Journal of Current Ophthalmology
Volume:31 Issue: 3, Sep 2019

To review the clinical features, diagnosis, treatment modalities, and prognosis of Bartonella-associated neuroretinitis.

This is a narrative review on Bartonella-associated neuroretinitis including general and ophthalmological aspects of the disease. Acomprehensive literature review between January 1950 and September 2018 was conducted in PubMed database. Epidemiology, clinical fea-tures, diagnosis, treatment, and prognosis of Bartonella neuroretinitis were reviewed.

Cat scratch disease (CSD) is a worldwide distributed systemic infectious disease caused by a bacterium,Bartonella henselae (B.henselae)which is usually transmitted to humans through contact with infected cats. Ocular manifestations of CSD are diverse, with neuro-retinitis and superficial retinal infiltrates being the most common and typical manifestations. Neuroretinitis typically presents as optic disc edemawith a partial or complete macular star in association with mild vitritis. Macular star may be absent at the initial presentation, becoming evident1e2 weeks after the onset of optic disc edema. Diagnosis of CSD is confirmed by reliable laboratory tests. Neuroretinitis usually has a self-limited course. Antibiotic therapy is required for severe systemic disease and vision-threatening ocular involvement. The adjunctive use oforal corticosteroids may further improve the visual outcome.

The diagnosis of Bartonella-associated neuroretinitis is based on typical clinical findings and positive serology. The prognosis isusually favorable in immunocompetent individuals.

To assess the changes in biomechanical properties of the cornea after treatment of keratoconus patients with UV-A/riboflavin cornealcollagen cross-linking (CXL) using Corvis ST (Oculus, Wetzlar, Germany) and Ocular Response Analyzer (ORA; Reichert Ophthalmic In-struments, Inc., Buffalo, NY, USA) devices.

In this prospective, observational case series, 48 eyes from 48 consecutive patients with progressive keratoconus were enrolled.Patients with history or signs of ocular disorders other than keratoconus, previous eye surgery, systemic diseases, or inability to cooperate withany measurement device were excluded. Corvis ST and ORA images were obtained at baseline and 4 months after CXL. The primary outcomemeasures comprised Corvis ST corneal biomechanical factors [time of highest concavity (T), time of applanation 1 (T1), time of applanation 2(T2), length of applanation 1 (L1), length of applanation 2 (L2), velocity of applanation 1 (V1), velocity of applanation 2 (V2), deformationamplitude (DA), peak distance (PD), and radius (R)] and the ORA parameters [corneal hysteresis (CH), corneal resistance factor (CRF),Goldmann-related IOP (IOPg), cornea-compensated IOP (IOPcc), and waveform score (WS)].

The mean [±standard deviation (SD)] age of patients was 20±5 years, and 27 (56%) were male. At baseline, the averages of therefraction, mean keratometry, and keratometric astigmatism were
3.0±1.8 diopter (D), 47.0±1.8 D, and 3.5±1.5 D, respectively. Accordingto Corvis ST, L2 increased from 0.83±0.25 mm at baseline to 1.15±0.57 mm after CXL; and V2 decreased from
0.81±0.08 to
0.94±0.26 m/s (P¼0.001 andP¼0.032, respectively). ORA parameters showed significant decrease in the CRF (from 7.82±1.72 to7.21±1.05 mmHg;P¼0.036) and increase in the WS (from 4.58±2.55 to 6.12±1.92;P¼0.002).

According to in vivo observation with Corvis ST and ORA, CXL induces significant changes in corneal biomechanical propertiesin cases with keratoconus. The parameters with significant changes (L2 and V2) may reflect increased stiffness of the treated cornea. Theimportance of such observations should be elucidated in future studies

To evaluate the demographic profile, clinical, and topographic characteristics of keratoconus (KCN) patients attending at a subspecialty eye hospital in Tehran, Iran.

In this cross-sectional study, all patients who attended Noor Eye Hospital between March 2011 and March 2017 and had a diagnosis of KCN were identified, and the required number of patients was randomly selected. The following data were extracted from patient's records: age, sex, visual acuity, refraction, keratometry, pachymetry, and treatment procedures. The data of KCN laterality, severity, morphology, and cone location were also extracted by analyzing the corneal imaging maps.

