Journal of Current Ophthalmology
Volume:29 Issue: 4, Dec 2017

PurposeTo review the historical background and basic principles of collagen cross-linking, to bring together the data regarding the outcomes and complications of collagen cross-linking and finally to explore the efficacy and safety of new variations of this technique.
MethodsA literature review was performed using PubMed and Scopus. The following keywords were used for literature search: cross linking, crosslinking, cross-linking, keratoconus, keratectasia.
ResultsIn contrast to traditional treatment modalities for keratoconus (KCN), this new technique addresses the progression of the disease. Several clinical studies have been conducted to assess the efficacy of corneal collagen cross-linking (CXL) in the last decade. The results were promising as collagen cross-linking showed significant improvement in visual acuity and keratometric values. Moreover, initial results show that it is a safe procedure with few reported complications.
ConclusionCXL is an emerging treatment method in ophthalmology that offers the possibility to effectively treat progressive KCN.
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PurposeSurgical treatment in Duane retraction syndrome (DRS) can be very challenging even for the strabismus specialists because of a wide spectrum of diversity in clinical manifestations. The purpose of this article is to review these different surgical treatments.
MethodsA comprehensive search was performed using PubMed database with the different keywords of “Duane retraction syndrome” and “surgery”. Articles were selected from original English papers published since 2000. The full text of the selected articles was reviewed, and some articles were added based upon the references of the initial articles. We also provided selected case examples about some of these procedures.
Results125 articles were found in the initial search of which 37 articles were mostly related to the topic of this review. The number finally increased to 59 articles after considering the relative references of the initial articles. Different surgical methods performed on horizontal and vertical rectus muscles (recession, resection, transposition, Y splitting, periosteal fixation and posterior fixation suture) are reviewed. Careful selection of the surgical technique is important to achieve optimal results.
ConclusionWith accurate diagnosis of patients with DRS and proper surgical management, several adverse situations associated with this syndrome (amblyopia, abnormal head posture, upshoot, downshoot, and muscle underaction) can be prevented.
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PurposeTo test the hypothesis that macular choroidal thickness is lower in patients with pseudoexfoliation syndrome (PXS) as compared to healthy control subjects.
MethodsIn this cross-sectional, observational study, 38 non-glaucomatous PXS subjects and 37 healthy volunteers were enrolled in a tertiary care Glaucoma Clinic. The macular region was scanned with the enhanced depth imaging (EDI) protocol of a spectral domain optical coherence tomography (SD-OCT) device (Spectralis OCT, Heidelberg Engineering, Heidelberg, Germany). Macular choroidal thickness and volumes were compared in nine sectors of the Early Treatment Diabetic Retinopathy Study (ETDRS) layout profile across the central 3.45 mm zone after manual segmentation of the choroidal thickness. Linear mixed modeling was used to adjust for confounding variables.
ResultsSix PXS eyes and 8 control eyes were excluded due to poor image quality leaving 32 PXS and 29 control eyes for final analyses. The average age and axial length of the PXS and control groups were 67.94 ± 7.30 vs 64.86 ± 7.04 and 22.91 ± 0.77 vs 23.24 ± 0.66 mm, respectively, (P = 0.10 and 0.20). There was no significant difference in retinal nerve fiber layer (RNFL) thickness between the two groups (P = 0.24). The choroidal thickness was significantly lower in the central subfield subfoveal area (P = 0.02) and in the inner superior (P = 0.03) and inner nasal quadrants (P = 0.03) in the PXS group compared to the control group, as was the choroidal volume (P = 0.02). No significant difference was found in macular choroidal thickness after adjusting for age, gender, and axial length. While there was a significant negative association between age and central subfield choroidal thickness in the control group (r = −0.48, P = 0.01), this association was not significant in the PXS group (r = −0.08, P = 0.68).
ConclusionsOur findings demonstrate that the choroid does not seem to be significantly altered in PXS eyes. Choroidal thickness changes need to be explored in PXS eyes with glaucoma.

