مجله چشم پزشکی بینا
سال هجدهم شماره 2 (زمستان 1391)

To compare clinical outcomes of two methods of corneal transplantation, penetrating keratoplasty (PK) versus lamellar keratoplasty (LK), in patients with delayed-onset mustard gas keratitis (MGK). In this retrospective, comparative, interventional case series, 78 eyes of 55 victims of chemical warfare with delayed-onset mustard gas keratopathy who underwent PK or LK were enrolled. Two groups were compared in terms of best spectacle-corrected visual acuity (BSCVA), refractive error, and keratometric readings. The cumulative incidence of PK versus LK rejection-free graft survival, as well as graft survival were used to evaluate and compare the results. At the time of keratoplasty, mean age was 40.34.5 years in the PK group and 43.84.3 years in the LK group (P=0.08), the patients were followed for 53.227.5 and 40.429.6 months, respectively (P=0.09). At the last follow-up, both groups were comparable in terms of to BSCVA (P=0.87), refraction (P=0.08), and keratometric readings (P=0.27). The rejection-free graft survival rate was 33.6% in the PK group and 90% in the LK group at 33 months with a mean length of 34.5 and 84.8 months, respectively (P<0.001). At the same follow-up examination, the graft survival rate was 77.3% and 91.7% with a mean length of 67.5 and 75.1 months, respectively (P=0.03). Three eyes that had received LK required PK because of significant interface haze formation. LK is preferred to PK in the majority of mustard gas victims. However, PK may inevitably be performed in some conditions.

To evaluate the efficacy of pregabalin and gabapentin for post-photorefractive keratectomy (PRK) pain relief. 150 patients were divided into 3 groups. After undergoing PRK; groups 1, 2, 3 received pregabalin 75 mg, gabapentin 300 mg, and placebo 3 times daily for 3 days, respectively. Patients could take acetaminophen-codeine 300/10 mg tablets every 4 hours as needed. Patients completed a pain assessment survey (visual analogue scale ranging from 0 = no pain to 10 = most severe pain) 7 times in the first 3 days following PRK and also recorded the number of consumed acetaminophen-codeine tablets. The three groups were similar in terms of age, sex, refractive error, ablation depth, and mitomycin-C (MMC) application (all p values>0.05). Overall, pain score in the placebo group was higher than the pregabalin (P=0.029) and gabapentin (P=0.023) groups, respectively. Severe pain (score >7) was more frequent in the placebo group on the morning of the first postoperative day (P=0.043). The number of consumed acetaminophen-codeine tablets was lower in the pregabalin and gabapentin groups than the placebo group,but this difference didnt reach statistical significance (P=0.061). Pregabalin and gabapentin are helpful in alleviating post-PRK pain when combined with other medications. Depending on availability, either compound can be used as an adjuvant for pain control in this setting.

To compare repeated intravitreal injections of bevacizumab (IVB) with triamcinolone acetonide (IVT) for treatment of acute branch retinal vein occlusion (BRVO). This randomized clinical trial included, 86 eyes with recent onset (less than 12 weeks) BRVO. Participants were randomly assigned to two treatment groups: the IVB group (43 eyes) consisted of patients who received monthly injections of 1.25 mg IVB, and the IVT group (43 eyes) comprised of patients who received 2 injections of 2 mg IVT two months apart. Patients were examined 1, 2, 3, 4, and 6 months after enrollment. The main outcome measure was change in best-corrected visual acuity (BCVA) at 6 months. Secondary outcome measures were central macular thickness (CMT) and intraocular pressure (IOP) changes at month 6. Mean BCVA improved significantly up to 6 months in both groups from 0.250.68 to 0.31±0.21 LogMAR (logarithm of minimum angle of resolution) in the IVB group, and from 0.67±0.29 to 0.46±0.31 LogMAR in the IVT group, (P<0.001 for both groups). However, inter-group differences reached significant levels at months 4 (P=0.013) and 6 (P<0.001) in favor of the IVB group. In terms of CMT reduction, similarly, both groups showed a significant decrease at months 3 and 6, and the differences between the groups was statistically significant (P=0.031) at final visit. Dividing the cases into ischemic and non-ischemic types, a significant difference was noted only in ischemic cases regarding BCVA improvement and CMT reduction in favor of the IVB group. Mean IOP rise was significantly higher in the IVT group at all visits. Both 3 times monthly IVB injections and 2 times IVT injections with two month interval could be effective for improving BCVA and CMT in cases with recent onset BRVO up to 6 months. However, considering the better visual and anatomic outcomes after IVB injections and the potential complications of IVT injections, we would recommend prescheduled repeated IVB injections for such cases. The favorable responses were more pronounced in the ischemic types of BRVO in this trial; nevertheless, this should be confirmed in larger studies.