The records of 1080 eyes of 540 patients were evaluated. The mean age of the participants was 31.04 ± 8.54 years (range, 13e63 years), and 69.3% of the patients were male. The highest and lowest frequency of KCN was seen in the age group 20e30 years and above 50 years, respectively. Bilateral KCN was detected in 93.3% [95% confidence interval (CI): 91.68e94.75] of the subjects. 43.7% (95%CI: 32.88e54.48), 55.6% (95%CI: 44.73e66.38), and 0.8% (95%CI: 0.75e0.78) of the cases had nipple, oval, and globus cones, respectively. The cone was central in 52.1% (95%CI: 41.10e63.11), paracentral in 43.6% (95%CI: 36.13e51.04), and peripheral in 4.3% (95%CI: 00.76e7.86) of the cases. The frequency percentage of KCN according to severity was 15.2% (95%CI: 13.09e17.46), 56.4% (95%CI: 53.37e59.37), and 28.4% (95%CI: 25.75e31.21) for mild, moderate, and severe KCN, respectively. Among different parameters, only cone location had a significant association with age as the frequency of paracentral and peripheral cones increased with ageing (P ¼ 0.002).

The mean age of KCN patients in our study was higher than similar studies in other Asian countries. KCN was bilateral in most cases with an oval morphology and central cone location. Most of the patients had moderate to severe KCN.

To assess probable structural changes using spectral domain optical coherence tomography (SD-OCT) on sickle-cell disease (SCD) and beta thalassemia major (B-TM) patients, without any retinal abnormalities.

This cross-sectional study included 32 B-TM, 34 SCD patients, and 44 healthy controls. One of the eyes of all participants was evaluated for SD-OCT and choroidal thickness, retinal nerve fiber layer (RNFL) thickness, central macular thickness (CMT), ganglion cell complex (GCC).

Age, gender, and intraocular pressure (IOP) were not statistically different between the three groups. Hemoglobin (Hgb), hematocrite (Htc), and ferritin levels were not statistically different between the SCD and B-TM groups. Choroidal thickness at the subfoveal region was statistically higher in the control group (353.79 ± 71.93) than in the B-TM (317.41 ± 53.44) and SCD (283.21 ± 63.27) groups. In addition, it was statistically higher in the B-TM group than the SCD group (P ¼ 0.05). CMT did not differ among the three groups, average RNFL was only significantly thinner in SCD than in controls, and GCC thickness was significantly thinner in SCD than in controls and B-TM.

In both diseases, we can show early structural changes even if proliferative or non-proliferative retinopathy or other ocular manifestations were not developed yet.

To evaluate the efficiency and possible complications of intravitreal dexamethasone (IVD) implant in diabetic macular edema (DME) resistant to treatment of three consecutive intravitreal ranibizumab (IVR) injections.

Fifty eyes of 38 patients were considered in this study. The best corrected visual acuity (BCVA), central macular thickness (CMT), and values of intraocular pressure (IOP) were examined preoperatively and postoperatively in the 1st, 2nd, 4th, and 6th months of IVD implantation.

Twenty of the patients were women, and 18 of the patients were men. Mean age was 64.63 ± 7.15 (52e83) years. Mean number of IVR injection before IVD implantation was 3.4 ± 0.38. Mean BCVA (logMAR) was 0.874 ± 0.398 before IVD implantation, 0.598 ± 0.306 at the 1st month, 0.602 ± 0.340 at the 2nd month, 0.708 ± 0.359 at 4th month, and 0.800 ± 0.370 at 6th month. Mean of CMT was 519.700 ± 155.802 mm before IVD implantation, 274.000 ± 73.112 mm at the 1st month, 307.98 ± 87.869 mm at the 2nd month, 387.82 ± 110.503 mm at 4th month, and 478.54 ± 163.743 mm at 6th month. Improvements in BCVA and CMT were statistically significant (P < 0.05) at 1st, 2nd, and 4th months; however, these values were not statistically significant at 6 months. At 1st day, 1st and 2nd months, the values of IOP were increased significantly after IVD. Cataract progression was observed in just 1 of the 22 phakic patients.

