Journal of Current Ophthalmology
Volume:21 Issue: 3, Sep 2009

Globally, there were an estimated 33.2 million (estimate range, 30.6–36.1 million) people living with HIV infection or AIDS in 2007, an increase from 29.5 million in 2001.1 This retrovirus infections, unknown up to 30 years ago has already caused nearly 25 million deaths. The annual incidence of new HIV infections declined from an estimated 3.0 million in 2001 to an estimated 2.7 million (estimate range, 2.2–3.2 million) in 2007. There were an estimated 2.0 million (estimate range, 1.8–2.3 million) HIV-related deaths in 2007. From 2002 to 2007, the number of people receiving antiretroviral treatment (ART) in developing countries increased from 300 000 to 3.0 million, which was 31% of those who needed treatment.2 Although the number of new HIV cases has declined in recent years (3.0 million in 2001 to 2.7 million in 2007), but the rate has increased in many countries like Iran. Still sub-saharan Africa remains the mostly affected region in the world and contains 67% of all people infected by this retrovirus. According to this report of WHO1 an estimated 5.0 million people in Asia are infected and 380000 cases were newly recognized in 2007. In a report from the registry of the ministry of health of Iran in October 20083, 18,320 people were infected by HIV which indicates a 30% increase from 2007. In this report 1,542 of the infected cases have developed AIDS and 2800 have died. In Iran drug users compose 80.8% of the infected cases and 11.9% are infected by sexual pathway. According to the estimation of WHO the number of affected people with HIV virus in Iran is much higher than the official ministry report, and in 20092 it has been estimated that there are 83,000 people who are carriers of the AIDS virus in this country. The clinical manifestations of the disease pass through several stages. The incubation period is 2 to 8 weeks and in 10 to 40% of cases an acute infection with fever and lymph adenopathy develops which resolves in days or weeks, then a chronic infection ensures with gradual decrease in CD4 lymphocyte production and consequently reduction of immunity. This chronic stage may be asymptomtic or may be associated with fever, malaise, diarrhea night sweats and generalized adenopathy. Some minor opportunistic infections such as herpes could be present at this stage of the disease. Progression of the disease leads to AIDS which may take years. At this stage major opportunistic lesions develop. Since 1996 the use of highly active antiretroviral therapy (HAART) has reduced the severity and mortality of the disease. A standard HAART includes 3 or more anti-HIV drugs including “Reverse Transcriptase Inhibitors” blocking the enzyme “Reverse Transcriptase, responsible to change RNA (containing the genetic code) to DNA which is inserted into the host cells, and “Protease inhibitors” modifying and inactivating some of the HIV structural proteins. The ocular manifestations of HIV and AIDS are frequent (70%) and very diverse, including: herpes zoster ophthalmicus, Kaposi sarcoma, squameous cell carcinoma, uveitis, retinal vasculopathy, cytomegalovirus, acute retinal necrosis, toxoplasmosis, progressive outer retinal necrosis, tuberculosis, syphilis etc. which makes the task of ophthalmologist very difficult to diagnose and treat these lesions. In this issue of Iranian Journal of Ophthalmology Dr. Abdollahi et al (pages: 44-48) report 41 cases of HIV+ and AIDS patients in Iran and investigate their ocular lesions. 37% of these patients have had ocular disorders and only one patient has been on AIDS stage which is not surprising since they have been all on HAART. The most common ocular involvement has been vitritis (12.2%) and only one case of CME retinitis has been seen. Although, this is a small case series reported by the authors but this could initiate and follow many new investigations on such an important epidemiological subject. References: 1- UNAIDS/WHO. AIDS epidemic update: December 2007. Geneva: UNAIDS; 2007. http://data.unaids.org/pub/EPISlides/2007/2007_epiupdate_en.pdf. 2- UNAIDS/WHO. Report on the global HIV/AIDS epidemic 2008. Geneva: UNAIDS; 2008. http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/ 3- Iran Reports 30% Increase in HIV Rates Last Year. http://www.medindia.net/news/Iran-Reports-30-Increase-in-HIV-Rates-Last-Year-42919-1.htm.