To evaluate demographics and therapeutic outcomes of patients with third nerve palsy who had been treated between 1999 to 2009 at Labbafinejad Medical Center. In this retrospective study, we evaluated 52 patients with third nerve palsy who had been referred to Labbafinejad Medical Center over a ten-year period. In this retrospective study, subjects who had been treated for third nerve palsy from 1999 to 2009 at Labbafinejad Medical Center were enrolled. Of 52 subjects enrolled in this study 29 (55.8%) were men and 23 (44.2%) were women. Mean age was 21.1 (SD: 15.5); 25 subjects (48.1%) had third nerve palsy in their right eye and 26 subjects (50%) had it in their left eye. Both eyes were involved in one subject (1.9%). Etiologies of 3rd nerve palsy included congenital 16 (30.8%), trauma 26 (50%), ischemia 2 (3.8%), tumor 2 (3.8%), viral meningitis one (1.9%) and unknown causes in 5 subjects (9.6%). In 38 subjects (73.1%) the palsy was isolated but in 14 subjects (26.9%) it was associated with other cranial neuropathies or neurologic deficits. The palsy was complete in 24 patients (46.2%) and incomplete in 28 patients (53.8%). Ptosis was seen in 45 subjects (86.5%). The most common type of strabismus was exotropia associated with hypotropia (40%). Medical reatment was performed in 25 (48%) and surgical treatment in 46 (88.4%) subjects. One, two and three step strabismus surgery was done in 30 (65.2%), 11 (24%) and 5 (10.8%) subjects respectively. Mean horizontal deviation in primary position was 66 prisms before surgery which was decreased to 21, 13 and 6 after first, second and third surgery, respectively. Mean vertical deviation was 13 prisms before surgery which was decreased to 7, 4 and 1 after first, second and third surgery, respectively; 18 of 52 subjects 34.6 % underwent ptosis surgery.One, two and three step ptosis surgery was performed in 15 (83.3%), 1 (5.5%) and 2 (11%) cases respectively.Mean palpebral fissure height in patients who underwent ptosis surgery was increased from 4 mm to 7mm. In our study the first and second main causes of third nerve palsy leading to surgical intervention were trauma and congenital abnormalities, respectively. Great number of patients required surgery to achieve acceptable treatment results. In conclusion, surgical management of patients with third nerve palsy is difficult and challenging but most patients achieve good results with appropriate and stepwise surgical plans.

To compare complications and motility of hydroxyapatite versus medpor ocular implants after enucleation at Ahvaz Imam Hospital (from Jan 2010 to Jun 2011). In a clinical trial, 50 patients scheduled for enucleation were randomly divided in two groups of 25 patients. Group 1 underwent enucleation + hydroxyapatite (HA) and group 2 underwent enucleation +medor implant. All patients were operated by 2 surgeons. Then patients were visited 10, 30, 90 and 180 days after surgery for complication and motility. Patient age ranged from 8 to 68 years with a mean of 36.3 years, 52% of the patients were male and 48% were female. The most common used implant was 18 by size, the most common cause of loss of vision was trauma and the most common cause of surgery was cosmetic reasons in both groups. Complications in both groups were similar and the rate was high in both group in the early postoperative days. The most common complication was mucopurulent discharge, in the first month was 36% that reduced to 8% in the end of study. Mean amount of ocular motility was more in abduction: 4.72 mm and 4.58 mm in HA and medpor groups respectively but it was less in upgaze; 3.18 in HA and 3.14 in medpor groups. Complications and motility were similar in two groups and there was no significant difference (P= 0.99). According to our study, the rate of complications and motility are similar in HA and Medpor ocular implant after enucleation.

