Journal of Current Ophthalmology
Volume:22 Issue: 3, Sep 2010

It is a great privilege for the staff of the Iranian Journal of Ophthalmology (IRJO) to have the opportunity to publish a variety of subjects in ophthalmology and ophthalmic sciences which we receive from all over Iran and our medical centers. We do hope to extend this privilege to cover all Middle-East, Asia and even other continents. Our journal covers all kinds of subjects which makes it more colorful. In this issue of journal Oskooei et al1 (Pages: 68-70) report the discovery of a spectacle made of bone which has been found on the face of a skeleton of a young Iranian woman in a grave 3 to 4 millennia BC. The discovery was achieved by Professor Charles Berny in Yanik Tappeh in Eastern Azerbaijan Province, in 1962. Approved by UNESCO authorities this finding is of a very high importance since the history of the use of spectacles has still remained unsolved. Marco Polo in his trip to China on 12th century AC has indicated that Chinese did wear spectacles which they claimed that the technology has been brought from Middle-East. Yanik Tappeh spectacle opens a long discussion that spectacles were used at Middle-East even at the Iron era. It is of high interest to focus on few points published in this issue of IRJO.

To investigate long-term ocular manifestations of ocular Behcet’s disease (BD), and the causes for blindness. In August 2008, at Shariati hospital of Tehran (Behcet unit) all files of the ocular BD patients from 1976 to 2008 who were legally blind (Visual acuity=20/200 or less) at least in one eye at the last visit and had at least three years of follow-up were reviewed and the desired informations were extracted. In this retrospective, comparative, investigation, 187 patients (374 eyes) were included in this group (Group 1). They were compared with 81 nonblind (at the last visit) ocular BD patients (162 eyes) who were visited and consequently selected in 2008, our control group (Group 2). They were matched in term of the duration of BD, approximately 18 years. All patients had conventional treatments for ocular BD. 65.2% (N=122) of the blind group were males vs. 56.8% (N=46) of the nonblind (control group), χ2 =1.73, P=0.189. High number of initially impaired vision at presentation (vision of 20/200 or less) in the blind group; 230 eyes (61.5%) vs. 18 eyes (11.2%) in the control group was highly significant, χ2 =115.6, P=0.000. More frequent cases of visible retinal vasculitis (by ophthalmoscopy) in the blind group; 290 eyes (77.5%) vs. 107 eyes (66.5%) in the control group, χ2 =7.78, P=0.005, and higher frequency of vitritis and/or anterior uveitis 90.9% (N=340 eyes) vs. 75.3% (N=122 eyes) in the control group, χ2 =23.01, P=0.000 were both considered two major blinding risk factors in ocular BD. At the last visit 77.3% (N=289) eyes in the main group were blind and the main cause of blindness was end-stage disease (retinal vascular necrosis and consequently chorioretinal atrophy and optic atrophy) in 38.5% (144 eyes), and the second major blinding cause was macular scar ± optic atrophy in 14.9% (N=56 eyes). Although ocular BD can have a very severe and blinding outcome, early detection and prompt and intensive treatments may control the disease and save the sight.

To assess the outcomes of laser in situ keratomileusis (LASIK) in patients with multiple sclerosis (MS) 15 eyes of 8 patients with MS (2 men and 6 women) who referred for myopia treatment (with or without astigmatism) were undergone LASIK. After refractive and visual acuity examinations, topographic and pachymetry screening, intraocular pressure (IOP) measurement, biomicroscopy and retinal examination, those eligible for the LASIK surgery were included in the study. Patients with any signs and symptoms of optic neuritis in at least 6 months prior to the surgery were excluded. The patients were followed-up between 6 months (one patient) to 5 years after surgery. Mean spherical equivalent (SE), uncorrected visual acuity (UCVA) and best corrected visual acuity (BCVA) of the patients were recorded at 6 month after surgery. Follow-ups were done at the same day of the surgery and a week, 1, 6 months, and on annual basis after surgery. Mean age of the patients was 28.88±6.38 years and the MS diagnosis in patients dated back to 5.31±3.83 years before the study. The first episode of attacks happened 1.04±0.59 years after surgery. Mean SE of patients was -4.10±1.67 D before surgery that improved to -0.27±0.29 D after it. Mean UCVA of the patients was 0.11±0.07 before surgery and improved to 0.86±0.18 after surgery. Mean BCVA of the patients was 0.89±0.18 before and after surgery. Paired Sample T-test showed significant differences between mean SE and mean UCVA differences both before and after surgery. In our study, LASIK seems to be a safe surgery in MS patients.