Swine flu is a new emerging infectious disease originating in Mexico. This novel influenza is the present pandemic disease of the world. In this brief paper, the author discusses on conjunctivitis and other eye manifestations in swine flu. Iranian Journal of Ophthalmology 2009;21(3):3-4 © 2009 by the Iranian Society of Ophthalmology

To evaluate the near visual performance of an accommodative intraocular lens (IOL); Tetraflex, in comparison to a standard monofocal foldable IOL in cataract surgery. Setting: Eye Research Center, Farabi Eye Hospital, Department of Ophthalmology, Tehran University of Medical Sciences, Iran. Forty six eyes of 23 patients with cataract underwent phacoemulsification and accommodative IOL (Tetraflex) implantation bilaterally (case group). The same number of age-matched control group were implanted a foldable monofocal IOL bilaterally (control group). Outcome measures were uncorrected distance visual acuity (UCDVA), uncorrected near visual acuity (UCNVA), manifest refraction, best corrected distance visual acuity (BCDVA), distance corrected near visual acuity (DCNVA), and the amplitude of accommodation up to 6 months after surgery. The final BCDVA was better than 20/25 in all eyes. Mean±standard deviation (SD) DCNVA in the accommodative IOL group (0.69±0.25) was significantly higher than monofocal foldable IOL (0.18±0.09) six months following surgery (P<0.001). Eighty nine percent (41 eyes of 46) of the accommodative IOL group achieved DCNVA of 20/40 or better 6 months after surgery. At 1 month after surgery, mean±SD accommodation in the case group was 3.86±1.11 D compared to 0.27±0.18 D in the control group (P<0.001). Six months after operation, 95.7% of the patients in the case group had 2.5 D or more accommodation compared to a mean of 0.48 D in the control group. The accommodative IOL provides both enhanced near vision and good distance vision 6 month after surgery. It seems that patient''s dependence to near add will be decreased and they can have a good range of clear vision. Iranian Journal of Ophthalmology 2009;21(3):5-10 © 2009 by the Iranian Society of Ophthalmology

The objective of this study was to investigate the causes, the clinical presentation, and treatment modalities in patients with valsalva premacular hemorrhage. This case series study included 21 eyes of 21 patients referred to retina clinic of Farabi eye hospital and two private eye clinics during 2001-2006 with sudden loss of vision and clinical diagnosis of premacular hemorrhage due to valsalva retinopathy. Nd:YAG laser Hyaloidotomy was performed in 16 eyes with larger than 3 disc diameter (DD) hemorrhage in size and enough depth of hemorrhage pocket (dome-shaped) and conservative approach in 5 eyes with smaller than 3 DD in size. Main outcome measures including cause of valsalva premacular hemorrhage based on the history, success rate in performing hyaloidotomy, release of the entrapped blood into the vitreous cavity and the duration of its resorption, spontaneous resorption in observed cases, postoperative improvement in visual acuity (VA), additional intervention such as vitrectomy, and postoperative complications were recorded and analyzed. Premacular hemorrhage was a result of vigorous sexual activity in 10 patients (47.6%), heavy lifting in 2 (9.5%), end stage labor in 2 (9.5%), compressive trauma in 1 (4.7%), straining on toilet in 2 (9.5%), roller coaster riding in 1 (4.7%), sneezing in 1 (4.7%), and occurred during sleep or unknown in 1 (4.7%). Nd:YAG laser Hyaloidotomy was successful in (87.5%) of patients with large size hemorrhage and trapped blood was released in to vitreous cavity and absorbed within 6-23 (mean 14.5±5.1) days. In observed patients, spontaneous resorbtion of trapped blood was occurred within 21-83 (mean 47.2±22.8) days. No predisposing factor was seen in patients. During the follow-up of 38.47±19.2 months, an epiretinal membrane formation was seen in 1 eye. 85.7% of patients in laser group gained full vision. In our study, vigorous sexual activity was the most common cause of valsalva premacular hemorrhage. Nd:YAG laser Hyaloidotomy was a safe and simple procedure in patients with hemorrhage occupied more than 3 DD in size and enough depth of hemorrhage pocket (dome-shaped) and caused visual recovery in majority of patients.

This study was designed to assess and compare the thickness of the peripapillar retinal nerve fiber layer (RNFL) in amblyopic and normal eyes in unilateral strabismic ambelyopia using scanning laser polarimeter. Scanning laser polarimetry was performed on 17 patients with unilateral strabismic amblyopia who had an absence of neurologic diseases or glaucoma with a minimum age of 15 years. A mean retardation map was calculated from separate scans or was considered to be the best scan obtained for each eye. Polarimetric indices were analyzed comparing amblyopic and contralateral normal eyes. Mean±SD age of patients was 24±4 years (15-32 years). The male:female ratio was 10:7. There were six right and 11 left amblyopic eyes. Mean±SD visual acuity (VA) of amblyopic eyes was 0.57±0.26 logMAR. The average thickness of the nerve fiber layer was 57.01 μm in normal eyes and 58.38 μm in amblyopic eyes (P=0.22). Mean±SD polarimetric indices did not differ significantly between normal and amblyopic eyes with a P-value of 0.98 for total polar average. There was no statistically significant difference in thickness of the nerve fiber layer between amblyopic and normal eyes in unilateral strabismic amblyopia.