In DME resistant to treatment of consecutive IVR, IVD implantation has been observed to be effective in increasing BCVA and decreasing CMT in the first 3 months. IVD implantation can be considered an alternative method in the treatment of resistant DME.

To evaluate the optical coherence tomography angiography (OCTA) parameters in patients with diabetic retinopathy following panretinal photocoagulation (PRP).

Eleven eyes of 6 patients with very severe nonproliferative diabetic retinopathy (NPDR) or early proliferative diabetic retinopathy (PDR) were recruited in this prospective interventional pilot study. All patients underwent OCTA imaging at baseline, and choroidal flow, foveal avascular zone (FAZ), retinal thickness, and vascular density were measured at baseline. Three months after treatment, OCTA was repeated, and the alteration in variables was analyzed.

The FAZ area remained unchanged following treatment, (P ¼ 0.75). Retinal thickness increased along (P ¼ 0.02) with an increase in vascular density in the superficial and deep foveal area and the macular temporal sector (P ¼ 0.007, 0.03 and 0.049, respectively). Choroidal flow surface area was unchanged (P ¼ 0.10).

In this study, foveal vascular density increased and FAZ remained unchanged after PRP for diabetic retinopathy.

To determine the possible association of rs4151667 (L9H) complement factor B (CFB) gene with age-related macular degeneration (AMD). The L9H is one of the functional variations of the CFB. CFB gene encodes the most important protein of the complement system.

Two hundred sixty-six patients with AMD and 194 unrelated age/sex-matched controls were genotyped for CFB gene (rs4151667) using the polymerase chain reactionerestriction fragment length polymorphism (PCR-RFLP) method. All research subjects were selected from three regions of Iran (Tehran, Tabriz, and Gonabad).

The results showed a significant difference between the frequency of non-TT genotype in total patients and controls [odds ratio (OR) ¼ 0.424, P ¼ 0.038]. The analysis for each studied region showed that in patients originating from the Gonabad population, the frequency of TT and non-TT genotypes between patients and the control group were significantly different (OR ¼ 2.894, P ¼ 0.046 for TT genotype and OR ¼ 0.346, P ¼ 0.026 for non-TT genotype). In patients originating from Tabriz population, TT and non-TT genotypes and A allele revealed considerably different frequencies between the patient and control groups (OR ¼ 3.043, P ¼ 0.017; OR ¼ 0.329, P ¼ 0.013 and OR ¼ 0.347, P ¼ 0.048, respectively). Analysis of patients from Tehran also showed that there was a significant difference in the frequency of TT genotype between patients and controls (OR ¼ 2.168, P ¼ 0.04).

The results of the current study indicated a possible protective role for non-TT genotype in L9H variation CFB gene against AMD in a sample of the Iranian population. The region segregation results showed that TT genotype might be a risk factor for susceptibility to AMD.

To determine the postoperative horizontal alignment changes following different inferior oblique (IO) weakening procedures on cases with IO overaction (IOOA).

A total of 40 patients undergoing IO weakening surgery participated in this prospective interventional case series. A comprehensive ophthalmic examination was performed on all patients. The grade of IOOA was assessed based on the muscle function in the gaze of elevation in adduction. All study subjects were operated on by one of the IO weakening procedures including recession, myectomy, or anteriorization, and all were followed up for at least three months after the surgery. Postoperative change of the horizontal alignment in primary position was the main outcome measure.

Our findings showed that all types of IO weakening surgeries improved the postoperative muscle function, hypertopia, and V-pattern significantly (P ¼ 0.001). Generally, IO weakening surgeries had no effect on the postoperative horizontal alignment, and mean exoshift of 0.44 ± 6.2 prism diopters (PD) was observed in all study subjects, specifically. It was found that 70% of cases had no postoperative horizontal changes, 15% showed improvement toward orthophoria, and 15% shifted away from orthophoria.

Based on our findings, no horizontal alignment change would be expected in the majority of cases undergoing weakening procedures of overacted IO. Most of our cases did not show any change while a few of them presented eso- or exoshift less than 5 pd which can be clinically ignored.

To determine the agreement of table-mounted and handheld auto-refractometers and to evaluate the effect of age and different types of refractive errors on this comparison.

