Journal of Current Ophthalmology
Volume:21 Issue: 4, 2009 Dec

Since the modern protocols of chemoreduction1 and local treatments of regressed retinoblastoma (RB) has been proposed and in the developed countries efforts have been made to salvage and preserve the diseased eye, the protocols have found way and being applied in the developing countries, but for what prices? In this issue of the Iranian Journal of Ophthalmology (IrJO) (Pages: 17-24) Naseripour and coworkers have presented their 10 years experience with RB from the ocular oncology center of Iran Medical School. They have emphasized that 7.9% of their patients were presented with proptosis and 51% had extraocular extension of the tumor. I was tempted to review the RB registry of Farabi Eye Hospital of Tehran Medical School from 1980 to 2002 to get an overlook on the conditions of our RB patients during that period. 558 RB cases have been hospitalized during that period which included 735 diseased eyes. 67.4% of cases were unilateral, 27.8% were bilateral, and 4.8% were confirmed familial cases, five of them unilateral. The mean delay in diagnosis and treatment (enucleation, exentration, irradiation, chemotherapy, and local treatments) of each group was 4.7± 6.1 m, 7.6± 10.3 m, 16.5± 29.3 m, respectively. 9.6% (N=71 eyes) of our RB patients were presented with proptosis, 8.3% (N=61) of the eyes had advanced glaucoma, 48.2% (N=353) of the eyes were in stage V of Reese-Ellsworth, 1.8% (n=13) eyes were phthisic, 1.8% (N=13) had the brain involved and 5.8% (N=33) had far metastases. Our pathologists reported 20.7% (N=152) cases of extension of RB to optic nerve and 9.1% (N=67) of orbital involvement. More advanced age of our patients compared with developed countries, delay in consultation and treatment, extensive local and extraocular extension of the tumor, and also cultural limitation and difficulties in transportation to the specialized medical centers are all factors to be considered in our therapeutic approach which force us to apply the more radical and rapid protocols. Most of our patients are from the rural and very low income communities, and in our series 29.9% (N=167) patients have never referred back to our center after the initial surgical and medical interventions. More than 90%2 of survival rate and salvage of the eye by modern protocols are every one''s dream, but we should be aware of the conditions of our patients and where we live, and what prices we are paying for these modern approaches.

