مجله چشم پزشکی بینا
سال چهاردهم شماره 2 (زمستان 1387)

To report the efficacy of a single intravitreal injection of bevacizumab (IVB) alone or in com-bination with intravitreal triamcinolone acetonide (IVT) versus macular laser photocoagulation (MPC) as primary treatment for diabetic macular edema (DME). This randomized three-arm clinical trial included 103 eyes of 97 patients with clinically significant DME and no previous treatment. The eyes were randomly assigned to one of the three study arms: the IVB group received 1.25 mg IVB (37 eyes), the IVB/IVT group received 1.25 mg IVB together with 2 mg IVT (33 eyes), and the MPC group underwent focal or modified grid laser photocoagulation (33 eyes). Primary outcome measure was change in best-corrected visual acuity (BCVA). Changes in BCVA (logMAR) at 12 weeks were -0.22±0.23, -0.13±0.31 and +0.08±0.31 in the IVB, IVB/IVT and MPC groups, respectively. The marginal regression model based on generalized estimating equation analysis demonstrated that changes in visual acuity was statistically significant in the IVB group at both 6 (P<0.001) and 12 (P=0.024) weeks but only at 6 weeks in the IVB/IVT group. Significant decrease in central macular thickness (CMT) was observed in the IVB and IVB/IVT groups at 6 weeks. Up to 12 weeks, IVB treatment in eyes with DME yielded better visual outcome than laser photocoagulation, although it was not associated with a significant decrease in CMT. IVT seemed to have no further beneficial effect in combination with IVB.

To evaluate the results of Verteporfin photodynamic therapy (PDT) in vasoproliferative tumors (VPT) of the retina and retinal capillary hemangiomas (RCH). In a retrospective case series, 6 tumors in 5 eyes with VPT, and 3 RCH in 3 eyes underwent PDT which was performed using intravenous Verteporfin. Eyes were evaluated for tumor regression, final best-corrected visual acuity (BCVA), and final retinal status. Patients were followed for a mean period of 7.1±3.9 months. Mean number of PDT sessions for each tumor was 1.33 (range 1-2). Overall, mean BCVA improved from 1.7±1.06 to 0.88±0.8 logMAR (P=0.017). Tumor thickness decreased from 3.53±0.83 to 1.73±0.73 mm (P<0.001). Subgroup analysis revealed improvement in BCVA and tumor thickness in the VPT group (P=0.04). However, in the RCH group, there was no statistically significant improvement in BCVA (P=0.43) despite significant reduction in tumor thickness (P=0.024). A favorable outcome characterized by improved or unchanged visual acuity was achieved and the tumor regressed in all eyes. Subretinal fluid was absorbed in all eyes except for one eye with preoperative proliferative vitreoretinopathy. Vasoproliferative tumors and retinal capillary hemangiomas can be treated effectively by Verteporfin PDT and a favorable outcome can be expected.

To evaluate the visual outcomes and complications of low power transpupillary thermotherapy (TTT) in patients with neovascular age-related macular degeneration (AMD). The study included 20 eyes of 17 patients. Diagnosis of exudative AMD was established on the basis of fundus examination and fluorescein angiography (FA). TTT was performed using a diode laser at 810 nm wavelength, spot size of 2.5 to 4 mm and duration of 60 seconds for each spot with power settings between 300-600 mw (20% reduction). Follow-up visits were scheduled 1 and 6 weeks and 1, 3 and 6 months after the procedure and yearly thereafter. Patients were followed for at least 6 months. Cases with persistent leakage from CNV in late frames of FA were referred for another treatment option. Patients included 10 men (12 eyes) and 7 women (8 eyes) with mean age of 70.71±9.8 (range 50-84) years. Baseline best-corrected visual acuity (BCVA) ranged from 20/50 to 20/1300. Post-TTT regression of leakage (clinically and angiographically), and improvement or stabilization of visual acuity, was not statistically significant (P=0.14). Post-TTT complications included subretinal prepapillary hemorrhages in 2 eyes, vitreous hemorrhage in 2 eyes and macular infarction in one eye. At final follow-up, fibrosis of the CNV was detected in 7 (35%) eyes and flat chorioretinal atrophy with hypopigmentation was seen in 11 (55%) eyes. There was no significant difference between cases with flat atrophy and those with fibrous scars in terms of BCVA (P=0.91). Subgroup analysis showed that patients with better visual acuity (≥20/60) had poorer visual outcomes after TTT (P=0.03). Overall, in spite of the low threshold, visual acuity remained unchanged or decreased. Although TTT can occlude choroidal neovascularization, it could not prevent retinal complications and occurrence or progression of chorioretinal atrophy or subretinal fibrosis.