Although applying mitomycin C (MMC) during photorefractive keratectomy (PRK) has shown to reduce postoperative corneal haze but there is considerable evidence of MMC toxicity in the literature and concerns exist regarding side effects and long-term complications. We conducted this study to compare the efficacy of MMC 0.02% and 0.01% in prevention of haze after PRK. 210 eyes were included in an interventional prospective comparative study. Both eyes of each patient were enrolled in this study. After laser ablation, MMC 0.02% (standard) were applied to right eyes of patients while the concentration was 0.01% (Low dose) for left eyes. Duration of MMC exposure was up to 40 seconds. Patients were followed on days 1 and 5 and 1, 3, 6 months after surgery and examined for refraction, uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA) and corneal haze. Ablation depth was 60-120 microns in all patients. One month after PRK, mean UCVAs were 0.06 and 0.04 and mean BCVAs were 0.02 and 0.01 in right and left eyes respectively. In the second follow-up visit performed 6 month after surgery mean UCVAs were 0.05 and 0.04 and mean BCVAs were 0.01 and 0.01 in right and left eye respectively. One month after PRK, 13 right eyes and 8 left eyes had grade 1+ and 2+ of haziness, while 6 months after surgery no haze were detected. Our data suggest that low dose (0.01%) MMC (LDMMC) can be as effective as standard dose (0.02%) MMC (SDMMC) in prevention of corneal haze after PRK, while reducing the side effects and future complications.

To compare postoperative anatomical sclerotomy sites of transconjunctival sutureless vitrectomy (TSV) with conventional 20-gauge vitrectomy In this prospective, nonrandomized study 30 consecutive patients divided in 2 groups: group I, 15 eyes from 15 patients underwent conventional 20-gauge and group II, 15 eyes from 15 patients underwent TSV (23, 25-gauge) pars plana vitrectomy (PPV). Wound gap, wound healing, vitreous incarceration and fibrovascular ingrowth (FVIG) at the sites of sclerotomy were assessed using ultrasound biomicroscopy (UBM) at week 8, postoperatively. In group 1 (conventional), healing of infusion cannula, vitrectomy and illuminating sites had occurred in 53.3%, 60% and 66.7% of patients. In group 2 (TSV), healing of infusion cannula, vitrectomy and illuminating sites occurred in 66.7%, 66.7% and 80% of patients. There was no significant difference between the two groups. FVIG was solely observed in diabetic patients in total sclerotomy sites (9 patients, 27 sclerotomy sites in conventional and 8 patients, 24 sites in TSV group). FVIG occurred in 7/27 sites (25.9%) in 20-gauge group and 5/24 sites (20.8%) in TSV group which was not significantly different (P=0.18). Wound gap was not found in any patient of the two groups. The overall comparison of sclerotomy sites (45 sites in each group) showed no significant difference regarding wound healing and vitreous incarceration. No case of ocular hypotony or endophthalmitis was observed at the end of follow-up time. Based on the UBM images of sclerotomy sites, there were no significant differences, in vitreous incarceration, wound healing, wound gap and FVIG between TSV and conventional PPV.

To evaluate the effect of intraviteral bevacizumab (IVB) in diabetic macular edema (DME), using multifocal electroretinography (mfERG) Sixty-four eyes of 32 patients with bilateral symmetric clinically significant macular edema (CSME) were included in the study. After taking a baseline mfERG, macular photocoagulation (MPC) was done in all eyes. After 7 days, 1.25 mg of bevacizumab was randomly injected in one eye of each patient and the other eye assigned for sham injection. mfERG was repeated 8 weeks after injection, and changes in visual acuity and mfERG compared in two groups. The mean best corrected visual acuities (BCVAs) at baseline were 0.55 in IVB group and 0.51 in control group and at 8th week were 0.41 and 0.53 respectively, also the amplitude and implicit time showed significant improvement in mfERG. Significant improvement in visual acuity and amplitude of waves of mfERG were observed compared with sham group. IVB injection can augment the effect of MPC in DME and can be used as an adjunctive treatment in these cases.

