Intravitreal fasudil monotherapy for treatment of refractory diabetic macular edema: A prospective interventional case series

BACKGROUND

Suboptimal response to conventional treatments in refractory diabetic macular edema (rDME) encourages efforts to identify new therapeutic options.

PURPOSE

To evaluate the effect of three monthly intravitreal injections of a Rho-associated protein kinase (ROCK) inhibitor (Fasudil, Asahi Kasei Pharma Corporation, Tokyo, Japan) in eyes with rDME.

METHODS

Ten eyes of 10 patients with DME unresponsive to at least six previous intravitreal bevacizumab (IVB) injections were recruited and underwent 3 consecutive monthly intravitreal injection of 0.025mg/0.05mL Fasudil. Best-corrected visual acuity (BCVA) and central macular thickness (CMT) were evaluated as functional and anatomical response indicators, respectively.

RESULTS

The mean age was 60.1±5.1 years (range, 53-68). Five cases responded to treatment, two with both anatomical and functional responses (reduction of CMT from 521 to 395 and from 390 to 301 microns and improvement of BCVA from 0.3 to 0.1 LogMAR and 0.6 to 0.4 LogMAR, respectively) and three with only functional improvement (0.7 to 0.4; 0.7 to 0.4; and 0.3 to 0.1 LogMAR). Of note, cases with no significant change in CMT showed morphologic improvement of the retinal microstructure to some extent. No adverse event was observed during the study period.

CONCLUSION

Monotherapy with intravitreal injection of ROCK inhibitors appears to have moderate visual benefits in eyes with DME refractory to IVB. Such effects may be functionally significant without obvious anatomical improvement.

Association between vitamin D and cardiovascular health: Myth or Fact? A narrative review of the evidence

Vitamin D deficiency is prevalent worldwide. Since the discovery of the expression of vitamin D receptor in ventricular cardiomyocytes, fibroblasts, and blood vessels, there has been a growing body of literature assessing the link between vitamin D status and cardiovascular health from one side, and the effect of vitamin D supplementation on prevention of cardiovascular diseases from the other side. In this review, we summarized studies highlighting the role of vitamin D on cardiovascular health, namely atherosclerosis, hypertension, heart failure, and metabolic syndrome, a recognized significant risk factor for cardiovascular diseases. Studies showed discrepancies between findings from cross-sectional and longitudinal cohorts and those from interventional trials, but also between one outcome and another. Cross-sectional studies found a strong association between low 25 hydroxyvitamin D (25(OH)D3) and acute coronary syndrome, and heart failure. These findings encouraged the promotion for vitamin D supplementation as a preventive measure for cardiovascular diseases in the elderly, namely in women. This fact, however, turned out into a myth with the results of large interventional trials that did not show any benefit from vitamin D supplementation in reducing ischemic events, heart failure or its outcomes, or hypertension. Although some clinical studies showed beneficial effect of vitamin D supplementation on insulin sensitivity and metabolic syndrome, this effect was not consistent across all studies.

Prevalence of menopausal hot flashes in Lebanon: A cross-sectional study

Background

Menopausal hot flashes or vasomotor symptoms are prevalent and could be debilitating in postmenopausal women. There is controversy regarding the risk factors for hot flashes, some of which may vary from one country or culture to another.

Objective

To shed light on this matter by assessing the prevalence of hot flashes, their effect on quality of life, and their association with certain factors such as physical exercise, caffeine, spicy food consumption, dietary intake, smoking, alcohol, etc.

Materials and Methods

A large cross-sectional study was conducted among 627 Lebanese women, aged 45-67 yr using a well-developed and comprehensive questionnaire, in order to better assess the prevalence of hot flashes, focusing on their characteristics, association with various factors, severity, and effect on the women's quality of life.

Results

62.5% of participants experienced hot flashes. A statistically significant difference was noted between women who experience hot flashes and their counterparts with respect to smoking, body mass index, spicy food consumption, education level, age, menstrual status, and parity. An association was not found with physical activity or other dietary factors.

Conclusion

As an alternative for hormone therapy, clinicians should consider lifestyle changes to help manage hot flashes, which impose a tremendous physical and social toll on the women experiencing them.

Minimally invasive parathyroidectomy guided by intraoperative parathyroid hormone monitoring (IOPTH) and preoperative imaging versus bilateral neck exploration for primary hyperparathyroidism in adults

BACKGROUND

Bilateral neck exploration (BNE) is the traditional approach to sporadic primary hyperparathyroidism. With the availability of the preoperative imaging techniques and intraoperative parathyroid hormone assays, minimally invasive parathyroidectomy (MIP) is fast becoming the favoured surgical approach.

OBJECTIVES

To assess the effects of minimally invasive parathyroidectomy (MIP) guided by preoperative imaging and intraoperative parathyroid hormone monitoring versus bilateral neck exploration (BNE) for the surgical management of primary hyperparathyroidism.

