0%) in the case group vs 58 subjects (69.9%) in the control group had hearing loss in one or both ears (P< 0.001; OR=6.72; 95%CI, 2.42-18.62). Hearing thresholds at each of the examined frequencies and the HTL-1,2,3 were also significantly higher in individuals with PXF. Although glaucoma was significantly more common in subjects with PXF (51.8% vs 22.9%, P<0.001), it was not associated with hearing loss in any of the study groups. Hearing thresholds at frequencies which are important for speech comprehension are significantly worse in individuals with ocular PXF as compared to matched controls. This finding may support the multi-organ nature of PXF syndrome.

To evaluate the etiology of cataracts in children less than 3 years of age particularly the association of rubella virus infection and galactosuria with congenital cataracts at Khalili Hospital, Shiraz-Iran from 2003 to 2006. This prospective study included 46 patients less than 3 years undergoing lensectomy for the management of significant cataracts. Lens aspirate specimens were obtained from some cases. Serum samples for detection of anti-rubella IgM and IgG antibodies and urine samples for detection of galactose were also obtained. Out of 46 patients, 78.3% had congenital cataracts and 21.7% had traumatic cataracts. Patients with congenital cataracts were male in 45% and female in 55% with mean age of 5.12±5.23 months at the time of diagnosis. In the congenital cataract group, 2.8% had history of failure to thrive and 16.7% had low birth weight; 80.6% had bilateral and 19.4% had unilateral cataracts; 77.8% had isolated cataracts, 16.7% were associated with other ocular disorders and 5.6% were associated with systemic diseases; 11.1% had family history of congenital cataracts and 10.5% had galactosuria. Rubella virus was isolated from one (5.3%) of 19 cultured lens aspirates. No cases had anti-rubella IgM antibody. Congenital cataract is the most common type of cataracts in children under age 3 years in our area and most of them are idiopathic. The prevalence of rubella induced cataract in our country is less than developing countries but more than developed countries.

To evaluate the 8-year results of excimer laser photorefractive keratectomy (PRK) for myopia in terms of safety, stability and late complications. Of 203 myopic patients who underwent PRK with single-step method using NIDEK EC-5000 excimer laser with 5-6 mm ablation zones at Basir Eye Center, Tehran-Iran from 1996 to 1998, 179 eyes of 98 patients who completed 8 years of follow up were included in this study. Results of follow up examinations at 1, 3, 6 and 12 months and 2 and 8 years after surgery were analyzed. Treated eyes were divided into three groups according to preoperative refractive error: low (≤ -6.00 diopter [D]), medium (-6.10 to -10.00 D) and high (> -10.00 D) myopes. Eight years after PRK, emmetropia (within ±1 D) was achieved in 69.1%, 30% and 46.15% of the low, medium and high myopia groups, respectively. Although a small myopic shift occurred up to 8 years after surgery, myopic regression stabilized in all groups within 24 months and was correlated significantly to preoperative spherical equivalent refraction. Corneal haze occurred in 5% especially in medium and high myopic groups but cleared within two years in 89% of cases. Only one eye lost two lines of best spectacle-corrected visual acuity due to corneal haze. According to this study, postoperative refraction remains stable two years after PRK and most cases of corneal haze clear within two years after surgery. Therefore, PRK seems to be a safe and stable surgical procedure in myopic patients.

To compare tear secretion values following LASIK (laser in situ keratomileusis) and photorefractive keratectomy (PRK).

Patients referred to Aban Eye Clinic (Isfahan, Iran) for refractive surgery were randomly assigned to LASIK or PRK. Exclusion criteria were contraindications for refractive surgery, usage of topical ocular drugs, dry eye and reoperation. Schirmer test was performed pre- and 1, 3 and 6 months postoperatively.

The study included 176 eyes of 88 patients (30 male and 58 female) with mean age of 24.7±3.5 (range 19-34) years. Each group included 44 patients without any statistically significant difference regarding age, sex, mean spherical equivalent and corneal thickness. Mean values of Schirmer test were 13.5±5.3 mm in the PRK group and 14.5±7.1 mm in the LASIK group (P=0.08) preoperatively which reached 11.7±4.2, 12±4.1 and 12.7±5 mm in the PRK group and 13.5±3.6, 14.3±5 and 14.2±5.1 mm in the LASIK group at 1, 3 and 6 months postoperatively, respectively (P=0.07, P=0.09 and P=0.17, respectively). There were 4 cases (4.5%) of dry eye 6 months postoperatively in the LASIK group vs nill in the PRK group (P= 0.04).

