Journal of Current Ophthalmology
Volume:35 Issue: 2, Apr-Jun 2023

To review the principles and different techniques of minimally invasive procedures in strabismus surgery.

This is a narrative review on minimally invasive procedures in strabismus surgery including general aspects and different new modifications on conventional strabismus surgery. We reviewed 24 articles published between 1993 and 2020.

Minimal invasive procedures could be categorized into two subsets: one which minimizes conjunctival opening size and another which minimizes the muscle manipulations. Different conjunctival approaches have been introduced, such as Cul‑de‑sac and minimally invasive strabismus surgery incisions. Furthermore, there are different techniques for extraocular muscle weakening, strengthening, and transposition, such as mini‑tenotomy, plication, mini‑plication, Nishida, and modified Nishida procedures. Moreover, there are some techniques for handling strabismus in heavy eyes with high myopia and using adjustable sutures for strabismus correction.

Minimally invasive procedures in strabismus surgery consist of surgical procedures that minimize tissue disruption, speed up rehabilitation, and often ultimate better outcomes. These techniques could be replaced traditional methods to reduce conjunctival and lid swelling in the direct postoperative period.

To discuss the safety and efficacy of various forms of ab‑interno trabeculotomy procedures.

A comprehensive search in PubMed and Google Scholar was done using the keywords “glaucoma”, “microinvasive glaucoma surgery”, “complications”, “goniotomy”, and “trabeculotomy”. Publications discussing ab‑interno trabeculotomy procedures were selected; furthermore, the relevant references in these articles were gathered and the search was updated during the article preparation. Since gonioscopy‑assisted transluminal trabeculotomy was first introduced in 2014, we had no time restriction.

Ab‑interno trabeculotomy procedures, as a type of minimally invasive glaucoma surgeries, facilitate the natural trabecular outflow and lower the intraocular pressure (IOP) while preserving the conjunctiva for possible future glaucoma surgeries. It can be done alone or in combination with cataract surgery and effectively lowers the IOP and the number of antiglaucoma medications in various forms of glaucoma.

By appropriate patient selection, ab‑interno trabeculotomy could be selected as a safe and effective procedure in the management of various forms of glaucoma either as an isolated procedure or in combination with cataract extraction.

To present updated information on the role of anti‑vascular endothelial growth factor (anti‑VEGF) therapy for treating retinopathy of prematurity (ROP).

We searched through PubMed and Scopus databases using the keywords of this article and gathered relevant published articles from the year 2005 to December 2022. The selected articles were classified and summarized, and reasonable conclusions were made accordingly.

Considering the current evidence, anti‑VEGF agents are superior to laser therapy for the initial treatment of type 1 ROP in zone 1 or posterior zone 2. However, there is a substantial risk of reactivation or persistent avascular retina after solo treatment with anti‑VEGFs, and many cases may require laser therapy within the following weeks or months. Thus, vigilant follow‑up examinations are mandatory.

The role of anti‑VEGF agents in the treatment of ROP is indispensable. However, future studies are required to improve indications and dosage and determine long‑term ocular and systemic safety.

To determine the distribution, ocular, and systemic determinants of peripapillary retinal nerve fiber layer thickness (pRNFLT) using spectral‑domain optical coherence tomography (SD‑OCT) in an elderly population.

This report is a part of the Tehran Geriatric Eye Study, a population‑based cross‑sectional study conducted in Tehran, the capital of Iran. The study population was all residents aged 60 years and above in Tehran. The sampling was performed using a multi‑stage stratified random cluster sampling method. All study participants underwent ocular examination (including measurement of visual acuity, objective and subjective refraction, and slit‑lamp biomicroscopy), anterior segment imaging using Pentacam HR, and ocular biometry using IOLMaster 500. The OCT imaging was performed for a random subsample (1307 individuals) using Spectralis SD‑OCT.