To determine the efficacy of three therapeutic regimens for the treatment of amaurosis fugax secondary to embolic sources from the heart Sixty patients randomly divided into 3 groups (20 patients in each group). Group 1 received 100 mg Aspirin/day, group 2 received the same dose of Aspirin plus dipyridamole 75 mg twice daily and group 3 received 10 mg warfarin for 3 days followed 5 mg thereafter. All patients were followed every 6 months for relapse of amaurosis fugax and cardiac status. Data were collected and analysed. Forty-nine patients (81.6%) were female and 11 patients (18.4%) were males. The mean ages of patients in group 1, 2, 3 were 44.85±14.56, 45.55±15.49 and 4490±14.87, respectively (P=0.98). The mean duration of amaurosis fugax stroke was 7 minutes (ranged 4-11 minutes). 91.6% of the patients had type A personality by anxiety and neurosis. Stroke was seen in 47 (78.3%) patients in both eyes, in 10 patients (16.6%) in the left eye and in 3 cases (5.1%) in the right eye. After one year of treatment, relapse of amaurosis fugax stroke was developed in 7 (35%) patients in Aspirin group, 5 (25%) in Aspirin plus dipyridamole group and 1 (5%) in warfarin group. Warfarin group had lower relapse than those in other groups (P=0.022). The results show that warfarin has better efficacy for the treatment of amaurosis fugax than Aspirin or Aspirin plus dipyridamole.

To investigate the discriminative ability of contrast sensitivity (CS), color vision and best corrected visual acuity (BCVA) in detecting functional losses in diabetic participants with and without retinopathy In this cross sectional study we examined 105 patients in Khatam-Al-Anbia Eye Hospital of Mashhad University of Medical Sciences including 70 diabetic patients (35 with retinopathy and 35 without retinopathy in fundus photography) with 35 control non-diabetic subjects matched for age and sex. The diabetic participants were subgrouped according to the level of retinopathy (EDTRS classification). CS was examined by means of CSV-1000 E instrument at 3, 6, 12 and 18 cpd, respectively in each eye. Color discrimination ability was measured with the Farnsworth D-15 test and BCVA by Snellen chart. When comparing visual performance of the right and left eyes of patients in each group, only the mean CS values at 6 cpd differ significantly in diabetics without retinopathy (P=0.01). CS was significantly lower in the diabetic eyes with retinopathy than in the normal eyes in all spatial frequencies. Comparing to control group, there was a statistically significant CS loss in spatial frequencies of 3, 6, 18 cpd in the diabetic eyes without retinopathy (P<0.05). The mean logMAR BCVA and color vision abnormalities were significantly higher in the diabetic eyes with retinopathy than in the normal eyes or the diabetic eyes without retinopathy (P<0.001). There was no significant difference between the visual performance of those diabetics without retinopathy compared to the control group. The sensitivity and specificity were almost identical for all tests of visual function in the right and left eyes. The sensitivity and specificity of the CS test in 6 cpd were 71% and 82% which were significantly higher than other spatial frequencies. So the discriminative ability of this spatial frequency in detecting diabetics with retinopathy was 71% and in detecting those without was 82%. The sensitivity and the specificity of the color vision test and BCVAs (logMAR≥0.05, Snellen≤9/10) were 79% and 94% respectively. There was significant difference between the visual performance of those diabetics with retinopathy compared to those without. There was excellent agreement between the results of these three tests. The findings also suggest that the appropriate combination of existing tests may be a useful method of improving screening accuracy in diabetic patients.