In this cross-sectional study conducted in 2015 using multi-stage cluster sampling, two underserved villages were selected randomly in the north and southwest of Iran. All the selected participants underwent optometric and ophthalmic examinations. Refraction was measured using handheld and table-mounted auto-refractometers in 652 subjects.

The mean age of the subjects was 32.7 ± 18.72 years, and 58.3% of them were female. A significant difference was observed in the results of sphere, spherical equivalent (SE), and J45 vector between the two devices (P < 0.012), but there was no significant difference in J0 vector. There was a significant difference in the results of sphere between the two devices in all age groups under 50 years (P ¼ 0.005), but there was no difference in age groups above 50 years. Correlation coefficients of the two devices were 0.989, 0.986, 0.908, and 0.951 for the results of sphere, SE, J0 vector, and J45 vector, respectively (P < 0.0001). The 95% limit of agreement (LOA) of the two devices was 0.31 to þ0.53 for sphere, 0.27 to þ0.63 for SE, 0.27 to þ0.27 for J0 vector, and 0.16 to 0.17 for J45 vector.

According to our findings, the spherical error and cylindrical power measurements of the two devices have a significant correlation. Although there is a significant difference in the mean values between the two devices, this difference may be considered clinically insignificant, and considering the narrow 95% LOA between the two devices, the results may be used interchangeably.

To determine the distribution of iris color and its relationship with some ocular diseases in a rural population of Iran.

Two rural areas of the north and southwest of Iran were selected by a cross-sectional study using multi-stage cluster sampling. After selecting samples, the participants had an eye examination including measuring visual acuity, refraction, and Pentacam imaging. Then an eye examination for individuals was performed by slit-lamp.

Out of 3851 invited people, 3314 participated in this study (participation rate, 86.05%). Dark brown [41.28%, confidence interval (CI) 95% ¼ 31.88e50.68] and blue (0.99%, CI 95% ¼ 0.57e1.41) were the most and the least type of iris colors among participants of this study. Compared to others, people with a dark iris have the biggest anterior chamber depth (ACD), angle and volume while central corneal thickness (CCT), keratometry and pupil were highest among people with a dark brown iris (P < 0.002). Considering the dark brown group as a base group, the chances of being afflicted to cataract among people with dark, light brown, green, and blue irises are 1.89 (CI 95% ¼ 1.25e2.86), 1.53 (CI 95% ¼ 1.17e2.01), 4.60 (CI 95% ¼ 2.17e9.71), and 12.17 (CI 95% ¼ 5.05e29.31), respectively. The chance of being afflicted to myopia among people with green irises and to hyperopia among people with blue irises were high (1.60, CI 95% ¼ 1.08e2.36 and 3.20, CI 95% ¼ 1.03e9.97, respectively).

Dark brown was the most prevalent iris color in rural areas of Iran. The index of cornea among people with dark and dark brown iris color is higher than other people, and people with light iris color are at a higher risk of developing eye disease such as cataract, corneal opacity, and refractive error. To determine this relationship and its usage for therapeutic and public health purposes, further studies are recommended.

To quantify the risk of ocular adverse events with immune checkpoint inhibitors (ICIs) as reported to the Food and Drug Administration (FDA).

Disproportionality analysis using data from U.S. FDA's Adverse Events Reporting System (FAERS) database 2003 to 2018. Data from pharmaceutical manufacturers, healthcare providers, consumers in the U.S., and post-marketing clinical trial reports from U.S. and non-U.S. studies. All cases of uveitis, dry eye syndrome, ocular myasthenia and eye inflammation with use of the following ICIs: atezolizumab, avelumab, cemiplimab, durvalumab, ipilimumab, nivolumab and pembrolizumab. Reported odds ratios (RORs) and corresponding 95% confidence intervals (CIs) were computed for all drugs as a group or as individual agents.

We identified 113 ocular adverse events for all ICIs of interest including uveitis, dry eye, ocular myasthenia and eye inflammation. Nivolumab had the highest number of adverse events (N ¼ 68) associated with use of the ICI. Nivolumab had the highest association with ocular myasthenia [ROR ¼ 22.82, 95% CI (7.18e72.50)] followed by pembrolizumab [ROR ¼ 20.17, 95% CI (2.80e145.20)]. Among all ICIs approved in North America, atezolizumab had the highest association with eye inflammation [ROR ¼ 18.89, 95% CI (6.07e58.81)] and ipilmumab had the highest association with uveitis [ROR ¼ 10.54, 95% CI (7.30e15.22)].