Two thousand two hundred and forty‑six eyes of 1189 individuals were analyzed for this report. Of these, 691 (58.1%) were female, and the mean age of the participants was 67.3 ± 5.9 years (60–94 years). The mean overall pRNFLT was 98.6 µ (95% confidence interval [CI]: 98.0–99.3). There was a statistically significant difference in pRNFLT between different quadrants; the highest and lowest mean pRNFLT was related to inferior and temporal quadrants, respectively (P < 0.001). The multiple generalized estimating equation model showed that older age (coefficient: −0.15 [95% CI: −0.24 to −0.06], P = 0.001), diabetes (coefficient: −1.69 [95% CI: −2.82 to −0.55], P = 0.004), and longer axial length (coefficient: −0.52 [95% CI: −0.83 to −0.22], P < 0.001) were significantly associated with a decreased overall pRNFLT. Higher body mass index was significantly related to an increased overall pRNFLT (coefficient: 0.19 [95% CI: 0.07 to 0.30], P = 0.002).

The results of the present study can be used as a reference database for pRNFLT in the elderly population. Considering ocular and systemic determinants of pRNFLT is necessary for correct clinical interpretation of this parameter.

To analyze the glaucoma research in the Web of Science (WoS) and Scopus to determine the top features, trends, and subject clusters.

In this scientometric study, all glaucoma publications in Scopus and WoS were analyzed based on various characteristics such as authors, journals, and co‑word analysis. Data analysis was conducted using both Excel and VOSviewer.

A gradual increase in the publication rate was found for articles in the field of glaucoma in both Scopus and WoS databases. In this regard, most publications were conducted in the USA and the University of California System. The co‑word network was constituted of five clusters, including glaucoma, intraocular pressure, open‑angle glaucoma, visual acuity, and optic disc. It showed that the top 10 highly cited articles were more addressed by epidemiologic studies.

The findings of this study had a more precise vision of the previous research on the field of glaucoma. It also provided the possibility to discover hidden patterns and emerging events of a subject by explaining the most essential aspects of research and identifying the areas that need more research. The findings could be useful for authors and health policymakers in academia and countries.

To assess the agreement between biometric parameters measured by a spectral‑domain optical coherence tomography optical biometer device (Optopol Revo NX) with a validated swept‑source biometer (IOLMaster 700) and a validated optical low‑coherence reflectometry biometer (Lenstar LS 900), in cataract surgery candidates.

In this prospective comparative study, 100 patients (100 eyes) who were eligible for cataract surgery were involved. Bland–Altman plots were used to assess agreement between devices for biometric parameters including axial length (AL), anterior chamber depth (ACD), lens thickness (LT), and central corneal thickness (CCT).

AL measurements were successful in 82 eyes (82.0%) with Revo NX, in 91 eyes (91.0%) with Lenstar LS 900, and in 97 eyes (97.0%) with IOLMaster 700. When Revo NX was compared to IOL Master 700 and Lenstar LS 900, the mean differences were as follows: −0.02 ± 0.02 mm and −0.02 ± 0.03 mm (P = 0.313, P = 0.525) for AL, 0.01 ± 0.03 mm and 0.10 ± 0.03 mm (P = 0.691, P = 0.002) for ACD, −0.15 ± 0.03 mm and 0.001 ± 0.04 mm (P < 0.001, P = 0.95) for LT, and −2.29 ± 0.92 µm, and 0.73 ± 1.43 µm (P = 0.015, P = 0.612) for CCT. Three devices were highly correlated for AL, ACD, LT, and CCT (interclass correlation coefficient > 0.75). Bland–Altman plots showed a narrower 95% limit of agreement (−0.35 to 0.31) between Revo NX and IOLMaster 700 in measuring AL.

Despite the higher measurement failure rate in eyes with cataract, the Revo NX showed very good agreement with the IOLMaster 700 and Lenstar LS 900 optical biometers in measuring AL, ACD, LT, and CCT. However, ACD and LT measurements cannot be considered interchangeable between these devices.