SEARCH METHODS

We searched CENTRAL, MEDLINE, WHO ICTRP and ClinicalTrials.gov. The date of the last search of all databases was 21 October 2019. There were no language restrictions applied.

SELECTION CRITERIA

We included randomised controlled trials comparing MIP to BNE for the treatment of sporadic primary hyperparathyroidism in persons undergoing surgery for the first time.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for relevance. Two review authors independently screened for inclusion, extracted data and carried out risk of bias assessment. The content expert senior author resolved conflicts. We assessed studies for overall certainty of the evidence using the GRADE instrument. We conducted meta-analyses using a random-effects model and performed statistical analyses according to the guidelines in the latest version of the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

We identified five eligible studies, all conducted in European university hospitals. They included 266 adults, 136 participants were randomised to MIP and 130 participants to BNE. Data were available for all participants post-surgery up to one year, with the exception of missing data for two participants in the MIP group and for one participant in the BNE group at one year. Nine participants in the MIP group and 11 participants in the BNE group had missing data at five years. No study had a low risk of bias in all risk of bias domains. The risk ratio (RR) for success rate (eucalcaemia) at six months in the MIP group compared to the BNE group was 0.98 (95% confidence interval (CI) 0.94 to 1.03; P = 0.43; 5 studies, 266 participants; very low-certainty evidence). A total of 132/136 (97.1%) participants in the MIP group compared with 129/130 (99.2%) participants in the BNE group were judged as operative success. At five years, the RR was 0.94 (95% CI 0.83 to 1.08; P = 0.38; 1 study, 77 participants; very low-certainty evidence). A total of 34/38 (89.5%) participants in the MIP group compared with 37/39 (94.9%) participants in the BNE group were judged as operative success. The RR for the total incidence of perioperative adverse events was 0.50, in favour of MIP (95% CI 0.33 to 0.76; P = 0.001; 5 studies, 236 participants; low-certainty evidence). Perioperative adverse events occurred in 23/136 (16.9%) participants in the MIP group compared with 44/130 (33.9%) participants in the BNE group. The 95% prediction interval ranged between 0.25 and 0.99. These adverse events included symptomatic hypocalcaemia, vocal cord palsy, bleeding, fever and infection. Fifteen of 104 (14.4%) participants experienced symptomatic hypocalcaemia in the MIP group compared with 26/98 (26.5%) participants in the BNE group. The RR for this event comparing MIP with BNE at two days was 0.54 (95% CI 0.32 to 0.92; P = 0.02; 4 studies, 202 participants). Statistical significance was lost in sensitivity analyses, with a 95% prediction interval ranging between 0.17 and 1.74. Five out of 133 (3.8%) participants in the MIP group experienced vocal cord paralysis compared with 2/128 (1.6%) participants in the BNE group. The RR for this event was 1.87 (95% CI 0.47 to 7.51; P = 0.38; 5 studies, 261 participants). The 95% prediction interval ranged between 0.20 and 17.87. The effect on all-cause mortality was not explicitly reported and could not be adequately assessed (very low-certainty evidence). There was no clear difference for health-related quality of life between the treatment groups in two studies, but studies did not report numerical data (very low-certainty evidence). There was a possible treatment benefit for MIP compared to BNE in terms of cosmetic satisfaction (very low-certainty evidence). The mean difference (MD) for duration of surgery comparing BNE with MIP was in favour of the MIP group (-18 minutes, 95% CI -31 to -6; P = 0.004; 3 studies, 171 participants; very low-certainty evidence). The 95% prediction interval ranged between -162 minutes and 126 minutes. The studies did not report length of hospital stay. Four studies reported intraoperative conversion rate from MIP to open procedure information. Out of 115 included participants, there were 24 incidences of conversion, amounting to a conversion rate of 20.8%.

AUTHORS' CONCLUSIONS

The success rates of MIP and BNE at six months were comparable. There were similar results at five years, but these were only based on one study. The incidence of perioperative symptomatic hypocalcaemia was lower in the MIP compared to the BNE group, whereas the incidence of vocal cord paralysis tended to be higher. Our systematic review did not provide clear evidence for the superiority of MIP over BNE. However, it was limited by low-certainty to very low-certainty evidence.

Inter-professional physician-nurse collaboration in Lebanon

Purpose

A physician–nurse relationship is a complex, professional and shared-decision-making process, which is an important predictor of high-quality patient care. The purpose of this paper is to explore the attitude of the physician–nurse relationship in Southern Lebanon hospitals.

Design/methodology/approach

A descriptive institutional cross-sectional study was conducted among different departments of three hospitals in Southern Lebanon using a validated Jefferson Scale of Attitude.