The results of this disproportionality analysis suggest use of ICIs is associated with an increase risk for ocular adverse reactions. Future epidemiologic studies are needed to better quantify these adverse events.

To compare outcomes of intralesional triamcinolone acetonide (TA) injection and incision and curettage (I&C) in the treatment of chronic chalazion.

Patients with chronic chalazion were randomized in two groups. The patients in the TA received an intralesional injection of TA and patients in the I&C underwent I&C. The patients were followed up 3, 7, 14, 21, 28, and 45 days after the procedures. We defined success as 90% regression in the size of the lesion.

There were 26 patients in the TA and 25 patients in the I&C enrolled in this study. Complete resolution was achieved in 16 patients (61.5%) in the TA group and 21 patients (84%) in the I&C (P ¼ 0.072). Sex, initial size, and chalazion location did not influence treatment success in either group (P > 0.05). Lesion recurrence occurred in 9 patients (34.61%) in the TA group and 2 (8%) in the I&C (P ¼ 0.04). The average times to resolution were 8.8 ± 5.6 and 5.1 ± 4.5 days in the first and second groups, respectively (P ¼ 0.03). Drug deposition occurred in 24 (92.3%) patients in the TA group, and ecchymosis occurred in 14 (56%) patients in the I&C (P ¼ 0.004) group. Intraocular pressure (IOP) in the TA group and visual acuity (VA) in both groups remained unchanged.

Both TA injection and I&C modalities are effective in the treatment of chronic chalazia. Advantages of I&C in comparison to TA include less recurrence, shorter duration of complications, and a higher success rate.

To evaluate the clinical characteristics, histopathology, and treatment outcomes in adult and pediatric patients with nonspecific orbital inflammation (NSOI).

This retrospective study evaluates 76 patients with NSOI. The patients were categorized in 9 groups according to the site of involvement and histopathology results. These groups included: anterior involvement, dacryoadenitis, myositis, perineural involvement, acute fat involvement, focal mass, orbital apex involvement, diffuse sclerosing form, and multiple tissue involvement. The course of the disease was categorized as acute, subacute, or chronic. The cases with symptom duration of less than 1 week were classified as acute, 1 week to 1 month as subacute, and more than 1 month as chronic.

36 (47.4%) patients were males. The mean age was 41.68 ± 17.62 (6e75) years. The most common signs and symptoms were periorbital pain, periorbital edema, decreased ocular movements or diplopia, and conjunctival injection. The most common group was dacryoadenitis in 29 (38.1%) cases. The most common form of disease was the acute involvement (50% of patients). Most of the patients were treated by oral corticosteroids. Duration of follow-up was 7.17 ± 6.26 months. Recurrence occurred in 9 (11.8%) of patients during the follow-up period.

This study presents a new categorization in which multiple tissue involvements were separated. Some of the NSOI features differ between adults and children. In most patients, treatment especially with corticosteroids, resolves the clinical findings.

To evaluate the multimodal imaging including optical coherence tomography angiography (OCTA) findings in patients with posterior microphthalmos (PM).

In an observational case series, four eyes of two patients, eight and twenty-three years old, with clinical proven PM underwent complete ophthalmic examination, including refraction, fluorescein angiography, optical coherence tomography (OCT), OCTA, B-scan ultrasonography, axial length measurement using IOL Master optical measuring, and Pentacam evaluation.

Both patients were high hyperopic with partial thickness retinal fold in macula, retinoschisis, and foveal hypoplasia. Axial length was less than 17 mm with scleral thickening in all eyes. OCTA showed absence of foveal avascular zone (FAZ) in both superficial and deep capillary plexuses. Pentacam showed corneal steepness, shallow anterior chamber, and low anterior chamber volume.

OCTA findings showed absence of avascular zone in both superficial and deep capillary plexuses, while OCT shows partial thickness retinal fold and retinoschisis.