To compare ipsilateral and contralateral carotid wall thickness in patients with acute unilateral non-arteritic anterior ischemic optic neuropathy (NAION). This prospective case series included 17 (10 male and 7 female) patients with unilateral NAION of less than 8 week's duration who underwent B-mode ultrasonography to measure intima-media thickness (IMT) in the common carotid and internal carotid arteries. IMT values of the affected side were compared with those on the contralateral side. Mean patient age was 59.6±10.8 (range 45-74) years. Mean interval between onset of NAION and measurements was 27.6±13.2 (range 10-45) days. Mean IMT of both common and internal carotid arteries on the affected side (1.19±0.14 and 1.41±0.29 mm, respectively) was significantly (P<0.001) higher than the non-involved side (0.92±0.11 and 0.83±0.2, respectively). NAION may be accompanied by increased carotid wall thickness. Carotid wall thickness measurement using ultrasound in patients with NAION may be useful to identify concomitant carotid artery disease

To report the outcomes of surgical and non-surgical treatment for sixth nerve palsy and paresis in our center. Hospital records of 33 patients (35 eyes) with sixth nerve dysfunction who were referred to Labbafinejad Medical Center from September 1996 to September 2006 and underwent surgical procedures or botulinum toxin injection were reviewed. Patients were divided into three groups: Group A had muscle surgery without transposition; group B had transposition procedures and group C had botulinum toxin injection. The deviation improved from 50.3±16.8 to 6±9.8 prism diopter (PD) after the first operation and to 2.5±5 PD after the second operation in group A; from 56.9± 24.3 to 5.5±16 PD after the first operation and to almost zero following the second operation in group B; and from 44.3±10.5 to 15±20 PD 6 months following botulinum toxin injection. Head posture and limitations of motility also improved significantly in all three groups. The overall reoperation rate was 18.2%. Various procedures are effective for sixth nerve dysfunction; all improve ocular deviation, head turn and abductive capacity of the eye. The rate of reoperation is not high if treatment is selected appro-priately according to the patient's condition.

To determine the effect of occluding a normal eye on visual acuity, contrast sensitivity and stereopsis in amblyopic school children. Amblyopic children from primary schools of region 2 in Mashhad were identified and referred to Optometry Clinics of Mashhad Medical University through a screening program. Informed consent was obtained from the parents. All subjects underwent an ophthalmologic examination including visual acuity, subjective refractive error, biomicroscopy and funduscopy. Best-corrected visual acuity (BCVA), contrast sensitivity and stereopsis were measured by Snellen E chart, Cambridge low contrast chart and Titmus stereotest, respectively. All tests were repeated 2 weeks, 1 month and 3 months after initial examination. Of 1,947 children, 289 (14.8%) were amblyopic of whom 62 subjects were eventually enrolled for the study. BCVA in the amblyopic eye was less than 3/10 in 25.8% of subjects before treatment however all children had BCVA of 3/10 or better afterwards. Mean BCVA in amblyopic eyes significantly increased from 0.53±0.26 logMAR to 0.24±0.23 logMAR after 2 months of treatment (P<0.001). Mean contrast sensitivity in amblyopic eyes was 68.3 before treatment which improved to 152.5, 138.2 and 198 after 2 weeks, 1 month and 2 months of treatment, respectively (P<0.001). Contrast sensitivity may provide better assessment of visual function as compared to visual acuity. Changes in contrast sensitivity are more sensitive to occlusion therapy as compared to visual acuity. Therefore, contrast sensitivity may yield better evaluation of subclinical changes not detectable by testing visual acuity.

To compare general anesthesia (GA) with local anesthesia (LA) in terms of safety and patient satisfaction. In this interventional case series, 928 consecutive patients who underwent vitreoretinal surgery were included. Data for analysis were type of anesthesia and operation, patient compliance, operating conditions and pain scores. General anesthesia was provided with a standard method and local anesthesia was performed through peribulbar or retrobulbar routes. Selection of the type of anesthesia was determined by patient age and co-morbidities based on the surgeon's opinion. Patients were operated under local anesthesia in 343 (36.9%) and general anesthesia in 585 (63.1%) cases. Mean age was 68.8±7.3 (range 51-78) years in the LA group and 55.9±6.5 (range 43-70) years in the GA group (P= 0.041). ASA (American Society of Anesthetics) physical status score in the LA group was higher than GA group. Patients were in appropriate condition in 96.4% and operating conditions were good or excellent in 98.8%. The majority of patients (97%) said they would choose local anesthesia for their next vitreoretinal procedures. Local anesthesia is a useful and flexible method of anesthesia for vitreoretinal surgery, with excellent patient tolerance, especially in old patients and those who suffer from concurrent diseases.

To compare the efficacy and safety of Ahmed Glaucoma Valve (AGV) implantation in the superior versus inferior quadrants. This prospective parallel cohort study was performed on 106 eyes of 106 patients with refractory glaucoma. Main outcome measures included intraocular pressure (IOP) and rate of complications. Other outcome measures included best-corrected visual acuity (BCVA), number of glaucoma medications and success rate (defined as at least 30% IOP reduction and 5Results