To determine the fusional amplitudes and the frequency of hetrophoria, in our patients In this cross sectional study, 111 adults with mean age of 25.6 years were included. All participants had best corrected visual acuity (BCVA) better than 20/25, more than 60 sec of arc stereopsis and had no heterotropia or other significant eye disorders. Fusional amplitudes were measured at far (6 meters) and near (40 centimeters) by rotary prism and hetrophoria was evaluated by Maddox wing. The total frequency of hetrophoria was 57.7%, and exophoria, esophoria, hyperphoria and cyclophoria were 51.4%, 0.9%, 3.6% and 9.9% respectively. The mean of convergence fusional amplitudes for far and near were 11 prism diopters (PD) and 16 PD and for divergence fusional amplitudes were 7 PD and 14 PD respectively. There were correlations between convergence and divergence fusional amplitudes at far and near. The amount of exophoria had not affected the fusional reserves and the presence of hetrophoria was not related to the visual complaints like asthenopia and transient diplopia.

To report the evaluation of the treatment response in choroidal hemangioma with application of enhanced depth imaging optical coherence tomography (EDI-OCT) technique Case report : A 73-year-old woman with a circumscribed choroidal hemangioma in the posterior pole of her left eye underwent photodynamic therapy and intravitreal injection of bevacizumab. EDI-OCT obtained from the affected eye before and after the treatment. The efficacy of treatment evaluated with indocyanine green and fluorescein angiography (FA). The EDI-OCT taken before treatment showed increased thickness of choroidal layer as multiple large dark spaces in the outer and middle layers of the choroid. After treatment, EDI-OCT revealed shrinkage of the choroidal thickness (from 712 µm to 273 µm) more pronounced in outer and middle layers. EDI-OCT may be used as a noninvasive test to help in the diagnosis and evaluation of the treatment response and follow-up of patients with choroidal hemangioma.

To report a new familial presentation of hypoplasia and absence of superior rectus in the form of unilateral monocular elevation deficiency Case report : A 7-year-old boy was referred to our center (Poostchi eye clinic) with a chief complaint of ocular misalignment in his right eye since birth. One of his siblings was a known case of unilateral monocular elevation deficiency and was operated previously. Other family members were normal. Ocular motility examinations revealed more than 60 prism diopters hypotropia of right eye in primary position associated with limitation of elevation in both abduction and adduction. No pattern (A, V, etc.) was detected. There was no sign of craniosynostosis by neurologic exams or by imagings. Unilateral monocular elevation deficiency was diagnosed. Under operation congenital absence of superior rectus was found while in her sister’s chart review, only congenital hypoplasia of superior rectus was reported. This is the first report of familial presentation of monocular elevation deficiency resulted from both hypoplasia and absence of superior rectus. This finding may suggest the possible role of a genetic mechanism to be responsible for this disorder.

The first report of electroretinographic changes following the intravitreal injection of carboplatin in a patient with retinoblastoma Case report : Recurrent tumors after chemoreduction and adjunctive local treatment in a case of familial unilateral retinoblastoma, group C, was treated with intravitreal carboplatin (10 µg) injections. The tumor was regressed after 3 injections. Flat electeroretinogram (ERG) amplitude was noted following the intravitreal injection of carboplatin. After nearly one year tumor-free period in this case, visual acuity (VA) in the affected eye was 20/800 despite a flat ERG. Intravitreal carboplatin can effectively treat intraretinal tumor recurrences but de-novo tumors can be produced causing therapeutic problems. Intravitreal injections of carboplatin can cause retinal toxicity and flat ERG.

To report a case of congenital macular macrovessels Case report : An 8-year-old girl was referred for decreased vision in her right eye. Her best corrected visual acuity (BCVA) in the right eye was 20/200 and in the left eye 20/20. Anterior segment examinations were normal in both eyes. Posterior segment examination of the right eye showed abnormal macrovessels crossing the macula and passing over the fovea. Left funduscopy finding was insignificant. Congenital retinal macrovessels are rare anomalies. They are aberrant retinal vessels, usually venules, present in the posterior pole and crossing the avascular foveal region. Most of these cases are unilateral and stable with excellent visual prognosis and are detected on routine examination. Foveal cysts, hemorrhages and displaced foveola may be also associated with this anomaly. These entities must be distinguished from racemose angiomas, capillary hemangiomas of the retina and even when associated with neurological symptoms, should be considered as part of the Wyburn-Masson syndrome. In children with CRM and decreased visual acuity, it should be treated promptly to avoid amblyopia. Regular examination and careful follow-up of vascular lesions is mandatory to limit possible complications.