Presbyopia is a major refractive challenge for the coming decades. A variety of surgical procedures like scleral expansion, zonal photorefractive keratectomy, and corneal inlay implantation have been investigated; none have yet gained popular acceptance. Implantation of intraocular lenses (IOLs) at the time of cataract surgery or refractive lens exchange provides another opportunity to tackle the presbyopia challenge. A simple kind of postoperative multifocality, i.e., myopic astigmatism, has long been recognized as a favorable refractive outcome as it creates “pseudo accommodation”. An apparent accommodative behavior was also attributed to conventional monofocal IOLs. These observations set the stage for the development of accommodative and then multifocal IOLs (MFIOLs). Popular FDA-approved brands of such IOLs include Crystalens HD (Bausch & Lomb), TECNIS (AMO), ReZoom (AMO), and AcrySof ReSTOR (Alcon). The Journal has recently published two studies on accommodative and MFIOLs in which the current thinking is replicated.1,2 There is a consensus that presbyopic IOLs outperform monofocal ones; under standard testing conditions, the far visual acuity is comparable and the near vision is better for presbyopic IOLs; and the patients are generally more satisfied because of less spectacle dependence. But when it comes to contrast sensitivity, glare, long-term accommodative stability, and quality of life, the evidence is not yet conclusive. An inevitable drawback of MFIOLs is a reduction in contrast sensitivity function (CSF); an 18 dB relative loss in CSF at 6 months has been reported.3 Disabling photic phenomenon is another challenge for MFIOLs (20-30% complaint of glare and nocturnal halo at month one follow-up has been reported)3; in extreme cases, these even necessitated IOL explanation. Some authors report CSF loss as the main reason for unequal patient satisfaction between this group and those receiving monofocal IOLs despite spectacle independence.4 MFIOLs are pupil-size-dependent5 and this adds to their unpredictability. Neuroadaptation – a crucial phenomenon which has not yet been fully understood – is quite relevant for the case of MFIOLs and an improvement in CSF with time has been reported.6 To further complete our understanding, MFIOLs studies need to be designed with a number of factors in mind. Random allocation is specially important, as the attitude, motivation, and the involvement of economic elements in decision making can influence the performance of the subjects, even in semi-objective assessments like visual acuity testing. This is not observed in Hashemi et al’s study.2 Accommodative stability is the major concern for accommodative IOLs. Postoperatively the patients are instructed to do accommodative exercises to re-establish the accommodative ability of the eye. An accommodative amplitude of 2.0 D or more in 75% of the cases at month 6 follow-up has been reported.7 Capsular opacification and contraction are common8 and a positional malfunction, i.e., the ''Z syndrome'', has been described in this regard.9 Long-term studies are needed to quantify the accommodative regression.10 Rahimi et al’s study does not provide data for beyond 6 months.1 Standard efficacy and safety evaluations may not address the whole outcome, and in assessing the performance of premium IOLs, more sophisticated approaches should be adopted; we should think and measure binocularly, specifically include intermediate vision testing, and apply customized quality of life instruments (covering spectacle dependence, full range vision, vision fluctuation, glare disability, adaptation period, costs, etc). Contrary to the way it is needed to go randomized in clinical studies, it is desired to observe an individualized approach in the clinical practice of presbyopic IOLs. A great commitment on the part of the clinician is required; extensive patient education (facilitated audio visually or by patient education brochures) on IOL choices and their pros and cons should be delivered. Patient life style and visual tasks (e.g. night driving, computer work, etc) have to be scrutinized. It should be noted that any significant ocular comorbidity is a contraindication for these types of IOLs and IOL power calculation should be as accurate and as reliable as possible. Patients should be informed of the possible need for additional procedures like keratorefractive enhancement (for residual error or astigmatism) and even IOL exchange for refractory disabling monocular diplopia. Presbyopic IOLs are costly and this adds to the complexity of their counseling. Policies on insurance coverage and reimbursement can influence their choice. Clinicians should maintain their patient advocate stance rather than a sales representative one. Some suggest inclusion of a family member in the counseling process and asking questions from the patients to verify that they have realistic expectations.11 It is inherent to the current presbyopic IOLs that far, intermediate, or near vision should somehow be sacrificed for another. Novel modified monovision has been proposed to address this limitation; for instance, in a ‘mix and match’ recipe, implanting a ReSTOR IOL for far and near vision in one eye and a ReZoom IOL for far and intermediate vision in the fellow eye could be considered. Alternatively, an accommodative IOL with a plano target refraction in one eye for far and intermediate vision and another accommodative IOL in the fellow eye with a target refraction of -1.00 for intermediate and near vision could be planned. This is called ‘partial monovision’. We seem closer than a decade to a perfect solution for presbyopia; dual and dynamic optic IOLs and keratorefractive procedures are expected to provide better solutions sooner.

To review epidemiological aspects of uveitis in Asia and compare it with few major reports from outside of this continent We have reviewed 522 articles concerning the causes and patterns of uveitis and 22 major epidemiology reviews, registered from 1962 to 2009 in Medline-Database. We have selected 7 major reviews from Asia and compared it with five major articles from Africa, France, East and West USA and Argentina. We have also used 59 reviews and reports to show some local and regional aspects of uveitis in developed and underdeveloped countries and to indicate the changes in trends of uveitis in recent years. In these collected data from 12 countries, 14.0% to 51.2% no cause has been found for the uveitis (idiopathic). In almost all these reports noninfectious uveitis (45.0% to 94.8%) dominated the infectious causes. Infectious uveitis such as tuberculosis, leptospirosis … are present more frequently in the developing countries with exception of herpes simplex which is dominated in the western world. Toxoplasmosis remains the predominant etiology of posterior uveitis in most reports, excluding cytomegalovirus (CMV) retinopathy which has dominated all causes of posterior uveitis during the last 30 years due to the global extension of AIDS. Despite all the new progresses in laboratory techniques, imaging technology and finding new causes for uveitis such as HTLV1 and HLA dependent diseases, the number of uveitis with unknown etiology (idiopathic) is increasing. That could indicate the uprise of new immunological phenomena. The prevalence of uveitis which was estimated to be around 17.4 per 100,000 population in 1960’s, in a more recent investigation has been reported to be 52.4 per 100,000 people and the incidence seems upraising. Iranian Journal of Ophthalmology 2009;21(4):4-16 © 2009 by the Iranian Society of Ophthalmology