Tear secretion decreases following both PRK and LASIK, however it seems to be more severe after LASIK.

To determine the amplitude and facility of accommodation after photorefractive keratectomy (PRK) in myopic subjects. The study was performed on 160 eyes of 80 patients aged 19 to 72 years. Amplitude and facility of accommodation was evaluated before and 2 weeks and one and three months after PRK. Amplitude of accommodation was evaluated by “Minus Lens” method and facility of accommodation was determined using alternate plus and minus lens technique. Overall 67.5% of cases were female and mean age was 26.1±5.4 years. Mean amplitude of accommodation was 3.8±1.4 diopters (D) preoperatively which reached 4.5±1.6 D (P=0.02) two weeks and 4.9±1.4 D (P=0.03) one month postoperatively but remained stable up to three months. Mean binocular facility of accommodation was 5.8±3.4 cycles/minute (c/m) preoperatively which reached 7.4±3.6 c/m two weeks (P<0.001), 9.2±3.4 c/m (P<0.001) one month and 10.0±3.2 c/m (P<0.001) three months postoperatively. The amplitude and facility of accommodation in young myopic patients gradually increases after PRK. Near work and accommodative vision will improve over time.

To evaluate the effect of laser in situ keratomileusis (LASIK) on stereoacuity (SA). In this prospective study, 200 patients scheduled for LASIK were evaluated for SA preoperatively and one week and one and three months postoperatively by Random Dot test. Patients with preoperative SA worse than 480 sec/arc were excluded. Patients included 138 female (69%) and 62 male (31%) subjects. Spherical equivalent was between -0.5 and -12.0 D. Mean preoperative SA was 124.80±124.64 (range 480-15) sec/arc which deteriorated to 138.30±126.48 sec/arc one week after surgery (P= 0.158) and improved to 111.30±112.15 sec/arc (P=0.002) one month and 103.65+112.20 sec/arc (P=0.001) three months postoperatively. Patients with anisometropia had lower SA. Eventually, SA increased in 5 non-amblyopic anisometropic patients. Overall, stereoacuity decreased in 9.5%, increased in 32.5% and remained unchanged in 58% of patients (P=0.007). Despite the overall improvement in mean SA after LASIK, a considerable number of patients experienced decreased SA. It seems that anisometropic patients without amblyopia have a higher chance for improvement in SA.

To compare the effect of religious fasting on basal tear secretion (BTS), tear break up time (TBT) and intraocular pressure (IOP) in Ramadan 2005. One-hundred fifty-six healthy male volunteers less than 40 years of age from Tehran, Zahedan, Ahvaz, Mashhad and Tabriz with no ocular and systemic disease participated in this study. Weight, urine specific gravity, BTS, TBT and IOP were measured at 8:00 AM one week before as well as at 8:00 AM and 5.00 PM in the third week of Ramadan. Mean age of participants was 305.9 years. Duration of fasting was 12-13 hours. Mean TBT, BTS and IOP decreased by 1.8 second (P<0.0001), 2.1 mm (P<0.0001) and 0.5 mmHg (P<0.0001), respectively at 5:00 PM in the third week of Ramadan compared to 8:00 AM one week before Ramadan. IOP reduction was not clinically significant. Significant decrease in BTS and TBT was seen after three weeks of religions fasting.

To evaluate diurnal variations in intraocular pressure (IOP) in normal adult residents of Yazd city. This cross-sectional study was performed on 800 eyes of 400 subjects aged between 20-80 years selected by cluster random sampling from residents of Yazd city during 2004-2005. IOP was measured by Goldman applanation tonometer in the morning (8-9 AM) and evening (8-9 PM). The difference between the two measurements was considered as diurnal variation of IOP. Mean IOP was 14.80±1.83 mmHg in the morning and 11.58±2.0 mmHg in the evening in right eyes and 14.79±1.89 mmHg in the morning and 11.33±2.0 mmHg in the evening in left eyes (P< 0.001). Mean diurnal variation of IOP was 3.23±1.23 mmHg in females, 3.46±1.23 mmHg in males and 3.34±1.05 mmHg, overall (P< 0.001). Morning IOP was higher in 84%, the same in 13.6% and lower in 2.4% compared to evening values. IOP increased with aging. There was no significant difference in mean IOP between males and females. This study revealed that IOP is usually higher in the morning in both eyes and increases with ageing in both sexes.

