Journal of Current Ophthalmology
Volume:23 Issue: 4, 2011 Dec

Ophthalmologists visit patients with “20/20” vision post-op who are not satisfied and at times encounter cases with significantly lower visual acuity who are totally satisfied; quality of life is at the heart of this. Quality of life (QoL) approach—in the healthcare context—advocates a focus on the softer psychosocial aspects of health care vis-à-vis the harder biological aspects and the adoption of a more holistic approach towards the patient. It closely relates to the biopsychosocial model,1 and its instruments provide an operational guide for psychosocial needs that are of relevance in tailoring the healthcare delivery and better service.2 As a consequence, QoL expands the evidence on clinical effectiveness into comprehensive effects of care on one’s life. Chronic illnesses like cancer, heart failure, renal failure, and rheumatologic conditions are most typical of the QoL question and in the era of rising life expectancy, QoL becomes all the more relevant. QoL questionnaires are put into two categories: generic—assessing one’s overall health under various disease conditions—and specific—used for defined disease entities. This is a sample of a QoL question:3

To compare the effectiveness and safety of trabeculectomy with mitomycin C (MMC) versus trabeculectomy with OculusGen In this prospective study 14 eyes of 7 patients with a diagnosis of primary open angle glaucoma (POAG) that required trabeculectomy for both eyes were enrolled. For each patient we randomly performed trabeculectomy with MMC for one eye and trabeculectomy with subconjunctival OculusGen for fellow eye. Main outcome measures were: intraocular pressure (IOP), number of IOP reducing medications and surgical complications. Data analysis was performed using SPSS software version 15. Mean age of the patients was 59±12.6 years. Mean duration of follow-up was 13±3.7 months for OculusGen group and 14.42±6.6 months for MMC group. Mean preoperative IOP was 19.14±3.8 mmHg with 3.14±0.37 number of medication and at last visit was 14.43±3.3 mmHg with 0.86±1.21 number of medication for OculusGen group. Mean preoperative IOP was 21.71±4.1 mmHg with 2.86±0.89 number of medication and at last visit was 12.29±3.5 mmHg with no medication for MMC group. The cumulative success at last visit was 100% in MMC group and 71.5% in OculusGen group (P=0.008%). No systemic or ocular complications related to MMC or OculusGen were seen. Trabeculectomy with OculusGen is a safe procedure with IOP reduction, at least in short-term, comparable to trabeculectomy with MMC, but with significantly more requirements for IOP lowering medications.

To determine the distribution of cataract surgery in Iran between 2000 and 2005 In a retrospective study based on files, cataract surgery centers were selected. Between 2000 and 2005, one week of each season was selected randomly and all cataract surgery files of the center were studied. The surgeries were analyzed based on type, types of the lenses, intraoperative complications, hospitalization time, length of waiting time before surgery, sex and age. Mean age of 13,409 cataract cases (50.2% males, 49.8% females) was 64.9±14.7. Mean age of males (64.37) was significantly less than females (65.5) (P<0.001). Age-related (89.26%) and congenital (0.99%) cataract were the most and the least common surgery cases, respectively. Extracapsular method had the highest prevalence (50.76%). However, within 2000-2005 its prevalence decreased from 56% to 20.5%. Instead, the Phaco method, with a prevalence of 47.01% increased from 12.5% to 77.5% during the same period of time. During that time window of 6 years, the prevalence of outpatient surgeries was 31.42%. This study reports the overall status of cataract surgery in Iran between 2000 and 2005. In comparison to some developed countries, although the transition to Phaco method was done with a delay, its prevalence in 2005 was 77.5% and is expected to replace quickly other surgical techniques in the country.