To describe the survival characteristics and prognostic factors of patients with retinoblastoma in a referral center in Iran From medical records, we retrospectively analyzed the data of 139 consecutive children diagnosed in our hospital between 1991 and 2001 as having retinoblastoma. Information on gender, laterality, age at diagnosis, presenting signs, tumor staging, treatment modality, survival rate, and family history were collected. Eighty-eight (63.3%) of the cases were unilateral and 51 (36.7%) of the cases were bilateral. The mean age overall at the time of diagnosis was 26.9 months; in unilateral cases, 32.7 months; and in bilateral cases, 22.8 months. The most common presenting signs were leukocoria (72.7%), strabismus (12.2%), and proptosis (7.9%). Fifty-one percent of patients had extraocular extension. The 5-year cumulative survival rate was 69.62% and the 10-year overall survival rate was the same as the 5-year survival rate. Patients with an age at the time of diagnosis of ≤2 years, with stage I and with positive family history had significantly better survivals both at the 5 and 10 years analysis (P<0.002, P<0.002, P<0.041 respectively). None of the patients developed a secondary neoplasm. In this study the mortality rate of patients with retinoblastoma is higher than the reports from developed countries. Availability and quality of registration data on retinoblastoma need to be improved for effective quantitative evaluation of incidence and survival.

To compare visual quality in patients receiving Alcon AcrySof ReSTOR multifocal versus AcrySof SA60AT monofocal intraocular lenses (IOL) In this interventional study, patients with senile cataract undergoing surgery were enrolled. The age of the patients ranged between 40 and 85 years, and their potential preoperative vision was 20/30 or better. In all patients phacoemulsification was performed through a temporal 2.8 mm incision. Postoperative visual acuity (VA), refraction, and contrast sensitivity (with and without glare) tests were done at 1 and 3 months. A total of 101 eyes were evaluated. A multifocal IOL was implanted in 52.5% of cases, and in the rest, a monofocal IOL was used. At 3 months, the mean distant VA without and with correction was 0.11 and 0.04 logMAR, respectively, in the multifocal IOL group, and 0.14 and 0.03 logMAR, respectively, in the monofocal IOL group (P>0.10). The near VA without and with correction was 0.14 and 0.05 logMAR, respectively, in the multifocal group and 0.22 and 0.04 logMAR, respectively, in the monofocal IOL group, statistically significantly better in the multifocal group (P=0.038). At 3 months after surgery, contrast sensitivity with and without glare showed statistically significant inter-group differences at 6, 12 and 18 cycles per degree (CPD), and at 6 and 12 CPD, respectively. These figures were higher in monofocal group. Use of multifocal IOLs in cataract surgery can restore near vision to some extent in addition to distant vision. Contrast sensitivity in recipients of multifocal IOLs is lower than those with monofocal IOLs.

Rhinoplasty is one of the most common cosmetic surgeries. Lateral osteotomy is one of the surgical steps used in rhinoplasty. There are several procedures to determine the tear passage time through nasolacrimal duct (NLD) such as dacryocystography, dacryoscintigraphy, taste test, etc. One of the useful tests which can be used for determination of tear passage through NLD is dripping of chloramphenicol drop in the eye and recording the passage time by its bitter taste perception by the patient. It should be pointed out that this test is easy to do, inexpensive, accessible, and safe. In this interventional case series study (before and after intervention), 37 patients (74 eyes) were examined. The chloramphenicol taste test was done one week before and one week, one, three and six months after rhinoplasty was performed. All the results were statistically analyzed through paired T-test. The average time (±SD) of tearing passage was 291.90 (±120.04) seconds before surgery, which have reached in turn to 503.00 (±241.37), 478.62 (±212.86), 398.78 (±157.46), 359.86 (±159.51) seconds on the first week, first, third and sixth months after surgery. In this study, the postoperative average tear passage time was significantly longer than preoperative time (P=0.001). We did not find any permanent obstruction after rhinoplasty. The results showed that tearing passage time increased after rhinoplasty.