PurposeTo compare chilled and room temperature balanced salt solution (BSS) and bandage contact lens (BCL) on post photorefractive keratectomy (PRK) pain.
MethodsIn a prospective, single-masked, controlled eye study, one hundred eyes of fifty patients were divided into two groups which received room temperature or chilled BSS and BCL in each eye, and compared for post-PRK pain. Three different pain evaluation systems were used to evaluate pain between the groups at 1 and 6 h and days 1, 2, 3, 5, and 7, postoperatively.
Results15 patients were male (30%), and 35 were female (70%). The mean age was 29 ± 5 (20–40) y/o. The mean spherical equivalent (SE) of preoperative refractive error in both groups was not statistically significantly different (−4.18 ± 1.5 in chilled and −4.19 ± 1.7 in room-temperature groups, respectively; P = 0.94). The mean time of epithelial healing was 6.16 ± 1.7 (3–13) days in the chilled and 6.10 ± 1.59 (3–12) in the room temperature group (P = 0.32). Best corrected visual acuity (BCVA) at 1 month was 0.013 ± 0.03 (0–0.22) logarithm of the minimum angle of resolution (logMAR) in the chilled group and 0.014 ± 0.04 (0–0.22) logMAR in the room temperature group, postoperatively (P = 0.84). No statistically significant difference was found between the two groups by any of the three pain scoring systems. No clinically important corneal haziness was found in the groups during follow-up.
ConclusionChilled BSS and BCL do not seem to be superior to room temperature in reducing post-PRK pain.

PurposeTo determine the effect of night-time working on dry eye signs and symptoms.
MethodsA total of 50 healthy subjects completed a dry eye questionnaire and underwent clinical examinations including basic Schirmer's test and tear breakup time (TBUT) test on two consecutive days, before and after the night shift (12-hrs night-shift).
ResultsAll dry eye symptoms were aggravated significantly after the night shift (P ConclusionOur study showed that night-time working can cause tear film instability and exacerbation of dry eye symptoms.

PurposeTo evaluate the visual outcomes, pseudoaccommodation, and wavefront aberrometry after implantation of Wichterle IOL-Continuous Focus (WIOL-CF®, Gelmed International, Kamenne Zehrovice, Czech Republic) by i-Trace aberrometry.
MethodsIn this retrospective interventional case series study, after cataract surgery with implantation of accommodative WIOL-CF®, the patients were evaluated with i-Trace aberrometer for measurement of modulation transfer function (MTF), point spread function (PSF), total aberrations, higher order aberrations (HOAs) at far and near and pseudoaccommodation. The pre and postoperative visual acuity at near and distance were also measured.
ResultsForty eyes of 20 patients (aged 40–77 years) were enrolled in this study with mean follow-up time of up 13.10 ± 5.52 months. The mean logMAR corrected distance visual acuity (CDVA) improved from 0.20 ± 0.14 preoperatively to 0.10 ± 0.09 at the last follow-up after surgery (P = 0.002). The results were 60% J1, 70% J2, 85% J3, 90% J4, 95% J5 and 100% for J6. The mean pseudoaccommodation, range of accommodation volume, and average of peak accommodation were −2.52 ± 1.56 diopters (D), 1.50 to 5.25 D and −3.25 ± 1.25 D, respectively. The mean MTF at 5 cycles per degree at far was 0.200 ± 0.10 and for near was 0.207 ± 0.10. PSF at far and near was 0.0002 and 0.001, respectively. The mean root mean square (RMS) value of HOAs; total, coma spherical aberration, trefoil, and secondary astigmatism were 1.08 ± 0.48 μm, 0.89 ± 0.45 μm, −0.33 ± 0.23 μm, 0.25 ± 0.17 μm, and 0.15 ± 0.13 μm for far and 0.88 ± 0.49 μm, 0.73 ± 0.46 μm, −0.25 ± 0.22 μm, 0.19 ± 0.16 μm and 0.11 ± 0.10 μm for near, respectively. There was a decrease in HOAs at near relative to far (P ConclusionWIOL-CF® seems to be an acceptable accommodative intraocular lens (IOL) in terms of uncorrected near and distant visual outcomes, MTF and HOA.

