Journal of Current Ophthalmology
Volume:19 Issue: 2, Jun 2007

To assess the effectiveness of intravitreal injection of triamcinolone acetonide on macular edema associated with branch retinal vein occlusion (BRVO). Design: A prospective noncomparative interventional case series. Patients & Fourteen eyes of 14 patients with macular edema associated with BRVO were enrolled. In all patients after thorough ophthalmic examination, 4 mg triamcinolone acetonide was injected intravitreally, then all eyes followed at 1 day, 1 week, 1, 3 and 6 months. Ten eyes were followed until 9 months. Central macular thickness was measured with Optical Coherence Tomography (OCT) at baseline and 3 months after injection. Best Corrected Visual Acuity (BCVA) and 1-mm central macular thickness were main outcome measurements. Mean baseline BCVA: 1.33±0.52: logarithm of Minimum Angle of Resolution (logMAR) improved to 0.81±0.56 (P=0.002) at 1 month, 0.65±0.48 (P=0.001) at 3 months, but decreased to 0.85±0.44 (P=0.005) at 6 months. In 10 eyes of 14 eyes that were followed for 9 months, mean BCVA decreased to 1.20±0.48 (P=0.171). A 32% reduction of pre injection value of 1 mm central foveal thickness observed at 3 months (565±199.58µm versus 383.78±145.70µm, P=0.001). Ocular hypertension was developed in six patients that was controlled by topical antiglaucoma medication. Cataract developed or progressed in two eyes. Intravitreal triamcinolone acetonide can decrease macular edema and improve visual acuity in BRVO in short term but further study is required with control group and longer follow up to clarify the benefits and risks of this treatment.

To evaluate the effectiveness of intravitreal triamcinolone acetonide on visual acuity and macular thickness using optical coherence tomography in macular edema associated with nonischemic central retinal vein occlusion (CRVO). Design: A prospective interventional case series. Patients & Twenty eyes of 25 patients with nonischemic CRVO and macular edema with visual acuity of less than or equal to 0.4 logarithm of minimum angle of resolution (logMAR) received 4 mg intravitreal triamcinolone acetonide after baseline examination which included measurement of best corrected visual acuity (BCVA) and intraocular pressure, slit lamp examination, fluorescein angiography, and optical coherence tomography (OCT) of macula. The main outcome measures were visual acuity after 1, 3, 6, and 9 months and 1-mm central macular thickness change at 3 months after injection. Mean duration of symptoms before injection was (83.72±57.60 days). Mean visual acuity significantly improved from baseline 1.34±0.71 (20/400) to 0.67±0.42 (20/100), P=0.000, 0.61±0.42 (20/80), P=0.000, and 0.90±0.62 (20/160), P=0.004, at 1, 3, 6 months, respectively, but decreased to 1.43±0.76 (20/600), P=0.188 at 9 months. A 42.85% reduction observed in mean baseline 1-mm central macular thickness 634.36 ± 212.70 µm to (362.56±199.63 µm, P=0.000) at 3 months. Intravitreal triamcinolone acetonide can significantly be effective in reducing macular edema and improving visual acuity in nonischemic CRVO at least in short term but it is necessary to investigate the risks and benefits of this option with a control group.

Central retinal vein occlusion (CRVO) is the most common vascular event in the eye after diabetic retinopathy. This study was conducted to evaluate the effect of intravitreal triamcinolone (IVT) on acute CRVO. In a randomized sham-controlled clinical trial, 27 eyes with recent onset (less than 2 months) CRVO were randomly assigned to two groups. The treatment group (13 eyes) received 4 mg IVT and the control group (14 eyes) received a sham subconjunctival injection. The main outcome measures were visual acuity (VA), occurrence of neovascularization of the iris (NVI), and central macular thickness (CMT) measured by optical coherence tomography. Examination was repeated 1, 2, 3, and 4 months after intervention. The m ean (standard error) CMT before, 2 and 4 months after injection was 565(50), 259(15), and 290(53) µ in the treatment group and 629(43), 470(62) and 413(59) µ in the sham group, respectively. The 2- month difference was significant (P=0.003). The difference between VA changes (0.39 logMAR) was significant only at 1 month (P=0.013). There was no meaningful difference in the occurrence of NVI between the two groups. The therapeutic effect of IVT on acute CRVO is greatest at months 1 and 2 with regard to VA and macular thickness, respectively, and decreases up to the 4th month.