To quantify the effects of Descemet stripping automated endothelial keratoplasty (DSAEK) on corneal clarity and densitometry of patients with long‑standing pseudophakic bullous keratopathy (PBK) complicated with subepithelial fibrosis.

Thirty‑four eyes with PBK complicated with corneal edema for more than 6 months and subepithelial fibrosis were enrolled. All subjects underwent complete ophthalmic examination and corneal densitometry module of Pentacam HR, before and 1, 3, and 6 months after DSAEK.

Thirteen patients were excluded due to postoperative complications or missed to follow‑up visits. Finally, twenty‑one patients’ data were analyzed. Corneal densitometry measures significantly decreased in all three layers (anterior, central, and posterior) 3 and 6 months after surgery compared to preoperative values; however, the differences did not reach statistical significance in the 1st month. Moreover, densitometry measurements were significantly lower at month 6 compared to month 1, but not at month 3 compared to month 1. Corneal densitometry of the anterior layer was significantly higher than central and posterior layers in 2 mm and 6 mm zones preoperatively and at all postoperative visits. Corneal light backscatter of each three layers was not statistically different between 0–2 mm and 2–6 mm in all pre‑ and postoperative visits.

Corneal densitometry in cases of PBK begins to improve after DSAEK in different layers in a slow and continued trend which takes up to 6 months for an effect to be seen. Interestingly, this improvement is possible even in complicated corneas with long‑standing edema. Hence, corneal densitometry can be used as an objective method for quantification of the outcome of DSAEK in complicated cases of PBK.

To investigate the outcomes of unilateral Supracor treatment to enhance near vision while maintaining good distance vision in hyperopic eyes.

This prospective interventional study includes consecutive hyperopic patients with presbyopia. All eyes underwent femtosecond laser‑assisted in situ keratomileusis treatment for hyperopia with an additional Supracor multifocal treatment algorithm in nondominant eyes. Monocular and binocular uncorrected and spectacle‑corrected distance visual acuity (UCDVA and SCDVA), monocular and binocular uncorrected near visual acuity (UNVA), and distance‑corrected near visual acuity at 40 cm and high‑order aberration changes and complications were evaluated for 6 months.

Sixty‑four patients with a mean age of 51.91 ± 3.64 were enrolled. After 6‑month follow‑up, the mean binocular UCDVA and UNVA were 0.03 ± 0.05 and 0.04 ± 0.06 logMAR, respectively. UCDVA (logMAR) of nondominant and dominant eyes was 0.30 ± 0.18 and 0.03 ± 0.05, respectively. Preoperative and postoperative mean ± standard deviation manifest refraction spherical equivalent was +1.84 ± 0.75 and −0.48 ± 0.57, respectively, in nondominant eyes and +1.77 ± 0.69 and +0.12 ± 0.33, respectively, in dominant eyes. No complications were observed.

Supracor procedure in nondominant eyes may improve functional near, intermediate, and distance vision without significant photic phenomena in presbyopic patients with low and moderate hyperopia.

To obtain a reactive and specific antibody against truncated matrix metalloproteinase 9 (MMP‑9), that has reactivity toward the native protein. Precision, accuracy, specificity, and sensitivity were evaluated using a point‑of‑care test.

An in silico study was used to confirm the anti peptide truncated MMP‑9 is against native MMP‑9. After an antibody titer assessment, purification, and characterization, the anti MMP‑9 was assessed. The cut-off value was determined using the purified gelatinases of the supernatant HCT 116 cell line. The supernatant was purified by preparative native‑polyacrylamide gel electrophoresis based on charge and size of the proteins. Furthermore, quality control (QC) of the results were performed following standard densitometry methods.