To demonstrate visual evoked potential (VEP) changes in multiple sclerosis (MS) disease A case series study of VEP changes in forty-nine patients with definite, probable and possible diagnoses of MS referred to electrophysiology ward from January 2002 to December 2005. Pattern VEP was done for those with good visual acuity (VA), and flash VEP was done for those who did not have central fixation or good VA. Characteristics of P100 wave in pattern VEP and P2 wave in flash VEP were evaluated. The implicit time of P100 and P2 waves in pattern and flash VEP, demonstrated severe abnormalities in 84.5% of definite MS. In probable MS, implicit time increased in 81.8% cases. In possible MS cases, increased implicit time was seen in more than 50% of patients. Decrease in amplitude alone, was seen in a few cases. Combined changes of implicit time and amplitude were prominent. VEP is an invaluable electrophysiological test in MS for both diagnosis and follow-up of the patients. Concurrent with magnetic resonance imaging (MRI) and cerebrospinal fluid (CSF) analysis, VEP can help neurologists and ophthalmologists for better evaluation of MS patients.

To evaluate the accuracy of the two methods; the clinical history method (CHM), and the contact lens method (CLM), in refractive corneal power determination and comparing the accuracy of SRK II, SRK T and Holladay II (H II) formulas for intraocular lens (IOL) power calculation in patients who had laser in situ keratomileusis (LASIK) surgery for myopia with or without astigmatism In this interventional prospective study, we evaluated 46 eyes of 32 patients who had undergone LASIK for myopia with or without astigmatism and were visited at Noor Eye Clinic during September 2001 to September 2006, for cataract surgery. The corneal power was determined with two methods; CHM and CLM. Then, IOL power was calculated with three formulas; SRK II, SRK T and H II. We used the results of CHM+H II formula for IOL power selection. The manifest refraction (MR) one month after cataract surgery was regarded as the postoperative refraction. According to the rule that 1.5 diopter (D) change in IOL power results in 1.0 D change in a patient’s refraction at the spectacle plane, we calculated the expected refractive results with IOL powers based on other corneal power calculation methods and formulas, and compared them to results with CHM+H II formula. The mean difference between keratometry values by CLM with CHM methods was 2.53 ± 2.68 D (Pearson correlation, 0.6; P<0.0001). The mean manifest spherical equivalent (SEQ) was -10.44 ± 3.92 D, before refractive surgery, -0.84 ± 1.33 D (range; 1.00 to -5.00 D) before cataract formation, and -0.46 ± 1.04 D (range; 1.87 to -2.62 D) after phacoemulsification and IOL implantation with CHM+H II. The mean expected post-cataract surgery manifest SEQ using the CHM with SRK II and SRK T, were 1.39 ± 1.15 D and 0.56 ± 0.94 D, respectively. The mean expected post-cataract surgery manifest SEQ, using CLM with H II, SRK II and SRK T, were calculated as 1.91 ± 2.37 D, 2.97 ± 2.17 D, and 2.59 ± 2.07 D, respectively. CHM appears to be more accurate than CLM for true corneal power determination after LASIK surgery for myopia with or without astigmatism. In this series of patients, the most accurate formulas for IOL power calculation were H II, SRK T and SRK II, respectively.