Findings

In sum, 89 physicians and 245 nurses accepted to participate. The nurses’ mean age was 32 and the physicians’ was 44. The mean score was found to be 46 for all participants, with significantly higher scores noted among nurses compared to physicians (48 vs 43, respectively) and higher scores among females compared to males (48 vs 46, respectively). However, the study scored no significant difference in relation to the degrees attained by nurses and the participants’ years of experience. The majority had agreed that the shortage in the nurses’ staff affects proper patient care delivery. One fourth of the physicians disagreed that nurses should be considered as a collaborator and colleague. Therefore, more work is required to improve this collaboration.

Research limitations/implications

There is a complex relationship normally displayed by physicians and nurses, which cannot be easily interpreted and analyzed. Physicians and nurses may have given socially desirable responses while filling the questionnaire. Even more, this study was conducted in Hospitals in Southern Lebanon, and it would be nice to extend this study to include further hospitals in other regions in Lebanon as well.

Practical implications

Nurses had higher scores toward collaboration, with females scoring higher than males. However, overall scores are considered to be lower compared to other countries. Thus, more efforts should be done on improving this communication among nurses and physicians, through promoting inter-professional undergraduate and postgraduate education training toward more effective communication.

Social implications

Quality of patient care would be improved if more work is done on improving the collaboration between physicians and nurses, and this was shown to be required as per study results.

Originality/value

There is a gap in literature assessing this important topic which is the collaboration and attitude of nurses and physicians toward their relationship in Lebanon. It is extremely important that efforts should be taken in order to determine the type of nurse–physician relationship in every local context as this relationship affects quality of patients’ care.

Management and control of type 2 diabetes mellitus in Lebanon: Results from the International Diabetes Management Practices Study Wave 6

BACKGROUND

Diabetes mellitus is a worldwide public health problem associated with significant complications. There is lack of data on the quality of care of patients with diabetes, specifically among the non-Western countries. Efforts have been made in Lebanon to better study the characteristics of patients with diabetes mellitus in order to improve glycemic control and prevent late-term complications.

AIM

To investigate control and therapeutic management of patients with diabetes mellitus in the current medical practice in Lebanon.

METHODS

Wave 6 of the International Diabetes Management Practice Study in Lebanon is an international and multicenter study involving selected countries.

RESULTS

Only 1 patient with type 1 diabetes and 595 patients with type 2 diabetes were included in Wave 6. Average age was around 60 years, with a mean body mass index of 30. The mean fasting serum glucose was 159.42 mg/dL, and the mean glycosylated hemoglobin (HbA1c) level was 7.98 with around 30% achieving an HbA1c target of < 7%. More patients were on oral anti-diabetic medications. Screening of diabetic complications has improved over the years. A large percentage is diagnosed with hypertension and dyslipidemia, the majority of whom were treated but only a small percentage were controlled.

CONCLUSION

Diabetes, with its associated dyslipidemia and hypertension, is still not very well controlled. Screening for diabetes complications has improved over the years. Patients need to have more proper care, and physicians need to follow diabetes guidelines, and to have a larger number of patients who have appropriate treatment of diabetes, hypertension and lipids.

Perception of peri-menopausal and postmenopausal Lebanese women on osteoporosis: A cross-sectional study

INTRODUCTION

Osteoporosis is a generalized skeletal disorder characterized by decreased bone mineral density and microarchitectural deterioration, resulting in increased susceptibility to fractures. The prevalence of osteoporosis in Lebanon, defined as T-score <-2.5 at the total hip using NHANES gender-specific database was estimated to be 31% among postmenopausal women.

PURPOSE

To assess the general perception of osteoporosis among women in Lebanon as well as their general knowledge of its lifestyle, risk factors, diagnostic, preventive and therapeutic measures.

METHODS

A cross-sectional study was conducted in Lebanon between January and December 2017. Women above the age of 50 were invited to participate. A standardized questionnaire regarding the perception of personal risk of osteoporosis and fractures was used. Risk factors for osteoporosis, previous fractures or falls, family history of fracture, smoking, alcohol consumption, and secondary causes of osteoporosis were evaluated. Data were recorded on excel and analyzed on SPSS using variety of descriptive analysis, ANOVA tests, and others. P value <0.05 was considered to be statistically significant.

RESULTS

From 396 interviewed women, 85% were in menopause and were more likely to be diagnosed with osteoporosis. 45% knew the true definition of osteoporosis and their most frequent source of information was doctors. Around 60% had heard of BMD screening but only 54.5% of those women actually did it.

CONCLUSION

This study reveals that osteoporosis knowledge and perception is low among the Lebanese woman aged 50 years and older.

Diabetes and depression in Lebanon and association with glycemic control: a cross-sectional study

BACKGROUND

Diabetes mellitus is a chronic noncommunicable disease characterized by hyperglycemia and is associated with chronic complications affecting the overall quality of life. As of 2017, the prevalence of diabetes in Lebanon is estimated to be 14.6%. Depression is noted to be common among Lebanese citizens, present in around 17.3%. This study aims to investigate the prevalence of depression among the diabetic Lebanese citizens and to study its relationship with poor glycemic control and diabetes complications.