Chlamydia pneumonia is a known endothelial pathogen in several vascular diseases including atherosclerosis, age-related macular degeneration and non-arteritic anterior ischemic optic neuropathy. Diabetic retinopathy is a retinal vascular disease that may similarly be affected. We serologically investigated the presence of C. pneumonia infection in patients with proliferative diabetic retinopathy. Design: Pilot case-control study. Patients & During a period of 12 months, we examined sera of 27 type I diabetic patients with different stages of diabetic retinopathy for anti-chlamydial IgG and IgA by enzyme-linked immunosorbent assay (ELISA). The IgG seropositivity was significantly different between different diabetic retinopathy groups (P=0.017). Rate of seropositivity was higher among patients with PDR comparing to patients without PDR, with a marginal significance (P=0.062). Although the titer of IgA was negative in all patients (less than 0.357 U/mL), the IgA titer was higher in patients with PDR than those without PDR, reaching the significance at P<0.06 level. C. pneumonia may be an independent risk factor for proliferative diabetic retinopathy.

To develop a guideline for the treatment of incompletely removed histopathologically documented ocular surface neoplasia (OSSN) with mitomycin C (MMC). Through an interventional case series, 17 eyes of 17 patients presented with incompletely removed OSSN were treated according to a protocol using 2-3 alternate 7-day courses of MMC 0.04%. Clinical recurrence was re-treated with the same protocol. All patients had weekly follow up visits to the end of treatment course, then biweekly visits for 3 months, and monthly visits thereafter. Four patients (23.5%) experienced recurrence after the initial treatment, 3 of them responded to re-treatment and were disease-free till the end of follow up. All patients reported mild to moderate redness and irritation which was controlled with lubricants and mild corticosteroid eye drops. No serious ocular or systemic side effects were observed. MMC drop 0.04% used as 2-3 alternate seven-day courses is a safe and effective treatment for OSSN. Attempting more than 2 courses of treatment (up to 4) in the initial regimen may result in lower recurrence rates.

To report the long-term outcome of patients with iridocorneal endothelial syndrome (ICE) who required surgery for glaucoma. This retrospective, noncomparative case series was conducted on 11 patients with ICE who underwent surgery to control their glaucoma between 1992 and 2004 in Farabi Eye Hospital. The first surgery was trabeculectomy with Mitomycin C except in one patient in whom Mitomycin C was not used. If intraocular pressure was not controlled, redo trabeculectomy and alternative procedures such as Molteno tube implantation, bleb revision, and cyclodestructive procedures were performed. Nine patients were female and two were males. The mean age of the patients was 39.4 ± 11.2 years and they were followed for a median of 22 months (minimum: 6, maximum: 146 months). The first surgery in all patients was trabeculectomy with adjunctive Mitomycin C except in one for whom trabeculectomy was carried out without Mitomycin C. Seven (63.7%) patients had intraocular pressure less than 21 mm Hg only one of them was on topical medications. Four (36.4%) of the patients had intraocular pressure less than 21 mm Hg after the first surgery at the last follow up. The IOP was controlled in one patient after the second trabeculectomy and in two other cases it was controlled following other procedures such as bleb revision and cyclodestructive procedures (following the second trabeculectomy). The surgical intervention failed in four patients two of them had intraocular pressure>21 mm Hg after the first surgery and the other two developed no light perception vision despiet Molteno tube implantation. Seven (63.7%) of the patients had visual acuity of ³ 20 /200 at the last visit. In one patient due to corneal decompensation penetrating keratoplasty was done. Glaucoma associated with ICE syndrome can be managed successfully surgically in the majority of cases, however multiple procedures are often needed.

To evaluate the efficacy and safety of pars plana Ahmed valve implant combined with pars plana vitrectomy and endolaser photocoagulation for the treatment of neovascular glaucoma in patients with vitreous hemorrhage. Retrospectively, we evaluated the records of 18 eyes of 17 consecutive neovascular glaucoma patients who had undergone pars plana vitrectomy and pars plana Ahmed valve implant. The patients were followed for a mean time of 14.2 months (range 6 to 28 months). Mean preoperative intraocular pressure with oral and two or three topical antiglaucoma medications was 53.3±10 mm Hg, and mean postoperative intraocular pressure without oral antiglaucoma medication was 16.3±7.1 mm Hg (P<0.0001) at the final visit. Overall success rate was 72.2%, defined as an intraocular pressure of higher than 5 mm Hg and less than 21 mm Hg with or without antiglaucoma medication. A postoperative hypertensive phase occurred in 7 patients (38.8%) of which all but one responded to medical therapy. Visual acuity was stabilized or improved in 77.7% of the eyes. There was one case of each of the following adverse events: mild vitreous cavity hemorrhage, hypotony, choroidal effusion, epiretinal membrane, corneal edema, and corneal ulcer. Two cases developed phthisis bulbi and lost light perception. Pars plana vitrectomy and Ahmed valve implantation seems to be a viable surgical modality in the management of neovascular glaucoma and coexistent posterior segment pathology with a relative low rate of serious permanent postoperative complications.