To compare the ability of scanning laser polarimetry (GDx VCC), and optical coherence tomography (OCT) to discriminate eyes with primary open angle glaucoma (POAG) from normal eyes and to assess the relationship between their parameters Eighty-seven glaucomatous eyes of 87 patients and 25 normal eyes were enrolled. The mean age of patients and normal group were 54.96±18.34 and 50.02±20.15, respectively. All subjects underwent a full ophthalmic examination, automated perimetry, GDx VCC and OCT. Correlation coefficients between the parameters of OCT and GDx VCC were calculated. We calculated area under the receiver operating characteristic curve (AROC) for GDx VCC and OCT main parameters. Statistically significant correlations were observed between GDx VCC and OCT parameters. Pearson coefficients ranged from 0.731 for inferior average to -0.858 for nerve fiber indicator (NFI)/average thickness of OCT. The greatest area under AROC parameter in OCT (inferior average 0.97) had a lower area than that in GDx VCC (NFI; 0.99). There was a significant statistical correlation in all visual field (VF), GDx VCC, and OCT variables between two groups. Many parameters of GDx VCC were significantly correlated with those of the OCT. Inferior average and NFI had the greatest area under AROC parameter in OCT and GDx VCC, respectively. NFI had high sensitivity and specificity for the diagnosis of POAG.

There are controversial reports regarding the long-term intraocular pressure (IOP) lowering effect of non-penetrating glaucoma surgery (NPGS). The reported complete success rates from studies in different populations around the world are 13% to 77%. This prospective study was aimed to evaluate the IOP lowering effect of deep sclerectomy with Mitomycin C (DSMMC) in a group of Iranian patients with open angle glaucoma. Ninety eyes of 87 patients with medically uncontrolled primary open angle glaucoma (POAG) were consecutively enrolled in this prospective study and were surgically treated by DSMMC. All patients had complete eye examination before and at regular intervals after the operation. Surgical success was considered for IOP of ≤21 mmHg. The mean age was 64±12 years; the mean follow-up was 33±22 months. The mean preoperative IOP of 42±13 mmHg was significantly decreased to the mean final IOP of 22±11 mmHg (P<0.001). The IOP lowering effect of surgery reduced by time (P<0.001). Cystic bleb was developed in 13.3% of eyes. The probability for an IOP≤21 mmHg was 35% without the use of antiglaucoma drops and 71% with or without the use of antiglaucoma drops. DSMMC could effectively reduce IOP in eyes with POAG and was accompanied by few operative complications. Most of the patients needed to continue using antiglaucoma drops after the operation. This procedure is not fair whenever low target IOPs are required.

Contrast sensitivity (CS) evaluation by SV–1000E chart in all spatial frequencies after micro incision cataract surgery (MICS) and its comparison between two thin lenses after optical correction in natural and glare conditions In this cross sectional study, 100 eyes having MICS with Dodick ARC phacolaser system were evaluated. 50 Thinoptx lenses and 50 Acrismart lenses were randomly implanted in the eyes. Uncorrected visual acuity (UCVA), best spectacle corrected visual acuity (BSCVA), refractive error and CS, in all spatial frequencies were measured three months after surgery. CSV-1000E chart with or without glare test was used for CS evaluation. Normalized measures of CS were compared between two thin lenses with Student’s T-test. CS profile was within the normal range in 52% of eyes and 48% of eyes had CS in lower than the normal range. The differences of CS in lower spatial frequencies [3 and 6 cycle/degree (c/d)] and higher spatial frequencies (12 and 18 c/d) between two lenses were not significant (P<0.449 and P<0.835, respectively). After implantation of two lenses by MICS, the CS in all spatial frequencies was similar.

To report a case of adult ocular leech infestation Case report: A 67-year-old male presented to the emergency department of Farabi Eye Hospital with the complaint of bloody tear. Slitlamp biomicroscopy of left eye revealed bloody lashes, bloody tear and a large black green foreign body attached to the inferotemporal bulbar conjunctiva. One cc of lidocaine 2% was injected directly to the body of leech. 10 minutes after injection, removal with forceps was retried. Ocular leech infestation must be considered as a differential diagnosis of bloody tear and hemorrhagic conjunctivitis. Removal of leech after direct injection of lidocaine to its body seems to be a safe method.