Journal of Current Ophthalmology
Volume:31 Issue: 1, Mar 2019

To assess the literature on the effects of topical intraocular pressure (IOP)-lowering medications on the ocular surface. Ocular surface assessment in these patients is seldom a priority for most clinicians since the ultimate goal of management is to preserve vision. A literature search of articles (English only) on the subject matter was conducted and their findings summarized. This review assesses the prevalence of dry eye symptoms in glaucoma patients on topical IOP-lowering medications. We extensively reviewed the effects of the preservatives and active ingredients in these medications on the ocular surface. In particular, the effects of benzalkonium chloride (BAK), a widely used preservative, on meibomian glands are explored. Also mentioned in this review is the association between duration of therapy and severity of dry eye symptoms. The role of the pH of medications in the development of ocular surface disease is also reviewed. Finally, we probed the occurrences of ocular allergic reactions with the use of topical IOP-lowering medications. The preservatives and active agents in most topical glaucoma medications are implicated in the prevalence of ocular surface discomfort. Whilst clinicians involved in glaucoma care are encouraged to assess the ocular surface routinely, further studies are needed to demonstrate the contributions of other physiochemical properties of these medications to the development of ocular surface disease in these patients.

To summarize actual literature data on clinical signs, differential diagnosis, and treatment of acanthamoeba keratitis. Review of literature. Clinical signs of acanthamoeba keratitis are in early stages grey-dirty epithelium, pseudodendritiformic epitheliopathy, perineuritis, multifocal stromal infiltrates, ring infiltrate and in later stages scleritis, iris atrophy, anterior synechiae, secondary glaucoma, mature cataract, and chorioretinitis. As conservative treatment, we use up to one year triple-topical therapy (polyhexamethylene-biguanide, propamidine-isethionate, neomycin). In therapy resistant cases, surgical treatment options such as corneal cryotherapy, amniotic membrane transplantation, riboflavin- UVA cross-linking, and penetrating keratoplasty are applied. With early diagnosis and conservative or surgical treatment, acanthamoeba keratitis heals in most cases.

To evaluate the outcome of trabeculectomy versus Ahmed glaucoma valve (AGV) surgery in patients with Fuchs uveitis Syndrome (FUS). Twenty-eight eyes with uncontrolled glaucoma and at least 6 months of follow-up were enrolled. In 16 eyes trabeculectomy and in 12 eyes AGV implant were performed. The primary outcome measure was surgical success defined as 5 < intraocular pressure (IOP)
21 mmHg (criterion A) and 5 < IOP
16 mmHg (criterion B), with at least 20% reduction in IOP, either with no medication (complete success) or with no more than preoperative medications (qualified success). The sum of complete and qualified success was defined as cumulative success. The mean age of the patients in the trabeculectomy group and the AGV group was 44.92 ± 9.02 and 45.76 ± 7.10 years, respectively (P ¼ 0.79). The mean duration of follow-up was 23.06 ± 12.03 months in the trabeculectomy group and 22.83 ± 13.63 months in the AGV group (P ¼ 0.96). The baseline mean IOP in trabeculectomy was 26.81 ± 6.69 mmHg which decreased to 11.61 ± 4.15 mmHg at last visit (P < 0.001). In the AGV group, mean IOP was 31.41 ± 6.76 at baseline that changed to 22.41 ± 5.09 at last visit (P ¼ 0.005). According to criterion A, cumulative success rates were 100% and 91% at 6 months and 76% and 9% at 36 months in the trabeculectomy and the AGV group, respectively. Cumulative success rates at 6 months were 93% and 58% and 65% and 7% at 36 months according to criterion B in the trabeculectomy and the AGV group, respectively. Kaplan-Meier survival analysis revealed a significant association between surgical method and cumulative success rate over 36 months (based on criteria A: P ¼ 0.02, and based on criteria B: P ¼ 0.007). The success rate of trabeculectomy was higher than AGV in the surgical management of glaucoma in FUS during a medium-term follow-up.