Patients with infantile or childhood strabismus who do not achieve visual axes alignment early in life are believed to have poor prognosis with respect to the stereopsis. This study investigates the binocularity and stereopsis following delayed surgical alignment in patients with congenital and early-onset strabismus. Patients & 36 patients aged between 6-30 years participated in this study. The inclusion criteria were: constant horizontal deviation of 30 prism diopters (PD) or more, strabismus onset before age 3 and surgical alignment after age 6 years, alignment to within 10 PD of orthotropia after surgery. All patients were examined comprehensively and four binocularity and stereopsis tests including Titmus, Random dot E, Bagolini lenses and Worth 4-dot test were performed for all. Of 36 patients, 20 (55.5%) had binocular vision using Bagolini striated glasses, 14 (38.9%) with Titmus test, 12 (33.3%) with Worth 4-dot test and 8 (22.2%) with Random dot E test. The achievement of stereopsis after visual alignment was statistically significant (P=0.008). Of 14 patients with positive Titmus test, 8 (57.1%) had stereoacuity of 200 sec of arc or better. This study demonstrated that even after delayed alignment of eyes in patients with infantile or early childhood strabismus, some degrees of stereopsis can be achieved in most cases.

Visual loss associated with multiple traumas in the context of road traffic accident, especially when the maxillofacial and orbital areas are not directly injured, is an uncommon occurrence. The possibility of Purtscher’s retinopathy, i.e. retinal manifestation of mechanical trauma elsewhere in the body, as the cause of visual disturbance in these situations can often be overlooked. Patients & We present three cases of Purtscher’s retinopathy where the diagnosis was initially missed. All three patients presented to Accident and Emergency department with visual loss in the left eyes, having sustained compressive chest and/or abdominal injuries in road traffic accidents. None had direct trauma to the orbital region. Serial color fundus photographs, fluorescein angiogram, Goldman visual fields, and electro diagnostic tests were performed on each patient, with a mean follow-up of 8.3 months (Range 6 to 10 months). The correct diagnosis of Purtscher’s retinopathy was made retrospectively in all three cases. Two patients had persistent central scotoma despite complete resolution of the retinal signs. Purtscher’s retinopathy should be considered as a differential diagnosis in all cases of unexplained visual loss associated with multiple traumas. The retinal manifestations of Purtscher’s retinopathy can disappear in a short time interval. A retrospective diagnosis may be difficult in the absence of any fundal abnormalities if the diagnosis is initially missed on presentation.

To report an atypical case of acanthamoeba keratitis. Patients & A 19-year-old girl presented with a history of recurrent herpetic keratitis and a history of short-time contact lens wear. Laboratory work-up for herpetic, bacterial, and acanthamoeba sources were negative and the patient failied to follow up. On later presentation she had corneal necrotizing stromal ulcer needed penetrating keratoplasty. Histological examination revealed acanthamoeba cysts. When bacterial cultures are negative other infectious agent should be suspected. If clinical and laboratory work-up confirms the diagnosis of herpetic keratitis but antiviral treatment fails, a possible mixed infection should be looked for. If our work-up is negative, due to lower sensitivity of acanthamoeba culture, acanthamoeba should be suspected and evaluated with proper methods such as polymerase chain reaction.

To report a rare case of large vascularized astrocytoma on optic disc. Case Report: A 12-year-old boy with history of decreased vision in the left eye since 5-6 months ago was referred to the ocular oncology service at Rassoul Akram Hospital with provisional diagnosis of retinoblastoma. On examination, visual acuity was counting fingers at 50 cm, and a 3+ relative afferent pupillary defect response as well as an exodeviation was evident in the left eye. Fundus examination of the left eye revealed a large yellow-white mass with superficial vessels overhanging the optic disc. Right eye slit lamp exam and funduscopy were unremarkable. No clinical manifestation of tuberous sclerosis was found. Orbital CT scan, MRI and ultrasonography of the globe was done. Enucleation was performed because of the development of iris neovascularization and progressive enlargement of the tumor. Histologic exam confirmed the diagnosis of astrocytoma.