To evaluate the outcome of iris-claw phakic intraocular lens (PIOL) implantation for high myopia in a subspecialty training setting Iris-claw phakic Artisan (Ophtec B.V., Groningen, The Netherlands) intraocular lens implanted patients were invited for an evaluation visit: 83 eyes had been operated on by a group of 10 cornea fellows under the supervision of nine anterior segment faculty members during 2005-2006. Postoperative time course ranged from four to 38 months. The outcome was assessed in those who participated in the evaluation visit (50 eyes collectively). Evaluation visit uncorrected visual acuity (UCVA) was equal to or better than preoperative best spectacle corrected visual acuity (BSCVA) in 68% of the eyes; mean BSCVA had improved significantly (equivalent to two Snellen lines; P<0.004). Residual spherical equivalent (SE) was within ±1.00 diopter (D) in 68% and ±2.00 D in 92%; eyes with longer postoperative time courses (>10 months) were on average 0.94 D more myopic (P=0.007). No eye had lost BSCVA. No major complication like retinal detachment or cataract had happened. Better UCVA was predictable by shorter postoperative time course, milder baseline myopia, and better baseline BSCVA (P<0.004). Iris-claw PIOL implantation for high myopia was found efficacious and safe in subspecialty training. A noticeable myopic drift was observed, and refractive predictability was not as favorable as expected. Induced astigmatism, miscalculation, mislabeling/wrong refraction, and myopic progression could have been responsible for >2.00 D residual SE in four eyes.

To investigate tear film status after phacoemulsification surgery with temporal and supratemporal clear corneal incision in a cohort of patients with senile cataract We enrolled sixty eight eyes of 68 patients with senile cataract requiring phacoemulsification in a prospective, cohort study. All patients undergone Basic Tear Secretion Test (BTST), Tear Meniscus Height (TMH), Tear Break Up Time Test (TBUT) and Schirmer I test (SIT), preoperatively and three months after surgery. Preoperative keratometry was used to determine the steepest meridian and corresponding location of clear corneal incision. The cohort included 46 men (67.6%) and 22 women (32.3%), with an age range of 48 to 82 years (mean 66.9±9.4 years). Phacoemulsification was performed with temporal clear corneal incision in 36 eyes (52.9%) and with supratemporal clear corneal incision in 32 eyes (47.1%). There was no statistically significant difference between the results of pre and postoperative SΙT, TMH and BTST. The results of these tests were not statistically different according to incision location. In contrast, TBUT results differed significantly in pre and postoperative examination in both incision location groups (P<0.001); however, there was no statistically significant difference in TBUT results according to incision location. Phacoemulsification cataract surgery has no significant effect on tear film. In addition the location of clear corneal incision had no effect on tear

To quantitatively evaluate cataract surgeries performed between 2000 and 2005 at Farabi Eye Hospital, Tehran University of Medical Sciences This retrospective study aimed at patients who had cataract and underwent surgery at Farabi Eye Hospital, Tehran from 2000 to 2005. One week per season per year was randomly selected after excluding the first two weeks of the Persian Year which coincides with the New Year holiday and no elective surgeries are scheduled. In total, data from 24 weeks in these six years (2000-2005) was collected. In this study, 3254 records of cataract surgeries were reviewed. The rate of extracapsular cataract extraction (ECCE) decreased from 94% in the year 2000 to 17% in 2005. Phacoemulsification had the highest growth rate; 1.7% in 2000 to 77% in 2005 (P<0.001). The use of foldable lenses rose from 1.3% in 2000 to 77.2% in 2005. The risk of traumatic cataracts was significantly higher in men [Odds ratio (OR)=5.7, 95% confidence interval (CI) 3.3-9.7]. However, senile cataracts were more common in women (OR=2.07, 95% CI 1.6-2.7). The rate of phacoemulsification increased by 75% Compared to other surgical methods, phacoemulsification has low complication rates and has the advantage of shorter surgical time and faster recovery. Increased popularity of the method is expected to relieve the community of the social and economical burdens of cataract.