To demonstrate the use of an air bubble in infusion to ascertain infusion tip (IT) positioning before commencing vitreoretinal surgery (VRS) in eyes with media opacities.

Twenty-four eyes were studied. An air bubble was introduced into the IT by manually expelling fluid from the distal end of the IT. Passage of this air bubble into the vitreous cavity immediately on opening the infusion line confirmed IT position and VRS was commenced only after this event.

The air bubble was seen within the eye in 18/24 eyes immediately on opening the infusion line. In 6 eyes, the air bubble did not exit the infusion line, and VRS was commenced only after IT position was confirmed by other methods. In all 24 eyes, no untoward effect attributable to the air bubble was noticed during subsequent VRS.

An air bubble introduced into the IT helps to quickly confirm IT position when direct visualization of the IT is difficult. There were no untoward events in eyes where the air bubble could not enter the vitreous cavity

To report an interesting case of intraoperative opacification of intraocular lens (IOL).

This study is a report of a 61-year-old male patient who suffered from nuclear sclerosis cataract and had undergone phacoemulsification surgery. During surgery, intraoperative opacification of IOL (Cristal, Cristalens), which was a foldable, 13 mm, one piece, square edge and hydrophilic acrylic IOL, occurred. This phenomenon caused a surprise and a decision to explant the IOL, but the surgeon decided to keep the IOL in place. After a day, it was completely clear.

The surgery was completed successfully without any complications, and the IOL was completely clear the day after surgery.

Acute, transient IOL opacification with unproven etiology may occur during cataract surgery

To report a complication little reported until now: to and fro migration of the dexamethasone implant between the anterior and posterior segment (wandering Ozurdex) of sclera fixated intraocular lens (IOL) eyes and its effective management.

Two cases of to and fro migration of Ozurdex (wandering Ozurdex) in two pseudophakic patients with scleral fixated posterior chamber IOL: first, a case of Vogt Koyanagi Harada (VKH) disease and second, a case of pseudophakic cystoids macular edema (CME) were successfully managed.

Both patients were initially managed with repositioning of implants by supine posturing and use of drugs, but implants again migrated into anterior chamber and underwent surgical removal with preservation of corneal transparency.

Patients with scleral fixated posterior chamber IOL present a high risk of anterior chamber migration of the Ozurdex implant. Prompt removal of Ozurdex implant in these patients can reduce risk of endothelial decompensation. In such cases, returning the implant with positioning is not a good option.

To report a case of medial rectus (MR) muscle loss during the strabismus surgery with a late successful management and review of the literature.

The left MR was lost during resection in a 14-year-old girl who had undergone strabismus surgery elsewhere. The surgeon disinserted the antagonist lateral rectus (LR) muscle in the same session following unsuccessful attempts to retrieve the lost muscle. She was referred to our clinic two months later with a large angle exotropia and a complete lack of adduction. We performed a half-tendon transposition of vertical rectus muscles to the MR insertion and attached the residual fibers of the LR to the orbital periosteum.

She was orthotropic after the surgery and remained stable until 6 months with a significant improvement of the adduction.

Simultaneous LR disinsertion is not a solution for MR loss. Half-tendon transposition of the vertical recti to the original insertion of the lost MR and periosteal fixation of the LR are good options as a second-stage operation in patients with MR loss during strabismus surgery

To report spectral-domain optical coherence tomography (SD-OCT) findings of presumed Cryptococcus neoformans infection limited to the retina.

We report a 39-year-old male with decreased vision for 3 months. Clinical examination revealed multiple cream-colored retinal lesions in the posterior pole of both eyes. SD-OCT demonstrated multiple areas of discrete, hyperreflective deposits in the inner retina, outer retina, and subretinal space without evidence of choroidal involvement. Fundus autofluorescence demonstrated areas of hyperautofluorescence of lesions with variable areas of hypoautofluorescence.

Subsequent laboratory workup revealed systemic Cryptococcus neoformans infection. After 3 months of systemic antifungal treatment and follow-up, there was clinical improvement in the size of the lesions.

This is the first report of SD-OCT demonstrating presumed localized Cryptococcus infection confined to the retina. Our findings support the assertion that Cryptococcus can cause a focal retinitis involving all layers of the retina without demonstrable evidence of choroidal involvement.