METHODS

In total, 436 diabetic patients participated in this cross-sectional study. Patients with diabetes mellitus attending several private clinics and health care centers were asked to fill out a well-structured questionnaire developed by an expert. Depression was assessed using Beck Depression Inventory (BDI). The study collected demographic information about the participants including their lifestyles, their last reported glycosylated hemoglobin values, and their reported microvascular and macrovascular complications. Data were collected, entered, and analyzed on SPSS software version 23.1. A descriptive analysis is carried out by calculating the mean and standard deviation for continuous variables and number and percentage for categorical ones. Association between categorical variables is evaluated using a chi-squared test. A P-value of <0.05 is considered to be significant.

RESULTS

Depression was prevalent among 28.8% of the patients with diabetes mellitus. The average age of participants was 64.08 years. In total, 280 (64.2%) of the participants were females and the average diabetes duration was 8.89 years. There was no significant relationship found between depression and glycemic control. By contrast, a significant association between retinopathy, nephropathy, and stroke and depression was found.

CONCLUSION

Depression was found to be present among 28.8% of the patients with diabetes mellitus in Lebanon; however, no association was established between depression and glycemic control.

Therapeutic Effects of Laser Photocoagulation and/or Vitrectomy in Eales' Disease

PURPOSE

To determine visual outcomes and regression of retinal neovascularization following laser photocoagulation and/or vitrectomy in eyes with Eales' disease.

METHODS

In a retrospective noncomparative study, the authors reviewed the existing data of 67 eyes of 54 patients with a diagnosis of Eales' disease who had undergone laser photocoagulation and/or vitrectomy based on their clinical presentations. Main outcome measures were visual acuity changes and regression of retinal neovascularization of the eyes following treatment.

RESULTS

Both laser therapy and vitrectomy improved visual acuity and induced regression of retinal neovascularization. Forty-three eyes had undergone laser therapy; their rate of visual acuity 320/30 improved from 53% before treatment to 60% after treatment. Twenty-four eyes had undergone vitrectomy; rate of visual acuity 320/30 improved from 13% before surgery to 38% after surgery. In eyes that had undergone laser therapy, additional laser therapy controlled recurrent neovascularization in 47% of the eyes, but ultimately, 12% of them required vitrectomy. In the primary vitrectomized group, additional required treatment was repeat vitrectomy in 21%, and/or laser therapy in 29% of the eyes.

CONCLUSIONS

Although laser photocoagulation should be the first line of treatment in Eales' disease, it cannot always induce regression of retinal neovascularization. In such cases vitrectomy may further enhance therapeutic success.

Single-Session Photodynamic Therapy Combined with Intravitreal Bevacizumab for Neovascular Age-Related Macular Degeneration

Purpose

To evaluate the efficacy of combined single-session photodynamic therapy (PDT) and intravitreal bevacizumab (IVB) for treatment of neovascular age-related macular degeneration (AMD).

Methods

In a prospective interventional case series, patients with subfoveal choroidal neovascularization (CNV) underwent PDT followed by 1.25 mg IVB injection. Best-corrected visual acuity (BCVA) and optical coherence tomography (OCT) measurements were repeated at 6-week intervals and fluorescein angiography was performed after 12 weeks and when considered necessary thereafter. Repeat injections of IVB were performed based on fluorescein angiographic evidence of CNV leakage.

Results

Fourteen eyes were included in this study. Mean follow-up was 52.4±15.2 weeks (range: 26–74 weeks). Initially, mean BCVA was 0.80±0.42 logMAR and mean central macular thickness (CMT) was 308±88 μm. At week 12, BCVA improved to 0.62±0.47 logMAR (p=0.006) and CMT reduced to 186±53 μm (p=0.003). Corresponding results were 0.53±0.52 logMAR (p=0.02) and 193±78 μm (p=0.002) after 24 weeks. A second IVB injection was performed in 13 eyes with a mean interval of 16.3±5.9 weeks.

Conclusions

Combination therapy with single-session PDT and IVB can improve vision and reduce CMT in neovascular AMD. Repeat IVB injections may maintain the visual gain from the initial combination therapy.