Up to 70% of patients with acquired immunodeficiency syndrome (AIDS) have AIDS-related ocular involvements which may severely affect their quality of life caused by visual impairment. This study was designed to investigate the ocular manifestations in patients infected with human immunodeficiency virus (HIV). In this case series study, 41 HIV positive patients were investigated through the first 6 months of 2003, in Farabi eye hospital, in Tehran, Iran. They were all under highly active antiretroviral therapy (HAART), but none was taking rifabutin, protease inhibitors or cidofovir. Complete ocular examination was carried out for each by Slit-lamp biomicroscope and indirect ophthalmoscope after pupil dilation. Thirty seven percent of patients had ocular disorders. 93% were male, 40% of all patients were 30-40 years old, 93.3% were in HIV stage (not AIDS stage). Intravenous drug (IVD) pathway had infected 86.6% of the patients, and 46.6% (n=19) had been infected throughout the previous three years. The most common ocular involvements among HIV positive patients were cotton wool spots (CWS) and vitritis (12.2%), which includes 66.6% of ophthalmic symptoms. A variety of ophthalmic symptoms might affect HIV positive patients. These symptoms may cause severe disability in their lives, so ophthalmologists should pay more attention to HIV patients with ocular manifestations. Further studies are required for a better understanding of risk factors or possible human genes involved in occurrence of ocular involvement in HIV patients.

To evaluate the toxic retinal effects of intravitreal bevacizumab used for the treatment of exudative age-related macular degeneration (AMD) using Ganzfeld Electroretinography (G-ERG) In this prospective comparative interventional study, 23 patients with active choroidal neovascularization (CNV) associated with AMD were enrolled. Patients were received intravitreal injections of either 2.5 (12 patients) or 1.25 mg (11 patients) of intravitreal bevacizumab. Patients underwent complete ophthalmic examination including visual acuity testing, and G-ERG, at baseline, at one week, at one month, and at three months after intravitreal bevacizumab. Best corrected visual acuity (BCVA) significantly increased from 1.34±0.59 (logMAR) in preinjection examination to 1.07±0.47 (logMAR) at one month (P=0.01), and 1.03±0.46 (logMAR) at three months (P=0.001). G-ERG did not show any significant change in the waveform parameters following intravitreal injection of bevacizumab. No significant difference was found between the two groups in the amount of change in visual acuity and G-ERG recordings of postinjection measurements. Intravitreal bevacizumab did not appear toxic to the retina based on G-ERG recordings

Infectious corneal ulceration is a serious potential complication of PRK. Although gram positive organisms are the most common pathogens, in this study we present the first case of gram negative bacilli keratitis, Alcaligenes, after PRK. Case report : A 22-year-old man was referred to our institution due to infection following corneal refractive surgery. Three days after surgery, the patient developed redness, very intense pain and blurred vision in the treated eye and he admitted with the clinical diagnosis of right eye post-PRK keratitis. Microscopic examination of the smear showed presence of gram negative bacilli and culture was positive for Alcaligenes. He was treated with fortified vancomycin, amikacin and ciprofloxacin and clinical symptoms subsided after 3 days and uncorrected visual acuity (UCVA) had improved to 6/10, but central haze remained. Alcaligenes xylosoxidans has rarely been reported to cause postoperative endophthalmitis and infectious keratitis. Owing to a high degree of intrinsic antibiotic resistance, this organism presents a therapeutic challenge.

To report a case of recurrent corneal intrastromal cyst containing lymph fluid Case report: A 13-year-old girl presented with recurrent cyst of the left cornea, which had been drained three years before, but had gradually recurred. The cyst was successfully drained. Histologic examination, cytologic analysis, and protein electrophoresis were performed on the cyst fluid. Histopathologic examination of the cyst fluid revealed lipid-containing macrophages, White blood cells, and rare Red blood cells. Protein electrophoresis of the aspirate and blood serum showed a gamma globulin of 39% (higher than blood serum) and albumin of 52.5% (similar to blood serum) suggesting a lymph-containing corneal cyst. Corneal cysts are divided into different types: epithelial cysts which may be associated with surgery or trauma, cysts associated with an ectopic lacrimal gland or prolonged corneal edema. To our knowledge, this is the first report of a corneal cyst suspected to containing lymph fluid.

To present the clinical features, biomechanical properties and management of a patient who developed unilateral corneal ectasia after photorefractive keratectomy (PRK) Case report: The patient was a 24-year-old man without any obvious preoperative risk factor for ectasia who underwent bilateral PRK. Four years after keratorefractive surgery, the patient presented with loss of visual acuity (VA) in his right eye. Pentacam findings were persistent with corneal ectasia and Ocular Response Analyzer measurements showed differences in signal shape between two eyes. A single piece intrastromal segment ring was implanted and ceased the progression of ectasia until now. Corneal ectasia after PRK is extremely rare and can occur without tangible risk factors. Differences between signal shapes in Ocular Response Analyzer and abnormal measurements may be useful in detecting high risk patients. Intacs implantation appeared to improve ecstatic progressive changes and patient''s symptoms.