To evaluate usefulness of anterior segment optical coherence tomography (AS-OCT) in evaluation of filtering bleb functionality and to correlate its findings with clinical bleb examination In this cross-sectional, descriptive study 55 eyes with apparently functional bleb were evaluated. Following a comprehensive ophthalmic examination, filtering bleb grading was performed based on Indiana Bleb Appearance Grading Scale (IBAGS). The bleb was then imaged using AS-OCT. Two radial and tangential scans were obtained. The mean age was 57.69±12.47 years and 29 cases (53%) were female. The mean number of glaucoma medication and intraocular pressure (IOP) were 0.45±0.71 and 14.35±4.67 mmHg, respectively. On AS-OCT examination, the mean bleb height, bleb wall thickness, internal cavity height, posterior extension of the internal cavity were 1.5±0.47 mm, 1±0.4 mm, 0.59±0.28 mm, and 3.15±1.26 mm, respectively. The internal reflectivity was high in 15 cases (27%) and low in 40 cases (73%). There was a positive correlation between the bleb height, bleb wall thickness, and internal cavity height on AS-OCT and IOP. Also, a negative correlation between the posterior extension of the internal cavity and IOP was noted. There was also a positive correlation between the higher IOP and a high internal reflectivity. There has also been a positive correlation between the bleb height at IBAGS and bleb reflectivity at AS-OCT. We also found that there was a positive correlation between the bleb vascularity at IBAGS and internal reflectivity at AS-OCT. AS-OCT seems to be a useful device in evaluation of filtering bleb function. It yields valuable information regarding the internal bleb structures, and its findings are correlated with clinical examination of filtering bleb.

To determine the effect of carpet weaving on refractive errors In this cross sectional study, carpet weavers and non-weavers in the normal population of Mashhad were regarded as exposed and non-exposed groups, respectively. A carpet weaver was a person who wove carpets 7 hours a day for at least 2 years. The non-weavers group was selected from the population of Mashhad through stratified cluster sampling. The variables of age, gender, education, with respect to their frequency, were matched between the two groups. In this study, 266 carpet weavers (exposed individuals) and 549 non-weavers group (non-exposed individuals) were evaluated. The prevalence of myopia was 78.9% in carpet weavers and 19.0% in non-weavers [Odds ratio (OR)=16.03, 95% confidence interval (CI)=11.13-23.09]. The prevalence of hyperopia was 6.02% in carpet weavers, and 56.75% in non-weaver group (OR=0.05, P<0.001). The prevalence of astigmatism was 39.47% in carpet weavers and 21.46% in non-weavers. The odds of against-the-rule (ATR) astigmatism was 1.72 times more in carpet weavers as compared to non-weavers (P<0.001). The results of this study showed that carpet weaving had a strong correlation with myopia. In addition to myopia, the prevalence of astigmatism, specially ATR astigmatism, was higher in carpet weavers.

To determine the association between astigmatism and spherical refractive error in a clinical population In this cross-sectional study, 2,000 patients who presented to our optometry clinic were enrolled. All were tested for objective refraction with a Nidek AR-310A auto refractometer, and non-cycloplegic refraction. For those under 15 years of age, cycloplegic refraction was measured as well. Myopia and hyperopia were defined as a spherical power of -0.5 Diopter (D) or less and +0.5 D or greater, respectively. Astigmatism was defined as a cylinder power of ≥-0.5 D; with-the-rule (WTR) astigmatism if the steep axis was 0±20°, against-the-rule (ATR) astigmatism if the steep 90±20°, and oblique if the axis was in between. The mean age of the participants in this study was 31.52±18.39 years, and 910 (45.5%) were male. The Mean cylinder power of the subjects with high myopia and high hyperopia was 1.92±0.25 and 1.48±0.19 D, respectively. The lowest prevalence of astigmatism was found in subjects with emmetropia (P<0.001). There was an age-related decrease in the prevalence of WTR astigmatism, and an increase in ATR and oblique astigmatism (P<0.001). Mean cylinder error in WTR, ATR, and oblique astigmatism groups was 1.59±1.24, 1.10±0.76, and 1.16±0.04 D, respectively (P<0.001), and absolute mean spherical error was 1.97±2.03, 1.49±1.54, and 1.68±1.71 D, respectively (P<0.001). The results of this study indicated an association between astigmatism and spherical refractive error. Higher amounts of astigmatism were seen in subjects with high spherical ametropia. Astigmatism axis was related to the cylinder and spherical powers which were both higher in subjects with WTR than those with ATR and oblique astigmatisms. In those with ATR astigmatism with the refractive status was close to emmetropia.