PurposeTo compare the recurrence rate and surgical outcomes of amniotic membrane transplantation (AMT) and free conjunctival autograft (CAT) for pterygium surgery.
MethodsIn this prospective study, 60 patients with primary pterygium were randomly assigned to two groups of CAT or AMT and were compared in terms of recurrence rate, mean healing time of corneal epithelial defects, the mean level of inflammation, and complications.
ResultsThe mean ± SD age of patients was 48.98 ± 9.8 years (range, 27–71 years). 73.3% were men, and 26.7% were women. The groups did not differ with respect to demographic characteristics (P > 0.05). Patients were followed for an average of 12.6 ± 1.3 months. The recurrence rates were 6.7% and 3.3% in the AMT and CAT groups, respectively (P > 0.05). Comparison of mean inflammation score showed higher inflammation in the AMT group in the first, third, and sixth postoperative month (P ConclusionsNo significant complication was observed during or after both surgical methods. No statistically significant difference was seen in visual acuity changes and epithelial healing in CAT and AMT groups, but more inflammation and recurrence rate were seen in AMT group.

PurposeTo investigate the effects of religious fasting during the month of Ramadan on intraocular pressure (IOP), refractive error, corneal tomography and biomechanics, ocular biometry, and tear film layer properties.
MethodsThis prospective study was carried out one week before and in the last week of Ramadan. Ninety-four eyes of 94 healthy adult volunteers (54 males and 40 females) with a mean ± SD age of 35.12 ± 9.07 were enrolled in this study. Patients with any systemic disorder, ocular disease, or a history of previous surgery were excluded. Corneal tomography and biomechanics, ocular biometry, IOP, refractive error, and tear break up time (TBUT) were evaluated in non-fasting and fasting periods by the Pentacam (Oculus), Corvis ST (Oculus), IOL Master (Carl Zeiss), computerized tonometer (Topcon CT-1/CT-1P), auto kerato-refractometer (Topcon KR-1), and Keratograph 5M (Oculus), respectively.
ResultsThere was no significant difference in the central corneal thickness (CCT) between the study groups (P = 0.123) using the Pentacam while the Corvis ST showed a significant difference in all participants (P ConclusionThis study showed that ACD, IOP, CCT, and peak distance were different between fasting and non-fasting groups while no difference was observed in other ocular parameters. Interpretations of these significant differences should be considered in the clinical setting.

PurposeTo provide normative data of foveal avascular zone (FAZ) and thickness.
MethodsIn this cross-sectional study both eyes of each normal subject were scanned with optical coherence tomography angiography (OCTA) for foveal superficial and deep avascular zone (FAZ) and central foveal thickness (CFT) and parafoveal thickness (PFT).
ResultsOut of a total of 224 eyes of 112 volunteers with a mean age of 37.03 (12–67) years, the mean superficial FAZ area was 0.27 mm2, and deep FAZ area was 0.35 mm2 (P ConclusionThe gender and CFT influence the size of normal superficial and deep FAZ of capillary network.