Effects of Sodium Glucose Cotransporter-2 Inhibitors on Serum Uric Acid in Type 2 Diabetes Mellitus

Hyperuricemia has been linked to metabolic syndrome, cardiovascular disease, and chronic kidney disease. Hyperuricemia and type 2 diabetes mellitus were inter-related, type 2 diabetes mellitus was more at risk of having a higher serum uric acid level, and also individuals with higher serum uric acid had higher risk of developing type 2 diabetes in the future. Insulin resistance seems to play an important role in the causal relationship between metabolic syndrome, type 2 diabetes, and hyperuricemia. Oral diabetic drugs that would have additional beneficial effects on reducing serum uric acid levels are of importance. Selective SGLT2 inhibitors were extensively studied in type 2 diabetes mellitus and were found to have improvement of glycemic control, in addition to their proven metabolic effects on weight and blood pressure. Additional beneficial effect of SGLT2 inhibitors on serum uric acid level reduction is investigated. Recently, data have been accumulating showing that they have additional beneficial effects on serum uric acid reduction. As for the postulated mechanism, serum uric acid decreased in SGLT2 inhibitor users as a result of the increase in the urinary excretion rate of uric acid, due to the inhibition of uric acid reabsorption mediated by the effect of the drug on the GLUT9 isoform 2, located at the collecting duct of the renal tubule.

Role of sodium glucose cotransporter-2 inhibitors in type I diabetes mellitus

The burden of diabetes mellitus (DM) in general has been extensively increasing over the past few years. Selective sodium glucose cotransporter-2 (SGLT2) inhibitors were extensively studied in type 2 DM and found to have sustained urinary glucose loss, improvement of glycemic control, in addition to their proven metabolic effects on weight, blood pressure, and cardiovascular benefits. Type 1 DM (T1D) patients clearly depend on insulin therapy, which till today fails to achieve the optimal glycemic control and metabolic targets that are needed to prevent risk of complications. New therapies are obviously needed as an adjunct to insulin therapy in order to try to achieve optimal control in T1D. Many oral diabetic medications have been tried in T1D patients as an adjunct to insulin treatment and have shown conflicting results. Adjunctive use of SGLT2 inhibitors in addition to insulin therapies in T1D was found to have the potential to improve glycemic control along with decrease in the insulin doses, as has been shown in certain animal and short-term human studies. Furthermore, larger well-randomized studies are needed to better evaluate their efficacy and safety in patients with T1D. Euglycemic diabetic ketoacidosis incidences were found to be increased among users of SGLT2 inhibitors, although the incidence remains very low. Recent beneficial effects of ketone body production and this shift in fuel energetics have been suggested based on the findings of protective cardiovascular benefits associated with one of the SGLT2 inhibitors.

Editorial on the original article entitled "Changes in diabetes-related complications in the United States, 1990-2010" published in the New England Journal of Medicine on April 17, 2014

The paper entitled "Changes in diabetes-related complications in the United States, 1990-2010" published recently in the New England Journal of Medicine examined the spectrum of diabetes complications over the past 20 years based on a unique, nationally representative database in the Unites States. It was noted that although adults with diagnosis of diabetes have more than tripled between the years 1990 and 2010, the rates of all five major complications of diabetes have declined significantly with the greatest absolute declines being noted for acute myocardial infarction followed by stroke, lower-extremity amputation, end-stage renal disease and finally the death from hyperglycemic crisis. The greatest declines in most of the diabetes-related complications were observed among elderly persons who are above the age of 75 years with the exception of end stage renal disease which declined only in younger people but not among elderly. These findings could be due to the fact that over the past years there have been great advancements with regards to creating diabetes education programs especially after the publication of many trials that looked at the importance of intensive versus conventional glucose control, along with the enhanced management of other associated risk factors such as blood pressure, lipid levels, and smoking cessation.

The role of incretin-based therapies in prediabetes: a review

Prediabetes, a high-risk state for future development of diabetes, is prevalent globally. Abnormalities in the incretin axis are important in the progression of B-cell failure in type 2 diabetes. Incretin based therapy was found to improve B cell mass and glycaemic control in addition to having multiple beneficial effects on the systolic and diastolic blood pressure, weight loss in addition to their other beneficial effects on the liver and cardiovascular system. In prediabetes, several well-designed preventive trials have shown that lifestyle and pharmacologic interventions such as metformin, thiazolidinediones (TZD), acarbose and, nateglinide and orlistat, are effective in reducing diabetes development. In recent small studies, incretin based therapy (DPP IV inhibitors and GLP-1 agonists) have also been extended to patients with prediabetes since it was shown to better preserve B-cell function and mass in animal studies and in clinical trials and it was also shown to help maintain good long term metabolic control. Because of the limited studies and clinical experience, their side effects and costs currently guidelines do not recommend incretin-based therapies as an option for treatment in patients with prediabetes. With future clinical trials and studies they may be recommended for patients with impaired fasting glucose or impaired glucose tolerance.