To evaluate the changes in tear film osmolarity and Schirmer I test after cataract surgery. This single-center, prospective study included patients with no subjective complaints about dry eye disease. Patients with the following conditions were excluded: contact lens wearers, patients with diabetes, pseudoexfoliation, pterygia, and eye drops users. The eye that had not undergone surgery was considered the control group. Tear osmolarity and Schirmer I test were evaluated before surgery and during the first postoperative month. Thirty-seven patients were enrolled in the study. Before surgery, tear osmolarity was 301.2 ± 15.09 Osm/L in the study group and 302.3 ± 14.21 mOsm/L in the control group (P ¼ 0.2), while Schirmer I test averaged 13.4 ± 10.50 mm in the study group and 13.7 ± 10.79 mm in the control group (P ¼ 0.6). The next morning, the tear osmolarity decreased to <275 mOsm/L in the study group while in the control group, the value increased to 303.1 mOsm/L ± 13.68 (P ¼ 0.008). The Schirmer I test in the same morning showed an increase up to 19.9 ± 9.73 mm in the study group and to 15.7 ± 10.19 mm in the control group (P ¼ 0.01). One week later, the tear osmolarity increased to 311.8 ± 14.85 mOsm/ L, while the control group averaged 301.7 ± 11.84 mOsm/L (P ¼ 0.013). The Schirmer I test results decreased to 15.8 ± 9.37 mm in the study group and 13.9 ± 10.19 mm in the control group (P ¼ 0.07) one week after the surgery. One month after surgery, tear osmolarity and Schirmer I test results in the study group decreased to the control group level (P > 0.05). The tear osmolarity results increased to the dry eye disease level in the first postoperative week. Over the course of one month, the difference in tear osmolarity and Schirmer I test values for the study and control groups leveled off.

To evaluate static and dynamic cyclotorsions during photorefractive keratotomy (PRK) surgery in refractive surgery candidates and their correlations with preoperative factors. This cross-sectional case series was performed in 138 eyes of 77 patients who underwent PRK surgery by Technolas 217z100. Iris registration was used to evaluate the degree of static and dynamic cyclotorsion. Wavefront measurements were performed in sitting position using Zywave (versions 3.1 and 3.2, Bausch & Lomb) Hartmann Shack aberrometer (Bausch & Lomb), and the cyclotorsion from upright to supine position was measured using iris image comparison. Dynamic cyclotorsions were measured by Advanced Cyclotorsional Eye Tracker (ACE) mounted on Excimer laser machine Technolas 217z100 during surgery. The mean absolute static cyclotorsion that was captured in surgery time was 3.37 ± 2.38
(range, 0.00 to 11.30), and the mean absolute dynamic cyclotorsion was 2.54 ± 2.50
(range, 0.00 to 13.60). There was a significant correlation between dynamic cyclotorsions and static cyclotorsions (P < 0.001 and R ¼ 0.704). There was a strong association between preoperative refractive astigmatism and range dynamic cyclotorsion. Total pulses (P ¼ 0.009), ablation depth (P ¼ 0.012), gender (P ¼ 0.008) had significant correlations with cyclotorsional movements. The measurements of static and dynamic cyclotorsions are highly recommended for refractive surgery candidates with significant preoperative refractive astigmatism.