To compare the outcomes of microcoaxial phacoemulsification and conventional phacoemulsification techniques In this prospective comparative clinical study in the Negah eye center, 69 eyes of 69 patients with senile cataract of grade 3 to 4 on the Lens Opacities Classification System III (LOCSIII) were placed in two groups. Thirty nine eyes were assigned to undergo surgery by the microcoaxial technique (2.4 mm) and 30 eyes by the conventional coaxial technique (3.2 mm). All surgeries were performed by a single surgeon using the same machine (Sovereign WhiteStar, AMO). In all cases, a temporal clear corneal incision (CCI) was constructed and hydrophobic acrylic flexible intraocular lens (Acrysof Natural, SN60AT) were implanted. Intraoperative parameters including mean phacoemulsification time, total phacoemulsification percentage, effective phacoemulsification time (EPT), total volume of balanced salt solution (BSS) used, and the final size of the corneal incision were measured. Postoperative parameters including uncorrected and best spectacle corrected visual acuity (UCVA, BSCVA), keratometric and astigmatism changes by vector analysis, at 1 day, 5 days and 2 months, were checked. Postoperative BCDVA in 5 days and 2 months in conventional and microcoaxial groups were significantly different. At 5 days, BCDVA was 0.04±0.07 logMAR and 0.00±0.02 logMAR respectively (P=0.006). At 2 months BCDVA was 0.02±0.06 logMAR and 0.00±0.02 logMAR respectively (P=0.044). Mean induced keratometric change in 5 days in conventional and microcoaxial groups were 0.39±0.06 and 0.18±0.24 diopter respectively (P=0.035), but long-term keratometric values showed no significant differences. Other measured intraoperative and postoperative variables showed no significant difference between the two groups. There were no intraoperative or postoperative complications. Microcoaxial phacoemulsification showed significantly less induced keratometric changes and also better corrected visual acuity in early postoperative period. Long-term keratometric values showed no significant differences. Both techniques were effective for surgery in cases with senile uncomplicated cataract.

To study optical coherence tomography (OCT) findings in high myopic patients with the history of uncomplicated cataract surgery The sample included 34 eyes of 24 highly myopic patients with an axial length (AL) of 26 mm or more and a spherical equivalent (SE) of 8.0 diopter (D) or more who had uncomplicated phacoemulsification cataract surgery. OCTs were done in multiple sections around optic disc and fovea. The mean age of the 24 patients was 58.9±12.9 years, and the mean SE was 14.5±5.8 D. The mean time gap between cataract surgery and OCT studies was 15.6±18 months, and the mean AL was 29.1±2.1 mm. The most common OCT findings were vascular microfolds (67.6%) and paravascular retinal cysts (64.7%). Vascular microfolds were found significantly associated with age. Internal limiting membrane (ILM) detachment was significantly associated with gender (female group). Peripapillary choroidal cavitation had a significant direct association with postoperative elapsed time in all ages. Vascular microfolds and paravascular retinal cysts are the most common pathologies in myopic (aphakic and pseudophakic) persons. ILM detachment is more common in females. Peripapillay cavitation incidence is associated with postoperative elapsed time.