A truncated MMP‑9 is the major epitope peptide that can trigger the immune system to scavenge for a specific and reactive antibody against the native MMP‑9. The MMP‑9 native protein is purified from the supernatant of the HCT 116 cell line and the commercially available, full‑length MMP‑9. The cut-off value was estimated at 30 µg/mL. QC results indicated that the specificity was 80%, sensitivity was 96.7%, accuracy was 91%, and precision was 91.66%. The area under curve was 0.827 (P < 0.001). The positive predictive value was 83%, and the negative predictive value was 96%.

The antibody against the synthetic epitope peptide can detect the native MMP‑9. Native MMP‑9 is considered the main biomarker in an immunoassay POCT and is used to diagnose dry eye disease (DED). In accordance with QC results, MMP‑9 point of care test can be utilized for screening patients suffering from DED.

To evaluate the association of systemic inflammatory marker levels in macular edema with serous macular detachment (SMD) secondary to retinal vein occlusion (RVO).

Patients diagnosed with RVO were categorized into two groups based on the presence or absence of SMD: Group 1 included 30 eyes with SMD, while Group 2 included 30 eyes without SMD. Levels of neutrophils, monocytes, lymphocytes, thrombocytes, and mean platelet volume (MPV) were analyzed. Systemic inflammatory markers, including neutrophil‑lymphocyte ratio (NLR), platelet‑lymphocyte ratio (PLR), and systemic immune-inflammation index (SII), were calculated and compared between the two groups.

The mean neutrophil levels were significantly higher in Group 1 (P = 0.002). The mean lymphocyte, monocytes, thrombocyte, and MPV levels did not differ significantly between groups. NLR and SII levels were significantly higher in the SMD group (P = 0.004 and P = 0.016, respectively). There was no significant difference between the groups in terms of PLR. The optimal receiver operator characteristic (ROC) cut-off value of NLR for SMD was calculated as 1.55 with 73% sensitivity and 63% specificity (area under the curve [AUC] = 0.714, 95% confidence interval [CI]: 0.584–0.845). The optimal ROC cut-off value of SII for SMD was calculated as 451.75 with 63% sensitivity and 63% specificity (AUC = 0.681, 95% CI: 0.546–0.816). In this study, branch RVO was present in 48 patients, and central RVO was present in 12 patients. Neutrophil, MPV levels, and NLR, PLR, SII ratios were similar between patients with branch and central occlusion.

Neutrophil levels, NLR, and SII were found to be significantly higher in eyes with SMD secondary to RVO.

To describe the variance of inner, middle, and outer retinal layer thicknesses (IRT, MRT, and ORT) at the macular area in children and adolescents with normal eyes in different age groups.

This cross‑sectional study enrolled subjects aged 5–18 years with normal eyes. The macula was scanned by optical coherence tomography (6 mm × 6 mm AngioScan‑Optovue). Four age groups were defined (≤7, 7–10, 11–14, and ≥14 years). The influences of age and gender were analyzed.

One hundred and thirty‑nine eyes of 69 subjects with a mean age of 10.92 ± 3.51 years were registered. The mean whole macular thickness (MT) was 297.32 ± 11.05 in males and 303.197 ± 13.32 in females (P = 0.01, t‑test). The MT in each aging group was 301.47 ± 2.5, 295.53 ± 1.71, 300.81 ± 2.12, and 298.6 ± 1.87, subsequently (P = 0.17, analysis of variance test). Significant differences were found between the sexes at the perifoveal area and mainly in IRT. No correlation between eyes was noted. We observed that the RT fluctuates during growth and that gender has some influence on the evolution of RT. IRT and MRT changed reciprocally in all macular areas, whereas ORT expanded in all age groups of children and adolescents.

No subsegmental retinal thickness difference between eyes was observed in pediatric groups in this study, while gender had some influence on perifoveal IRT. Despite the fact that this study is not a longitudinal study, we can get some insight into the developmental changes in retinal thickness and its clinical applications in children and adolescents.

To determine which mechanisms are operative in releasing the extraocular myofascial tissue in response to extraocular myofascial release (EOMR) and to evaluate the effect of EOMR on saccadic velocity and esodeviation angle in patients with convergence spasm.