To investigate the features and outcomes of retinoblastoma (Rb) patients complicated by development of retinal detachment (RD) following systemic chemotherapy with or without local focal consolidation treatment and without external beam radiotherapy (EBRT). A retrospective study of all Rb patients between April 2002 and April 2012 at a tertiary hospital center (Birmingham Children’s Hospital and Birmingham Midlands Eye Centre, United Kingdom). All eyes that had developed RD during or after systemic treatment with or without local focal consolidation treatment were included in the study. The time interval between the type of treatment of Rb, development of RD and relevant surgical intervention were analyzed. Patients with exudative RD were treated conservatively through observation and patients with rhegmatogenous RD were treated with scleral buckling. Final anatomical retinal reattachment rate and visual acuity outcomes were analyzed. A total of 258 patients were treated for Rb over the 10-year period. One hundred sixty-nine patients were managed with globe conserving treatment. Ten (5.92%) eyes of 10 patients were complicated with RD. Five eyes were exudative or presumed exudative type of RD while the other five eyes were rhegmatogenous or presumed rhegmatogenous RD. In the exudative group, two patients achieved visual acuity (VA) of 0.2 Single Kays (20/32 Snellen), and the other two patients achieved 0.85 and 0.86 Crowded Kays (20/142 and 20/145 Snellen), respectively, after the RD had resolved. The last patient in the group had to be enucleated due to tumor recurrences. The median time for the exudative RD to resolve is 15 weeks (range, 4e36 weeks). In the rhegmatogenous group, 3 of the 4 operated patients achieved retinal reattachment. The final postoperative VA ranged between 0.05 Crowded Kays to 1.84 Crowded Kays (20/22 to 20/1384 Snellen). The other patient was treated conservatively as no retinal breaks were found with previous cryotherapy and thermotherapy. The final VA in this patient was hand movement, and the RD did not reattach. The median time for the rhegmatogenous RD to reattach is 6 weeks (range, 4e8 weeks). There were no intra- and postoperative complications. With long-term conservative management through observation, exudative Rb after systemic treatment of Rb will tend to resolve by itself. However, supplementary local treatment with cryoretinopexy or laser photocoagulation during the systemic treatment of Rb can lead to an increased risk of rhegmatogenous RD. In these cases, most rhegmatogenous RD are successfully repaired with non-drainage scleral buckling and cryoretinopexy.

To evaluate the choroidal thickness changes after cataract surgery in type 2 diabetic patients. Three groups of patients were enrolled into this prospective study. Group A included diabetic patients without diabetic retinopathy (DR) or with mild non-proliferative diabetic retinopathy (NPDR) who underwent phacoemulsification, Group B included non-diabetic patients with significant cataract who underwent phacoemulsification, and Group C included diabetic patients without DR or with mild NPDR who followed up without surgical procedure. Choroidal thickness in 5 points (subfoveal and 500 m temporal, nasal, superior and inferior to the fovea) and central macular thickness were measured before surgery using enhanced depth spectral domain optical coherence tomography. Patients were re-evaluated 1 week, 1 month, and 3 months after operation and compared with the baseline values. In total, 63 eyes from 63 patients were enrolled to this study, including 21 eyes in Group A, 22 eyes in Group B, and 20 eyes in Group C. After three months of follow-up of the patients, choroidal thickness in all measured points was decreased significantly, and central macular thickness was increased significantly following cataract surgery in diabetic eyes (Ggroup A); meanwhile, both choroidal thickness and central macular thickness were increased significantly in non-diabetic eyes (Group B). In Group C, choroidal thickness and central macular thickness had no significant changes, after three months. Unlike in non-diabetic eyes, choroidal thickness in diabetic patients decreased following cataract surgery.

To evaluate the effects of anti-vascular endothelial growth factors (anti-VEGF) on the vessels of the non-treated eyes following intravitreal injections. In this prospective, non-randomized trial, a total of 38 patients were recruited. 21 patients received ranibizumab, and 17 patients received bevacizumab. Fundus photography was carried out at baseline immediately before injection and at 3 days, 7 days, and one month after the injections. Using image analysis software, measurements were summarized as the central retinal artery equivalent (CRAE) and central retinal vein equivalent. In non-treated eyes, CRAE decreased significantly from 153.23 ± 15.20 mm before injection to 148.77 ± 17.21 mm 3 days after intravitreal bevacizumab (P ¼ 0.004). There was no significant difference in CRAE, between the pre-injection baseline, one week, and one month after intravitreal bevacizumab injection in non-treated eyes (P > 0.05). No significant difference was noted in CRAE in the non-treated eyes of the ranibizumab group at any post-injection visit (P ¼ 0.1). A significant transient narrowing effect of bevacizumab on retinal arterioles in the fellow non-treated eyes on the third day after intravitreal injection may show that plasma concentrations of these drugs are sufficient to spread the effect to the other eye.