To evaluate intermediate-term results of Baerveldt tube implantation for treatment of refractory glaucoma in young patients. We retrospectively studied 14 eyes of 11 consecutive patients aged<20 years with refractory glaucoma who underwent Baerveldt tube implantation after 1 to 3 previous surgical procedures. The glaucoma was congenital in eight eyes and following congenital cataract surgery in four eyes, deep vitrectomy in one eye and post-traumatic in one eye. This study included seven male and four female subjects with mean age of 8.6±6.3 (range 2-20) years. Mean follow up period was 38±0.9 months (range 1-4 years). Mean intraocular pressure (IOP) was 35±11 mmHg preoperatively which decreased to 16.5±4.7 mmHg postoperatively (P=0.001). IOP of 5 to 21 mmHg was achieved in six eyes (42.9%) without antiglaucoma medication and in 12 eyes (85.7%) with or without medication. No loss of light perception or phthisis bulbi occurred during the follow up period. Postoperative interventions included shortening of the tube in one eye (7%), iridectomy at the site of tube due to occlusion by iris in one eye and lens aspiration+PCIOL two years after tube implantation in one eye. Our results show that Baerveldt tube implantation is an effective and safe method for IOP control in young patients with refractory glaucoma

To evaluate the effect of location and size of chalazia on refractive error, corneal topography and visual acuity. This randomized non-controlled clinical trial was conducted on patients with chalazion aged more than 3 years with minimum duration of one month. All patients underwent chalazion excision by the internal or external approach. Two-hundred and fifty-three eyelids of 228 eyes of 195 patients (85 male, 110 female) with mean age of 31±14 (range 7-71) years underwent chalazion excision. Mean duration of presenting symptoms was 4±2.8 (range 1-24) months. Chalazia were single in 172 (88.2%) and multiple in 23 (11.8%) patients. Single chalazia were distributed almost identically in medial, central and lateral sites of lids. Mean difference of pre- and postoperative best-corrected visual acuity was 0.0004 LogMAR (P=0.3). Mean differences in pre- and postoperative values of sphere, difference in keratometry (DK) or cylinder and spheric equivalent (SE) were 0.005 D (P= 0.9), 0.17 D (P<0.001) and 0.006 D (P= 0.08), respectively. Mean differences between pre- and postoperative topographic indices including surface regularity index, surface asymmetry index, keratometry (D) and potential visual acuity (LogMAR) were 0.13 (P<0.0001), 0.09 (P<0.0001), 0.34 (P<0.0001) and 0.05 (P<0.0001), respectively. In comparison of single-central-firm chalazion with multiple-peripheral-soft type chalazia, the difference in mean DK was 0.53±0.15 D (P<0.0001) and the difference of mean changes of SE was 0.45±0.11 D (P=0.2). Mean difference of DK was 0.1±0.06 D in upper lid (P= 0.03) and 0.02±0.03 in lower lid (P=0.1). Excision of chalazion can decrease corneal astigmatism and irregularity, which is more prominent in single-central-firm and upper lid chalazia. In children who are at risk of amblyopia, any attempt to improve the refractive state is worthwhile.

To determine the frequency of otolaryngological disorders in patients with congenital nasolacrimal duct obstruction (CNLDO) as compared to controls. In this case-control study, 80 children with CNLDO (cases) and 80 children without CNLDO (controls) were examined for ophthalmological and otolaryngological dosirders. Data analysis was performed using Pearson Chi-square and Fisher exact tests for frequency values and t-test for mean values. Mean age was 22.7±14.3 (range 5-72) months in the case group and 23.4±13.7 (range 9-72) months in controls (P=0.76). CNLDO was bilateral in 7 (8.75%), left-sided in 23 (28.75%) and right-sided in 50 (62.5%) cases. There were no significant differences between cases and controls in nasal, oral and external ear examinations, however otitis media with effusion (OME) was found in 26.3% of cases vs 10% in controls (P=0.01). Odds ratio for OME in the CNLDO group was 3.2 (95% confidence interval, 1.32-7.75). Tympanometry was type A in 71.3%, type B in 22.5%, type C in 5% and unrecordable in 1.3% of cases compared to type A in 88.8% and type B in 11.2% of controls (P=0.01). The incidence of asymptomatic OME in patients with CNLDO is higher than controls therefore, children with CNLDO may need screening for OME for timely diagnosis and treatment.