To investigate long-term visual outcome and complications after cataract extraction and intraocular lens (IOL) implantation in Fuchs’ heterochromic iridocyclitis (FHI) In this retrospective study in a private eye clinic in Tehran, 25 eyes of 24 patients with FHI who underwent cataract extraction and IOL implantation were evaluated based on their visual outcome and intraoperative and postoperative complications. Cataract extraction was performed on 12 men and 13 women between 19 to 62 years old (mean 39.4±10.3 years) with 102.20±45.54 months (range, 61-200 months) follow-up. Mean visual acuity (VA) improved from 1.26±0.57 logMAR (less than 20/200) before surgery to 0.08±0.22 logMAR (more than 20/25) at the last follow-up (P<0.001). Fifteen eyes (60%) achieved VA≥20/20. Mean intraocular pressure (IOP) in the last follow-up was slightly lower than preoperation but was not statistically significant (P=0.42). Glaucoma was found in 2 (8%) cases before surgery and 3 more cases (12%) were diagnosed along the postoperative follow-up. Severe postoperative inflammation with hypopion and fibrin formation occurred in 2 (8%) cases and severe recurrent intraocular inflammatory episodes appeared in 4 (16%) cases during the follow-up. YAG laser capsulotomy was done in 7 (28%) cases were developed posterior capsular opacity. Long-term visual outcome after cataract extraction and IOL implantation in patients with FHI are satisfactory. However, possible inflammatory crisis and glaucoma necessitate intensive care and regular postoperative long-term follow-up of these patients.

To report a case of posterior keratoconus with atypical ocular findings Case report : An 8-year-old boy was referred to our clinic with the chief complaint of blurred vision in his right eye. The patient had no history prior ocular surgery of trauma. Her family history was also unremarkable. Comprehensive ocular examination was performed. The patient's best spectacle corrected visual acuity (BSCVA) was 3/10 in the right eye and 8/10 in the left eye with refraction of +11.5-0.5×75 (OD) and +4-0.25×25 (OS). On slit-lamp examination of the right eye, normal anterior corneal surface with central posterior corneal depression, pigment deposition and diffuse stromal edema was noticed. Fundoscopic examination and intraocular pressure (IOP) measurements were normal in both eyes. Specular microscopy gave normal corneal endothelial cell count values. Axial topography revealed central flattening of the cornea that corresponded to the area of posterior keratoconus with peripheral steeping in the right eye and asymmetric bow-tie astigmatism in the left eye. Measurement of central corneal thickness with ultra-sound pachymetry showed corneal thickness in the right eye (OD=616 µm and OS=559 µm). Orbscan II demonstrated anterior and posterior Diff of 17 µm and 48 µm respectively, which were within normal limits. Simulated keratometry showed corneal flattening (OD and OS: 37×23 and 36.5×113, respectively). Also, Visante revealed normal anterior surface but the irregularity of posterior corneal surface was typically compatible with the diagnosis of posterior keratoconus. Atypical forms of posterior keratoconus can be presented with thick cornea and central corneal flattening. Although both Orbscan and Visante can reveal posterior corneal surface abnormalities, the latter is suggested for studying corneal architecture and excavation.

To report the outcome of a case of primary conjunctival rhabdomyosarcoma treated by surgical excision combined with chemotherapy Case report : A 4-year-old boy presented with a visible recurrence of conjunctival mass in the left eye. The orbital magnetic resonance imaging (MRI) showed the lesion was confined to the conjunctiva without orbital infiltration. Histology and immunophenotype were consistent with an embryonal rhabdomyosarcoma. A surgical excision was performed followed by intensive chemotherapy. The patient remains clinically tumor-free during 4 years of follow-up, with 20/20 vision in both eyes and no treatment complications. The treatment by surgical excision combined with chemotherapy was justified in this case of primary rhabdomyosarcoma, which eliminated the potential complications of radiotherapy.

To describe the case of a 21-year-old patient with uveal effusion with no microphthalmia and any systemic disease that was treated with scleral window surgery and topical administration of mitomycin C (MMC) and zonulysis which was misdiagnose as a ring melanoma of cilliary body appeared shortly after the operation Case report : A uveal effusion was detected in the eye. Partial-thickness scleral flap with sclerostomy was performed and topical MMC was administered to inferotemporal quadrant of the equatorial sclera. The subretinal fluid resorbed gradually. In a short period after fenestration procedure and temporal zonulysis appeared in the eye. In a patient with idiopathic uveal effusion syndrome, a significant zonulysis without severe intraocular pressure (IOP) changes can appear after scleral fenestration procedure.