PurposeTo compare chronic subclinical inflammation induced after implantation of Artisan vs. Artiflex phakic intraocular lenses (pIOLs).
MethodsThis prospective, comparative, non-randomized study included consecutive patients with moderate to high myopia who underwent Artisan or Artiflex pIOL implantation with standard surgery and postoperative care. Anterior chamber flare was assessed quantitatively using laser flare photometry (LFP) at baseline, 1 week, 1 month, 3 months, 6 months, and 2 years after surgery.
ResultsPIOLs were implanted in 72 eyes (40 patients); Artisan pIOLs in 16 eyes (Artisan group) and Artiflex pIOLs in 56 eyes (Artiflex group). The mean preoperative anterior chamber flare was 6.5 ± 2.3 (range, 4.2–9.5) photons per millisecond (ph/ms) and 4.2 ± 0.9 (range, 2.5–11.7) ph/ms in Artisan and Artiflex groups, respectively (P = 0.400). In spite of early postoperative rise, the flare value returned to preoperative levels 6 months after pIOL implantation and remained stable up to 2 years. The amount of flare was not statistically different between Artisan and Artiflex groups in any postoperative follow-up (all P > 0.05). The trend in flare changes was not different between the studied groups (ANCOVA, P = 0.815).
ConclusionThe inflammatory response induced by implantation of either type of Artisan and Artiflex pIOLs is short-lived without statistically significant difference between the two models.

PurposeTo determine the prevalence of uncorrected refractive errors, need for spectacles, and the determinants of unmet need in underserved rural areas of Iran.
MethodsIn a cross-sectional study, multistage cluster sampling was done in 2 underserved rural areas of Iran. Then, all subjects underwent vision testing and ophthalmic examinations including the measurement of uncorrected visual acuity (UCVA), best corrected visual acuity, visual acuity with current spectacles, auto-refraction, retinoscopy, and subjective refraction. Need for spectacles was defined as UCVA worse than 20/40 in the better eye that could be corrected to better than 20/40 with suitable spectacles.
ResultsOf the 3851 selected individuals, 3314 participated in the study. Among participants, 18.94% [95% confidence intervals (CI): 13.48–24.39] needed spectacles and 11.23% (95% CI: 7.57–14.89) had an unmet need. The prevalence of need for spectacles was 46.8% and 23.8% in myopic and hyperopic participants, respectively. The prevalence of unmet need was 27% in myopic, 15.8% in hyperopic, and 25.46% in astigmatic participants. Multiple logistic regression showed that education and type of refractive errors were associated with uncorrected refractive errors; the odds of uncorrected refractive errors were highest in illiterate participants, and the odds of unmet need were 12.13, 5.1, and 4.92 times higher in myopic, hyperopic and astigmatic participants as compared with emmetropic individuals.
ConclusionThe prevalence of uncorrected refractive errors was rather high in our study. Since rural areas have less access to health care facilities, special attention to the correction of refractive errors in these areas, especially with inexpensive methods like spectacles, can prevent a major proportion of visual impairment.

PurposeTo present the qualitative and quantitative ultrasonographic findings of lower eyelid compartments in patients with chronic thyroid associated ophthalmopathy (TAO) compared to normal subjects.
MethodsIn a prospective study, dynamic and static ultrasonographic investigation, applying high resolution (15 MHz) ultrasound was performed to assess the lower eyelid, in 15 TAO patients that were in chronic phase and 10 normal subjects. The thickness and echogenisity of dermis, orbicular oculi muscle, lower eyelid retractor muscle, lower eyelid fat pads, and their qualitative relationships during vertical excursion of the globe were evaluated in static and dynamic investigation. Correlation of ultrasonic and clinical findings was evaluated.
ResultsThe mean age of the patients was 41.82 ± 7.4 years, and the controls were age-matched (mean age, 42.8 ± 5.6 years). Mean proptosis of the involved eyes was 3.3 mm, and mean lower lid retraction was 2.4 mm in chronic TAO group. Pattern of fat motion was blocky in chronic TAO patients compared to normal jelly motion of the fat in normal cases. In analyzing the range of motion, the difference was significant in the motion of both superficial and deep fat pockets between the two groups (P ConclusionDevelopment of a series of static and dynamic changes in ultrasound is related to the clinical findings in chronic phase of TAO. The limitation of motion and fibrotic changes of lower eyelid fat pads were more detectable in cases with a more severe proptosis and lower lid retraction. It is considered that ultrasound findings can be a representative of the severity of involvement in the chronic phase of the TAO.