To compare the efficacy of intravitreal bevacizumab (IVB) injection with conventional laser photocoagulation in eyes with type 1 zone II retinopathy of prematurity (ROP). Preterm infants with type 1 ROP in zone II (stage 2 or 3 ROP with plus disease) were randomly assigned to intravitreal injection of 0.625 mg/0.025 ml bevacizumab (Group 1) or laser photocoagulation (Group 2). Patients were followed weekly for 4 weeks and then biweekly till 90 weeks gestational age. Also, spherical and cylindrical refractive errors were compared at 90 weeks postmenstrual age (PMA). A total of 116 preterm infants (232 eyes) were treated and completed the follow-up period. IVB injection was done in 154 eyes (77 cases), and laser photocoagulation was done in 78 eyes (39 cases). ROP regressed after single IVB injection in 149 eyes (96.8%) and in 5 eyes (3.2%) after the second injection. Cataract developed in one eye (0.63%) after IVB injection. ROP regressed in 94.7% of treated eyes (76 eyes) in the laser photocoagulation group; however, retinal fold and traction developed in 2 eyes. Spherical and also cylindrical refractive errors had no significant difference. Both IVB injection and laser photocoagulation are effective methods for the treatment of type 1 zone II ROP. However, retreatment requirement may be higher in the IVB injection group. IVB re-injection is an effective option for re-treatment in persistent cases.

To report the results of aflibercept treatment in treatment-naive neovascular age-related macular degeneration (AMD) patients and suggest a suitable treatment algorithm for routine clinical practice. The medical charts of patients treated with intravitreal aflibercept for neovascular AMD were reviewed retrospectively. Best corrected visual acuity, slit-lamp examination, dilated fundus examination, applanation tonometry, and a total number of aflibercept injections were recorded. Aflibercept therapy was applied in an as-needed algorithm after three monthly loading dose. Additionally, optic coherence tomography data, including presence or absence of macular fluid and central macular thickness were recorded. Thirty-eight eyes of 36 patients were included in this study. The mean number of aflibercept injections was 4.86 ± 2.76 (3e18). Mean follow-up time was 12.1 ± 5.7 months (6e26). Thirty-seven eyes (97.3%) achieved maintenance of vision. The mean best corrected visual acuity (logMAR) increased from 0.98 ± 0.56 (0.2e2.4) to 0.57 ± 0.31 (0.1e1.3), (P ¼ 0.001). Mean visual acuity gain was 15.86 ± 12.18 letters at the end of the study. The mean central macular thickness decreased from 327.9 ± 56.5 mm (219e474 mm) to 277.0 ± 53.0 mm (197e405 mm), (P ¼ 0.016). Aflibercept therapy appears to be a safe and effective treatment for neovascular AMD. Injections applied in an as-needed algorithm after three monthly loading doses were successful to maintain and improve visual acuity.

To evaluate the diagnostic value of visual evoked potentials (VEPs) and to find out which test setting has the most sensitivity and specificity for amblyopia diagnosis. Thirty-three adult anisometropic amblyopes were intended in this study and were tested for visual evoked potentials with different stimulus conditions including three spatial frequencies [1, 2, and 4-cycles-per-degree (cpd)] at four contrast levels (100, 50, 25, and 5%).We also tested psychophysical contrast sensitivity and compared the results with electrophysiological ones. We plotted Receiver Operating Characteristic (ROC) curve for each VEP recording and psychophysical contrast sensitivity to evaluate the area under the curve, sensitivity, specificity, and cutpoint value of each test stimulus for detecting amblyopic eyes. Thirty-three amblyopic and 33 non-amblyopic eyes were examined for psychophysical contrast sensitivity and VEPs. Area under the ROC curve (AURC) findings showed that VEP with different stimulus settings can significantly detect amblyopic eyes, as well as psychophysical contrast sensitivity test. We found that P100 amplitudes had the largest AURC in response to stimuli of 2-cpd spatial frequency at 50 (P < 0.001) and 25% (P < 0.001) contrast levels, respectively. Cut-off amplitudes for these stimuli were 8.65 and 4.50 mV, which had a sensitivity of 0.758 and 0.697 and a specificity of 0.788 and 0.848, respectively. The sensitivity and specificity of VEP P100 amplitude in response to the stimuli with 2 cpd spatial frequency and 50 and 25% contrast were greater than the findings obtained from psychophysical contrast sensitivity test. According to our findings, assessment of VEP amplitudes in response to stimuli of 2-cpd spatial frequency at 50 and 25% contrast levels can best detect amblyopia with highest sensitivity and specificity and thus, are the protocols of choice for detection of amblyopic eyes.