Determinants of early onset haze were retrospectively explored in patients who had been undergone laser-assisted sub-epithelial keratectomy (LASEK) in a private eye clinic. The technique included creating an epithelial flap following 20 seconds exposure to 20% alcohol. ‘Optimized’ ablation profile was used by Allegretto laser (Wavelight Technologie). Following repositioning of the flap, a single-brand bandage contact lens was used. For eyes with a spherical equivalent of more than 3 diopters, intraoperative mitomycin C (MMC) was used for 20-30 seconds. Patients were visited at day 1, day 4, week 3, month 3, month 6, and year 1 postoperatively. Candidates included 130 patients (260 eyes), of whom 62% were female. Mean age was 29.0±10 years and baseline range of spherical equivalent was -11.50 to +5.75 (absolute mean 3.50) diopters. The epithelial flap was lost in 36 eyes (28%). Transitory haze was observed in 29 cases (21.5%), all of which had retained their epithelial flap; none of the epithelial flap lost eyes showed haze (P<0.004). Gender, age, MMC usage, and pre-existing astigmatism were not associated with transitory haze (P-values: 0.652, 0.575, 0.815, and 0.248 respectively). Haze was resolved in all of the eyes. No case of classic haze was noted. Contrary to the current concept that the epithelial flap acts as a biologic contact lens and controls wound healing in surface ablation,1,2 in the current series, loss of epithelial flap seems to have had a protective effect in (transitory) haze formation.

The Europeans consider Roger Bacon as the inventor of spectacles, and the 13th Century, as the beginning of using lenses as spectacles. It can truly be said that the lenses had not been born all of a sudden then. It may be concluded that the lenses had been available long before that time. We are all familiar with quartz, a transparent volcanic stone that begins its journey in the rivers after it forms. In the river, it rubs to the other stones and water and finds the shape of a lens. This beauty and transparency causes man to make glasses and put it in front of his eyes.

I read the recent publication on retinopathy of prematurity (ROP) screening with a great interest. Mousavi et al concluded that “Giving sufficient information about ROP to parents and educating them about this potentially blinding condition, along with making appointments for them and presence of facilities for free ROP screening exams, can increase the chance of on-time screening.1 I have some comments on this work. There might be some forgotten factors to be addressed. First, the background of the parents (Socioeconomic status, education status, psychological status, etc.) might have some effects on the final practice on screening. Second, the success of the program might be biased by the “making appointments”. Whether there is a control for technique on making appointment is still questionable. Third, the attendants in this work might also get the knowledge from other resources such as mass media. Finally, this is not a direct pre- and post - evaluation on the knowledge but it is the measurement of practice after implementation of knowledge. It is indirect relationship based on the knowledge-attitude-practice (KAP) principle.

This study has assessed some of the important factors affecting on-time attendance rate, although we agree that there are other factors affecting this issue. However, it is noteworthy to mention that our study was based on two major projects registered by Tehran University of Medical Sciences (No 19952 and 20499), in which we knew that the parents in our study did not have significantly different educational status. 2. As we have mentioned in our conclusion, “Giving sufficient information about retinopathy of prematurity (ROP) to parents and educating them about this potentially blinding condition, along with making appointments for them and presence of facilities for free ROP screening exams, can increase the chance of on-time screening”; thus we never claimed that only education was the reason of the difference observed. However, our data shows that in group A, 12 parents missed their on-time examination due to lack of knowledge about ROP (11 due to not being aware about the importance of time in ROP and 1 due to the misconception that the baby is too small for such examination), while only 1 missed the exam because they “did not know where to seek for screening”. The fact that none of these reasons were found in group B may lead us to guess that educating the parents played a more important role compared to other factors. Nevertheless, we are aware that the limitations of our study prevent us from direct conclusion. 3. Although mass media usually plays an important role in educating people about health issues, the issue of ROP is rarely discussed in our media. Thus we do not have any reason to believe that our participants were affected by any media. 4. This was not meant to be a pre and post knowledge evaluation. We actually assessed the effect of a practical tool [a piece of paper with health information plus a free appointment (the charge of ROP screening exam in university hospitals in Iran is not so much)] on the rate of on-time attendance