PurposeTo study the management and outcomes of patients with paintball injuries resulting in traumatic glaucoma.
MethodsA retrospective review was performed, identifying four patients with a confirmed diagnosis of traumatic glaucoma secondary to paintball sports.
ResultsFour male patients with paintball gun injuries presented with a mean follow-up time of 51 months after the date of injury. The mean age was 23.5 ± 18.6 years. Three patients presented with blunt trauma, while one patient had a ruptured globe. Presenting visual acuity (VA) was hand motions in three of the patients and no light perception in the fourth patient. All patients were diagnosed with traumatic glaucoma and treated with glaucoma medications during their follow-up. Two patients received tube shunts to control intraocular pressures (IOPs). At the time of most recent follow-up, three patients had elevated IOPs and were not on any medications. VA at the last follow-up was 20/400 or worse.
ConclusionsTraumatic glaucoma can be managed with surgical and medical interventions, while VA usually does not return to baseline levels prior to the injury. Prognostic predictors can be used to guide treatment and identify patients who should be closely followed. Because the presentation and onset is widely variable, follow-up and screening is crucial even years after the injury.

PurposeTo evaluate the effect of acupuncture therapy on visual function of patients with retinitis-pigmentosa (RP).
MethodsIn a prospective study, 23 RP subjects received ten sessions of body-acupuncture. Pre and post-treatment evaluations included best corrected visual acuity (BCVA), uncorrected visual acuity (UCVA), near visual acuity (NVA), and static 30-2 perimetry.
ResultsUCVA, BCVA, and NVA improvements after acupuncture therapy were statistically and clinically significant (P = 0.048, P = 0.0005, P = 0.002, respectively). The changes of mean foveal threshold (MFT) and mean deviation (MD) were statistically significant (P = 0.031, P = 0.02). There were no statistically significant difference between different age group and genders. Subjective symptoms of improvement were seen in most of cases.
ConclusionFuture studies are needed to show the effect of acupuncture therapy on visual function of patients with RP.

PurposeTo report removal of retained subfoveal perfluorocarbon liquid (PFCL) after vitrectomy for retinal detachment.
MethodsThree patients underwent 3-port 23-gauge vitrectomy in an attempt to remove retained subfoveal PFCL bubble secondary to retinal detachment surgery. In two patients, removal was achieved via a 23-G needle whereas the third patient with multiple small subfoveal droplets, multiple punctures were required and in that case a small 40-G needle was used.
We assessed best corrected visual acuity (BCVA), fundus imaging, and spectral domain optical coherence tomography (SD-OCT) of all patients before and after surgery.
ResultsThe subfoveal PFCL was successfully removed in all 3 eyes and although a functional improvement was documented, outer retinal atrophy and photoreceptor loss was observed in all our cases.
ConclusionsSD-OCT allows early recognition of retained subfoveal PFCL. Surgical removal may lead to retinal morphologic restoration and functional improvement. While we achieved complete removal of PFCL with both 23-G and 40-G instrumentation, we believe the versatility and ease justifies the universal usage of 40-G retinotomy needles.

PurposeTo report a case with Edward's syndrome and ocular manifestations.
MethodsA three-year-old female visited our clinic. The diagnosis of Edward's Syndrome was made prior to the ophthalmic visit based on a karyotype study report. Complete ophthalmic evaluations were done for the patient.
ResultsOn the initial ophthalmic examination, bilateral ptosis, epicanthal folds, and 40 prism diopters alternate esotropia (ET) were seen. In the fundus examination, decreased red reflexes along with retinal folds, pigmentary retinopathy (patches of hyperpigmentation in the fovea and retinal periphery), and optic disc atrophy in both eyes were seen.
ConclusionOur case adds some evidence to the literature that ET may be one of the classic manifestations and anomalies in trisomy 18.