Liver disease and diabetes: association, pathophysiology, and management

Diabetes is associated with a spectrum of liver diseases including nonalcoholic liver disease, steatohepatitis, and liver cirrhosis with their increased complications and mortality. Hepatitis C virus (HCV) and its associated liver cirrhosis has been associated with diabetes through insulin resistance. Cryptogenic diabetes occurs as a consequence of liver cirrhosis with the pathophysiology being complex, but mostly attributed to the increased insulin resistance in muscle, liver, and adipose tissue. As for the management of diabetes in patients with liver disease, lifestyle modification plays an important role. Oral diabetic medications are contraindicated in patients with advanced liver diseases with associated cirrhosis, ascites, or encephalopathy. As for stable liver disease, metformin and thiazolenediones have shown mixed results, with some showing them to be effective in improving liver transaminases in addition to histological improvement in steatosis and inflammation. α-glucosidase inhibitors may be helpful in decreasing hepatic encephalopathy. Upregulation of Dipeptidyl peptidase-4 (DPP-4) has been suggested as a possible pathogenetic mechanism for HCV-related insulin resistance, and treatment with DPP-4 inhibitors could improve insulin sensitivity in diabetic patients with liver disease. Patients with impaired liver function with associated insulin resistance may need increased insulin requirements. On the other hand patients with altered liver metabolism might need decreased insulin requirements.

Posterior sub-tenon triamcinolone for refractory diabetic macular edema: a randomized clinical trial

PURPOSE

To evaluate the effect of posterior sub-tenon triamcinolone acetonide (TA) injection on clinical, angiographic, and optical coherence tomographic (OCT) parameters in refractory diabetic macular edema (DME).

METHODS

In a double-masked placebo-controlled clinical trial, 64 eyes were randomly assigned to two groups. The treatment group (32 eyes) received 40 mg posterior sub-tenon injection of TA and the placebo group (32 eyes) received subconjunctival injection of a placebo. The injections were repeated after 2 months in both groups. Complete ophthalmologic examination, fluorescein angiography, and OCT were performed before intervention and after 4 months. Quantitative measurement of angiographic variables such as the amount of hard exudates (HE), size of foveal avascular zone (FAZ), and leakage severity was performed by computer, using Photoshop software.

RESULTS

Initial best-corrected visual acuity (VA) was 0.93+/-0.39 logMAR in the placebo group and 0.75+/-0.38 logMAR in the treatment group. At 4 months, corrected VA was 0.88+/-0.48 logMAR in the controls versus 0.71+/-0.42 logMAR in the cases. Mean central macular thickness measured by OCT before and 4 months after injection was 392 and 377 microns in the treatment group and 388 and 357 microns in the placebo group, respectively. No statistically significant difference was detected between the two groups. The difference was also not significant in HE, FAZ, and leakage in the angiograms.

CONCLUSIONS

Two injections of posterior sub-tenon TA had no therapeutic effect on refractory DME.

Effect of tranexamic acid on early postvitrectomy diabetic haemorrhage; a randomised clinical trial

AIMS

To evaluate the effect of tranexamic acid on early postvitrectomy haemorrhage in diabetic patients.

METHODS

In a clinical trial, 62 diabetic patients scheduled for vitrectomy were randomly assigned to two groups. The treatment group (32 eyes) received two doses of tranexamic acid (10 mg/kg) shortly before and after the operation intravenously, continued orally for 4 days (20 mg/kg/8 hours). The control group (30 eyes) received no medication. Both media clarity and visual acuity were compared during 4 weeks.

RESULTS

Four weeks after surgery visual acuity was low (< or =1 metre counting fingers) in 21.4%, moderate (>1 metre counting fingers but<20/200) in 14.3%, and good (> or =20/200) in 64.3% of the treated group. Corresponding figures in the control group were 26.1%, 26.1%, and 47.8%, respectively. These differences were of no statistical significance. The ratio of mild to severe vitreous haemorrhage during the first 4 days and after 4 weeks was 79% to 21% and 82% to 18% in the treatment group and 76.7% to 23.3% and 78.3% to 21.7% in the control group respectively, which showed no statistically significant difference.

CONCLUSION

Tranexamic acid, with the method of administration in this study, had no effect on reducing early postvitrectomy haemorrhage in diabetic patients.

Outcomes of surgical (pars plicata and limbal lensectomy, vitrectomy) and non-surgical management of persistent fetal vasculature (PFV): an analysis of 54 eyes

PURPOSE

To identify clinical characteristics associated with outcomes of treatment for persistent fetal vasculature (PFV based on a modified classification.

METHODS

In this noncomparative case series, 54 eyes of 47 consecutive patients with PFV managed from 1981 until 1998 at a tertiary eye hospital were reviewed. Pars plicata lensectomy and vitrectomy was performed in 34 eyes and translimbal lensectomy and vitrectomy in five. Fifteen eyes were managed non-surgically. The following outcomes were measured: 1) "Visual improvement", defined as at least one Zipf's category improvement of best corrected final vision as compared with initial visual acuity, provided that final vision of CSUM (central, steady, unmaintained) equal to 20/100-20/30 was obtained. 2) "Cosmetic acceptability", defined as the absence of the following: small orbit, externally small appearing eye with microcornea and hypotony, eye deviation more than 35 prism diopters without strabismus surgery and corneal opacity.