To determine the prevalence of color vision deficiency (CVD) in the northeast of Iran. This cross-sectional, population-based study was conducted in Mashhad, in the northeast of Iran. Multistage cluster sampling was used for selecting the participants. After preliminary screening, the subjects underwent a complete ophthalmic examination. The examination included the measurement of visual acuity, refraction, and slit-lamp biomicroscopy. The Farnsworth D-15 test was used to detect CVD. The color vision test was done with the best optical correction. Of the 4453 invitees, 3132 participated in the study (response rate: 70.4%). The overall prevalence of CVD in this study was 13.93% [95% confidence interval (CI): 12.44e15.41]. The prevalence of CVD in males and females was 15.85% (95% CI: 13.26e18.44) and 12.96% (95% CI: 11.22e14.71), respectively. The most prevalent types of CVD were tritanopia (6.96%; 95% CI: 5.84e8.08), deuteranopia (3.92%; 95% CI: 3.14e4.70) and tritanomalous (2.21%; 95% CI: 1.55e2.86), respectively. According to the results of logistic regression, the odds of having protanopia were higher in females than males [Odds ratio (OR) ¼ 4.80; 95% CI: 1.20e19.18]. The odds of having deuteranopia were lower in females than males (OR ¼ 0.52; 95% CI: 0.35e0.76). The odds of having CVD were lower in 16e30 (OR ¼ 0.52; 95% CI: 0.37e0.73) and higher in 46e60 (OR: 1.41; 95% CI: 1.01e1.97) year age groups compared to 7e15 year age group. The odds of having tritanopia in 16e30 and 46e60 year age groups was 0.56 (95% CI: 0.35e0.90) and 1.79 (95% CI: 1.19e2.67) compared to 7e15 year age groups, respectively. The prevalence of CVD was high in this study, especially in males and people over 46 years of age. Planning for involvement of ocular disease control programs in health care systems can be helpful in the reduction of CVD and improving the quality of life in affected patients.

To assess the correlation of peripapillary retinal nerve fiber layer (PRNFL) thickness with visual recovery in compressive optic neuropathy (CON) in patients with thyroid eye disease (TED). Twenty-three eyes of 13 consecutive patients with TED-related CON were prospectively recruited. Assessment of PRNFL by means of spectral domain optical coherence tomography (SD-OCT), visual field (VF) parameters, color vision, and visual acuity in logMAR were compared before and 6 months after decompression surgery in the operated eye for each patient, which in ten cases included both eyes. Decompression surgery was performed as medial and inferior wall decompression sparing the orbital strut by the same surgeon. There was a significant correlation between the preoperative PRNFL average thickness and postoperative improvement in visual acuity among all patients (P ¼ 0.048). This correlation was found to be significant in clinically non-edematous optic neuropathy cases (P ¼ 0.023) but not in edematous optic neuropathy (P ¼ 0.23). There was significant correlation between PRNFL thickness and improvement of postoperative mean deviation (MD) and pattern standard deviation (PSD) parameters in VF studies and in color vision scores (P ¼ 0.005, P ¼ 0.02, P ¼ 0.01, respectively). Average PRNFL thickness and quadrantal PRNFL were all significantly reduced after decompression surgery in all of the cases (P ¼ 0.024). PRNFL thickness measured by SD-OCT is correlated with visual recovery after decompression surgery in TED-related CON. In eyes with severe VF defect (MD worse than 10 dB), the ones with higher preoperative PRNFL thicknesses (>65 mm) had more improvement in MD compared with those with thin PRNFL measures (<60 mm).