To compare the results of two methods of canalicular laceration repair. This clinical trial was performed on 50 eyes of 50 patients with lacerated canaliculi who were randomly assigned to two groups. Direct reanastomosis of the lacerated canaliculus was performed using 8-0 Vicryl suture (25 eyes) and indirect repair was performed by reapproximation of the overlying orbicularis muscle using 8-0 vicryl sutures (25 eyes). Bicanalicular silicon stent intubation was performed in both groups and the stent was left in place for 3 months. Probing and irrigation of both canaliculi were performed at the time of stent removal and three months later to ensure anatomical patency. Probing and irrigation at final follow up showed patency in 25 and 24 eyes in the direct and indirect groups, respectively (P=1). Epiphora was completely relieved in 64% of the direct group and 72% of the indirect group (P= 0.5). Postoperative complications in the direct group vs indirect group were as follows: slit punctum (36% vs 28%, P=0.5), canalicular stricture (16% vs 20%, P=0.7) and granulation tissue (zero vs 4%, P=1). There are no statistically significant differences in success and complications rates between the two methods of canalicular laceration repair. Since reapproximation of overlying orbicularis muscle is technically easier, we recommend this method for inexperienced surgeons particularly in medial portion lacerations.

To report the clinico-pathologic features of an opacified single-piece hydrophilic acrylic intraocular lens (IOL).Patient and A 48-year-old male patient was evaluated for glare and markedly decreased vision in his left eye four years after phacoemulsification and implantation of a single-piece hydrophilic acrylic IOL (Ophthalmed). Best-corrected visual acuity was 20/60 and there was diffuse milky white opalescence of the IOL on slitlamp biomicroscopy. IOL explantation and exchange was performed and the explanted IOL was evaluated at the Eye Bank pathology laboratory by light microscopy. Full-thickness sections of the optic were stained with Hematoxylin and Eosin (H&E), Von Kossa and Gram Twort’s staining methods. Gross examination of the IOL disclosed opacification of the optic and haptics. Microscopic analysis of the sections revealed diffuse fine basophilic granular deposits of variable size within the lens optic parallel to the lens curvature with a clear zone from the optic surface. The deposits were of high calcium content based on the dark brown appearance on Von Kossa staining. This is the first clinico-pathological report of IOL calcification with involvement of optic and haptics in Iran. IOL exchange is an effective treatment in cases with calcified hydrogel IOLs.

To report a case of diffuse lamellar keratitis (DLK) 9.5 months after laser in situ keratomileusis (LASIK) associated with a corneal foreign body.Patient and A 32-year-old male developed DLK two days after removal of an intraepithelial corneal foreign body 9.5 months after noncomplicated LASIK. DLK was eliminated after two weeks of topical steroid application and visual acuity returned to the previous level. Post-LASIK eyes may develop DLK triggered by corneal foreign bodies for a long time after the procedure.

To report a case of unilateral Aspergillus fumigatus interface keratitis after laser in situ keratomileusis (LASIK).Case Report: A 22-year-old woman developed corneal infiltrates located at the flap- stroma interface in her left eye 48 hours after myopic LASIK. The infiltration progressed despite administration of topical fortified antibiotics therefore, the flap was lifted and irrigated with antibiotic solution. Six days after LASIK, visual acuity was counting fingers at 30 cm and a large full-thickness corneal infiltrate was located at the flap-stroma interface. On scanning confocal microscopy, fungal hyphae were observed as high-contrast filaments. The LASIK flap was amputated. Corneal scraping revealed fungal filaments in smears and culture. The fungus was identified as Aspergillus fumigatus. Fortified antibiotic drops were discontinued and intensive topical natamycin and systemic ketoconazole were initiated which controlled the keratitis. Two months after surgery the eye was quiet and vision improved to 20/200. Interface fungal infection after LASIK is a potentially vision-threatening complication. Early lifting of the flap, fungal culture and aggressive antifungal treatment are required to treat this complication. Confocal microscopy may be a fast and safe diagnostic tool in determining the presence of fungal hyphae in vivo within the human cornea.

To report a case of anterior ischemic optic neuropathy (AION) after ingestion of Tadalafil (a drug for management of erectile dysfunction).Patient and A healthy 26-year-old male was referred due to loss of vision and visual field defect in his left eye a few days after using Tadalafil. Visual loss was progressive during the following days. Examination revealed disc swelling which consequently led to optic atrophy. His visual acuity remained low during 12 months of follow up. Tadalafil may predispose to AION even in young men with no vascular risk factors.