To report the rate of visual impairment in pervasive developmental disorder (PDD). In this descriptive-analytic study 62 children with PPD diagnosed by a children psychiatrist were included. All subjects were evaluated for age, sex, systemic & eye conditions such as refractive errors,strabismus, oculomotor disorders, color vision, stereopsis, visual contact and fixation pattern. Overall, 68% of cases were male and 32% were female; age ranged from 5 to 15 years (mean age=8.4 year). Forty percent of case had no central fixation & 60% had inappropriate visual contact. 19.6% of cases had exotropia & 6.5% had esotropia.Cycloplegic refraction demonstrated hyperopia in 72% of cases (mean=+1.3D). Hyeropia ≥+ 1.5 was present in 50% of cases. The prevalence of astigmatism was 30% and 80% of them were with the rule. Ophthalmologic problems in PPD children appear to be mainly hyperopia, astigmatism and poor fixation. Strabismus (especially exotropia) also has a high prevalence among PPD children which can lead to amblyopia.Because of their limited communication; complete eye examination for early diagnosis should be recommended.

To determine the prevalence and causes of blindness and low vision in Yazd provice in 2008.

A population-based cross-sectional study was performed on inhabitants of in Yazd province in 2008. Using multistage cluster sampling, sample size was calculated based on the distribution of the total population of Yazd province derived from national census and estimated rates of blindness. Information was collected using a questionnaire, including general information and results of the optometrist’s and ophthalmologist’s diagnosis. Categorization of blindness and low vision was based on the international classification of diseases version 10 (ICD10).

Overall, 974 subjects with average age of 26.1±19.1 years participated (response rate 89.9%). 40 subjects (4.1%) according to best corrected visual acuity had visual impairment in one or both eyes. The prevalence of blindness was 0.3% (95% CI= 0-0.7%) and prevalence of low vision was 1.2% (95%= 0.4-2%). The leading causes of visual impairment were cataracts (32.5%), corneal opacities (12.5%) and amblyopia (10.0%).

It is estimated that about 2,576 cases of bilateral blindness and 11,899 people with low vision live in Yazd province. The prevalence rates of blindness and low vision were lower than global average and Tehran province. This study recommends similar studies with larger sample size and reinforces the need for expansion of health programs on prevention and control of visual impairment and their causes.

Vision disorders are closely associated with poverty, particularly blindness. We determined the prevalence of low vision and blindness in different socioeconomic levels. Our goal was determination of correlation between socioeconomic determinants and visual acuity in Varamin city. This community based study was done on 2737 people over the age of 50 years, living Varamin city and subsidiary regions. We selected samples according stratified cluster random sampling. We standardized the questionnaire and trained questioner to collect data by interview and ophthalmic examinations in home visits. Patients were referred to the ophthalmology clinic if we find problem in initial examinations. Quality controls were done during the processes. We analyzed data by ANOVA, chi-square and other nonparametric tests and concentration index in SPSS and STATA soft ware’s. We determined the socioeconomic level of people with 91% response rate. People with Low socioeconomic level had significantly lower education level, higher unemployment rate and lower marital status.Low socioeconomic level associated significantly with unilateral blindness, unilateral and bilateral low vision (P<0.001).Socioeconomic level and bilateral blindness didn’t have correlation (P=0.13). Visual defect significantly was seen in low socioeconomic (concentration Index=-0.24, 95%CI:-0.32,-0.16) and bilateral blindness didn’t seen in low socioeconomic groups. (Concentration index=-0.15, 95%CI:-0.37,0.06). Socioeconomic level had association with unilateral blindness, unilateral and bilateral low vision.Low socioeconomic people have low education, unemployment and low social support so they don’t care of themselves because of lack of knowledge, or low access to appropriate health care. We suggest moreinvestigation on these reasons.