RESULTS

Six eyes were inoperable. In 10 out of 33 operated eyes (30.3%) improvement of vision was obtained including four eyes with an anterior form and six eyes with a combined form of PFV. In univariate analysis, factors such as anterior form of PFV surgery in the combined form and having a normal retina, had a weak association with a higher chance of visual improvement. In multivariate regression analysis the likelihood of unacceptable cosmetic appearance was higher in females than males (OR = 10.5), and in bilateral cases (OR = 7.9). Offspring of consanguineous marriages had more severe forms of PFV.

CONCLUSIONS

Although visual potential is limited in PFV some eyes with an anterior or combined form and normal retina achieved improvement of visual acuity after surgery. However, statistically no single factor except sex and bilateral PFV (for cosmetic unacceptability) reliably predicted the results of treatment. Therapy should be individualized based on clinical findings. Genetic studies in offspring of consanguineous marriages with PFV may prove informative.

Intra-ocular lens implantation in children

Intra-ocular lens (IOL) implantation in a growing eye of a young child brings several problems unique to this age group. Better understanding of the rate of refractive growth in children's pseudophakic eyes may help predicting future refractions in these eyes more accurately. Opacification of the posterior capsule, if remained intact, interferes with visual rehabilitation in children. Primary posterior capsulectomy and anterior vitrectomy provides the clarity of visual axis. Optical rehabilitation of children with unilateral aphakia is usually problematic. Posterior chamber IOLs are preferred to anterior-chamber IOLs for secondary implantation. In the absence of adequate capsular support and contact lens intolerance, a scleral-fixated IOL can be implanted. Scleral fixation of a posterior chamber IOL has encouraging short-term results but the long-term risks are not known yet. Intra-ocular lens implantation in infants is associated with major complications and is not recommended at present. The occurrence of open angle glaucoma is a sight-threatening late complication of pediatric cataract surgery. Intra-ocular lens implantation plays a protective role against aphakic glaucoma in children.

Factors influencing anatomic and visual results in primary scleral buckling

PURPOSE

To identify the factors influencing anatomical and visual results in cases of rhegmatogenous retinal detachment undergoing primary scleral buckling.

METHODS

A retrospective study of 233 eyes of 226 patients was done. The data were evaluated by univariate analysis and stepwise logistic regression analysis.

RESULTS

Retinal reattachment was achieved with primary scleral buckling in 197 eyes (84.5%). The extent of retinal detachment, preoperative proliferative vitreoretinopathy (PVR), preoperative visual acuity and relative afferent pupillary defects were identified as influencing anatomical results, by univariate analysis. The predictive roles of extent of retinal detachment (P<0.0001) and preoperative PVR (P=0.0085) were shown to be significant by step-wise logistic regression. As well as the above factors, the patient's age, the duration of symptoms and the status of the macula were predictors of visual results, by univariate analysis. Stepwise logistic regression analysis confirmed the predictive roles of preoperative visual acuity (P<0.0001) and the extent of retinal detachment (P=0.0089).

CONCLUSIONS

Cases with a larger extent of retinal detachment, more advanced preoperative PVR and poorer preoperative visual acuity have less favorable anatomical and functional results.

Primary capsulectomy, anterior vitrectomy, lensectomy, and posterior chamber lens implantation in children: limbal versus pars plana

PURPOSE

To compare the results of a limbal versus a pars plana approach for primary posterior capsulectomy and anterior vitrectomy in the management of childhood cataract.

SETTING

Department of Ophthalmology, Labbafinejad Medical Center, Tehran, Iran.

METHODS

A randomized, controlled, double-masked clinical trial of 45 eyes was conducted. After being matched, 38 eyes were included in the study and were divided into 2 equal groups for data analysis. All eyes had lensectomy and posterior chamber intraocular lens (PC IOL) implantation. Primary posterior capsulectomy and anterior vitrectomy were performed through the limbus in half of the eyes and the pars plana in the other half. Main outcome measures included visual acuity, estimated red reflex, postsurgical inflammatory reaction, corneal clarity, posterior synechias, iris capture, IOL position, capsulectomy size, glaucoma, cystoid macular edema, retinal tear, and postoperative refraction.

RESULTS

No statistically significant differences were found between the 2 approaches in the outcome measures.

CONCLUSION

The anatomic and visual results were encouraging when posterior capsulectomy and anterior vitrectomy, using a limbal or pars plana approach, were combined with lensectomy and PC IOL implantation in children. The application of these techniques depends on surgeon experience and skill.

Surgical management of cataract and posterior chamber intraocular lens implantation in Fuchs' heterochromic iridocyclitis

BACKGROUND

To determine the inflammatory course and level of visual rehabilitation after cataract extraction and posterior chamber lens implantation in patients with Fuchs' heterochromic iridocyclitis complicated by cataract.