Fourteen patients with convergence spasm aged 20–35 participated in this research. The treatment included touching the medial rectus and its interrelated fascial tissue with the index finger pulp from over the eyelid for at least 300 s and applying very gentle and uniform pressure. We evaluated the saccadic velocity obtained from dynamic electrooculography (EOG) and the angle of deviation. The findings of dynamic EOG were used as a reliable quantitative method to assess eye movement function.

The amount of esodeviation decreased significantly at both far 2.39Δ, 95% confidence interval (CI) (1.27–3.52) (P = 0.002) and near 5.57Δ, 95% CI (4.67–6.47) (P = 0.001) after two sessions of EOMR in a week. There was no significant difference in saccadic velocities before and after treatment.

In the short term, the EOMR only affects the static condition of the eye. Therefore, a significant improvement could be seen in the deviometric findings. However, the dynamic properties of the extraocular muscles did not improve and probably needed a more extended treatment period for acting the long‑term mechanisms.

To describe delayed‑onset infectious endophthalmitis 4 months after intravitreal aflibercept injection.

An 80‑year‑old female was referred with signs and symptoms of clinical endophthalmitis 4 months after intravitreal injection of aflibercept for choroidal neovascularization. Noninfectious causes of panuveitis were excluded and she was diagnosed with delayed‑onset postinjection infectious endophthalmitis. Vitreous and aqueous specimens were prepared and antibiotics (vancomycin and ceftazidime) were injected intravitreally.

Vitreous culture was positive for Staphylococcus epidermidis. During the 1st month after the antibiotic injections, symptoms and signs of the patient improved and became stable during the 6‑month follow‑ups.

Delayed‑onset infectious endophthalmitis can be presented following intravitreal injections. Late presentation of uveitis in postinjected eyes needs complete investigations to rule out infectious endophthalmitis as an ophthalmic emergency.

To report a rare case of globe rupture following a spontaneous expulsive suprachoroidal hemorrhage without a predisposing event.

Case report.

A 40‑year‑old man presented with a 3‑week history of episodic eye pain, likely associated with uncontrolled glaucoma, and a spontaneous clot exuding from his right eye without a predisposing event. Notably, the patient had a remote past ocular history of posttraumatic glaucoma and untreated retinal detachment from childhood. He underwent uncomplicated evisceration of the right eye with polymethyl methacrylate implantation.

Spontaneous expulsive suprachoroidal hemorrhage without a predisposing event is an exceedingly rare phenomenon, with only six previously reported cases. It is possible that eyes with a history of trauma, possibly diseased eyewalls, and eyes with high intraocular pressure may be the most susceptible to spontaneous suprachoroidal hemorrhage and consequent globe rupture.

To report a rare case of microspherophakia and lens subluxation in a young patient with Klinefelter syndrome who underwent cataract surgery, emphasizing the importance of a thorough general health assessment and anamnesis prior to cataract surgery.

The case concerns a 52‑year‑old male referred for phacoemulsification under general anesthesia. A review of literature was performed.

Preoperative assessment revealed a corticonuclear cataract in both eyes, with dislocation of the crystalline lens in the left eye in an area of zonular dehiscence. Upon careful examination, both eyes showed a microspherophakic lens with an increased lens thickness and the lens equator being visible over 360° in the left eye. The patient denied any trauma or medical conditions. His medical health record revealed the coexistence of Klinefelter syndrome (47, XXY). The association between Klinefelter syndrome and microspherophakia has only once been reported in the literature. Intraoperatively, a more cautious approach was withheld and a capsular tension ring was used. Postoperative outcome was successful with good visual outcome and no interoperative complications.

This case report highlights the importance of proper preoperative assessment before cataract surgery, especially in unusual cases such as early‑onset cataract and/or lens subluxation. In addition, it stresses the importance of a systemic and/or genetic evaluation in patients with microspherophakia and an ophthalmological examination in patients with Klinefelter syndrome.