Stem cell therapy has been applied for the treatment of degenerative diseases encompassing corneal disorders.This consideration is regarding the unique characteristics of stem cells including self-renewal and pluripotency. Some corneal diseases result from deficiencies in the limbal region. In these conditions, limbal stem cell therapy is considered in which limbal stem cells are cultured in vitro and transplanted. However, allograft stem cell transplants may be rejected and the use of immonosuppressors may have adverse effects.Patient’s epithelial cells are suggested as a source for corneal stem cells. Animal studies have shown successful differentiation of hair follicle, dental pulp, bone marrow, oral mucus and mesenchymal stem cells to corneal epithelial cells. In this revie warticle, the corneal stem cells are first introduced. Various stem cell cultures are then discussed and the possibility of using other stem cell sources for the treatment of corneal disorders is evaluated.

Keratoconus is a non-inflammatory, progressive thinning process of the cornea. It is a relatively common disorder of unknown etiology that can involve each layer of the cornea and often leads to high myopia and astigmatism.Computer- assisted corneal topography devices are valuable diagnostic tools for the diagnosis of subclinical keratoconus and for tracking the progression of the disease. The traditional conservative management of keratoconus begins with spectacle correction and contact lenses. Several newer, more invasive, treatments are currently available, especially for contact lens-intolerant patients. Intrastromal corneal ring segments can be used to reshape the abnormal cornea to improve the topographic abnormalities and visual acuity. Phakic intraocular lenses such as iris-fixated, angle-supported, posterior chamber implantable collamer and toric lenses are additional valuable options for the correction of refractive error. Corneal cross-linking is a relatively new method of stiffening the cornea to halt the progression of the disease. The future management of keratoconus will most likely incorporate multiple treatment modalities, both simultaneous and sequential, for the prevention and treatment of this disease.

To report the possible transmission of Zygomycetes infection by a corneal graft harvested from a donor with signs of trauma to the orbital region to a keratoconic patient who underwent deep anterior lamellar keratoplasty (DALK).Case Report: A 19-year-old keratoconic man underwent DALK in the right eye. The corneal graft was harvested from a donor with signs of orbital trauma. On postoperative day 3, slit lamp examination revealed multiple refractile lines involving the entire donor stroma. With a possible potential diagnosis of lattice dystrophy of the donor cornea, the graft was replaced. Histopathologic analysis demonstrated Zygomycetes graft infection. This case report suggests that corneas harvested from donors with signs of orbital trauma may be at risk of donor-to-recipient transmission of Zygomycetes infections.

To present a case of orbital abscess secondary to mandibular odontogenic infection.Case report: A 30 year old man presented with ocular pain and exophthalmos of the left eye following a dental infection since a few days ago. A localized abscess was detected in the left orbital CT but the paranasal sinuses were clear. Involvement of the left third mandibular molar was evident on facial X-ray. Simultaneoussurgical drainage of the orbital and dental lesions was performed following failure of medical treatment.Consequently the patient’s clinical picture resolved completely. Mandibular odontogenic infection is a rare cause of orbital cellulitis and early surgical intervention has great value in treatment of this condition.

To report an extremely rare presentation of isolated orbital xanthogranuloma with no systemic disease, nor dermatologic manifestation.Case report: The patient was a 45-year-old man complaining of a mass lesion in the superior and inferior eyelids of his right eye; the lesions had been enlarging slowly and painlessly since 5 years before. Other examinations (including skin, heart, etc.) and lab data (CBC, lipid profile, liver and kidney function tests)were normal. The tumor on the superior eye lid was excised completely. Histopathology confirmed a diagnosis of xanthogranuloma. The tumor on the lower eyelid was excised, too. During 6 months of followup no sign of recurrence was found. Adult onset xanthogranuloma may manifest as an isolated orbital mass. In such situations,complete systemic examinations, serologic testing and paraclinic evaluation (ECG, imaging) should be done and long term follow up is recommended.