To evaluate the significance of choroidal substructure analysis in predicting the clinical response to adjuvant stereotactic radiotherapy (SRT) in neovascular age-related macular degeneration (nAMD) patients. Patients with nAMD, who underwent SRT (baseline) in addition to common intravitreal injections (IVIs) and subsequently had at least 12 months of complete follow-up, were enrolled. In a post hoc analysis, optical coherence tomography (OCT) data were reviewed, and subfoveal choroidal thickness (CT) as well as the thickness of choroidal substructures, such as choriocapillaris (CC), Sattler's layer (SL), and Haller's layer (HL), was measured to determine if these influenced SRT efficacy. A total of 35 eyes of 35 patients were included. While each of the 4 choroidal metrics significantly forecasts the clinical response to SRT, combining them all together produced the most reliable prediction model. In terms of clinical response to SRT in nAMD patients, choroidal substructure analysis does improve the quality of the prediction model when combined with subfoveal CT.

To report severe immunologic and toxic reaction due to corneal wasp sting that may cause catastrophic sight-threatening outcomes. A 45-year-old man referred to the emergency room with corneal wasp sting of Vespa Orientalis. The authors review previous Medline literature about this topic. In our case, the response to frequent topical corticosteroid was dramatic, and at the seventh day after injury, all inflammatory responses in the anterior segment of the eye had been resolved. Corneal wasp injury with Vespa Orientalis can cause severe inflammation of the cornea and the anterior segment. Topical corticosteroids are the mainstay of treatment.

To report a case of triamcinolone crystals associated miliary microemboli of the retinal arterioles and choriocapillaris. A 30-year-old woman with alopecia areata on her left auriculotemporal scalp, scheduled for 10 mg/ml triamcinolone acetonide steroid injections (maximum volume of 3 ml per session) for 1 month intervals, presented with a sudden decrease in vision in her left eye after 1 ml injection in a dermatology clinic. On ocular examination her best corrected visual acuity (BCVA) was hand movement in the left eye. Retinal examination showed multiple white-yellow steroid emboli in the superior and inferior temporal branch retinal arterioles which involves macula. Also there were diffuse yellow infiltrates in the choroid consistent with choroidal microemboli. Fluorescein angiography and optical coherence tomography images were suggestive for the retinal and choroidal ischemia. Subcutaneous triamcinolon injection may cause embolic occlusion of retinal and choroidal capillaries.

To report an accelerated course of visual recovery in a case of Leber's hereditary optic neuropathy (LHON) following treatment with idebenone and hormone replacement therapy (HRT). We hereby demonstrate the clinical utility of estrogen's protective role in LHON in vivo. We present a case of LHON in a menopausal woman carrying the 10197 mitochondrial DNA (mtDNA) mutation, who experienced loss of vision shortly after discontinuing her estrogen replacement regimen. Functional visual outcomes are reported following treatment with idebenone and HRT. The patient exhibited an accelerated course of visual recovery, experiencing improvement in vision as early as one month and complete reversal of vision loss by eight months post-therapy. Idebenone treatment combined with HRT may have a synergistic effect in enhancing cellular bioenergetics and may explain the patient's accelerated visual improvement.

To report a case of solar retinopathy due to inadvertent exposure to the sun while piloting a drone without protective eyewear. A 29-year-old male underwent a complete eye exam including optical coherence tomography (OCT) of the macula. Bilateral juxtafoveal outer retinal microcystic cavities present on OCT consistent with solar retinopathy. With the increasing popularity of unmanned aircrafts, eye protection awareness during drone use is essential.

To describe a case of bilateral choroidal osteoma (CO) in a patient with a history of langerhans cell histiocytosis (LCH). A 24-year-old man complaining of gradually decreasing visual acuity in both eyes is presented. He had a history of lymphadenopathy, respiratory symptoms, and pathology-proven diagnosis of LCH. Ophthalmic clinical and imaging studies revealed bilateral CO. In this patient, we suggest a possible relationship between LCH and CO.