METHODS

In a clinical trial, 32 eyes (visual acuity of 20/160 or worse) of 30 patients underwent extracapsular cataract extraction (19 eyes) or lensectomy (13 eyes) accompanied by posterior chamber intraocular lens implantation. Indirect ophthalmoscopy was performed intraoperatively prior to intraocular lens implantation and the extent of vitreous haze was assessed. If vitreous haziness was 3+ or more, core vitrectomy (two eyes) or three-port pars plana deep vitrectomy (four eyes) was performed.

RESULTS

After an average follow up of 14.4 months (6 to 24 months), there was no statistically significant increase in cell and flare in the anterior chamber and vitreous or in keratic precipitates compared with the preoperative status of the eyes. However, 12% of the eyes developed synechiae (anterior and/or posterior) in comparison to preoperative condition (p < 0.05). Eight-seven percent of the eyes gained visual acuity of 20/40 or better (P < 0.005). Using the logistic regression model, a higher level of preoperative inflammation was associated with reduced likelihood of gaining visual acuity of 20/25 or more (OR = 0.25, 95% CI 0.049, 1.255). The complications of surgery were synechiae, 12%; opaque posterior capsule, 12%; vitreous loss, 3%; chronic glaucoma, 3%; and retinal detachment, 3%.

CONCLUSIONS

Implantation of a posterior chamber intraocular lens can be well tolerated in patients with Fuchs' heterochromic iridocyclitis. Vitrectomy, whenever indicated in addition to cataract extraction, improves visual rehabilitation.

Posterior segment triple surgery after traumatic eye injuries

Cataract extraction, posterior chamber intraocular lens (PC-IOL) implantation, and complete vitrectomy combined in a one-stage procedure were performed in 16 eyes (16 patients) with traumatic eye injuries undergoing anterior lensectomy (seven eyes), extracapsular cataract extraction (six eyes), or pars plana lensectomy (three eyes). Membrane peeling and intraocular foreign-body removal (13 eyes, 6 with intraretinal foreign bodies) were performed as needed. Surgery was performed from 1 week to 10 years after injury. After an average follow up of 8 months, 13 eyes (81%) had a visual acuity of at least 20/200; 50%, at least 20/40.

Temporary keratoprosthesis for surgical management of complicated combined anterior and posterior segment injuries to the eye: combat- versus noncombat-injury cases

We used a Landers-Foulks temporary keratoprosthesis lens to combine penetrating keratoplasty with vitreoretinal surgery in 21 eyes of 21 patients. Ten of these patients were victims of combat injuries; 11 had traumatic injuries unrelated to war. After a mean follow up of 11 months, satisfactory overall results, ie, an attached retina and a clear cornea, were obtained in nine eyes (42.8%). In two, the retina was attached but the corneal graft was rejected. Eight eyes achieved a visual acuity of 5/200 or better. The visual prognosis as well as the rate of retinal reattachment for the combat-injured eyes were poorer than those for the traumatic noncombat-injured eyes. At the last follow-up examination, 60% of the combat-injured eyes were considered visually lost, as compared with 36.3% of the noncombat-injured eyes.

Bilateral simultaneous optic neuritis in childhood systemic lupus erythematosus. A case report

The authors describe an 11-year-old girl with systemic lupus erythematosus (SLE) who developed simultaneous bilateral acute optic neuritis. Severe initial visual loss followed by permanent visual deficit occurred in both eyes despite therapeutic intervention. Recurrence of optic neuritis in one eye caused the vision to deteriorate further. The most probable pathogenesis is occlusive vasculitis involving the small arterioles of the optic nerves.

Low dose cyclosporin-A therapy in Behçet's disease

The effect of systemic low dose cyclosporin-A (5 mg/kg/day as initial dose) combined with 0.2 to 0.6 mg/kg/day prednisolone (when necessary) in clinical course of 22 patients suffering from severe forms of Behçet's disease are reviewed. All the patients had received other drugs previously and had either no response to them or developed intolerable side effects, therefore, pre treatment visual acuity (VA) was compared to post treatment VA as "self control". The average age of our patients was 30.6 years (range 19-51 years). The average duration of our therapy was 19.5 months (range 4-32 months). Improvement or stabilization of vision was achieved in 21 patients (95%). The intraocular inflammation was controlled in all of the eyes and most of the non-ocular signs and symptoms were also improved. Serious side effects included rise in creatinine in 10 (45%) of the patients, rise in bilirubin in 6 (27%) and hypertension in 1 (4.5%). These side effects disappeared as the dose of cyclosporin-A was tapered. We believe this form of therapy is of great value in the management of severe forms of Behçet's disease.

Surgical management of intraretinal foreign bodies

PURPOSE

To identify the clinical features in eyes with intraretinal foreign bodies (IRFBs) and evaluate the results of surgical management in these cases.

METHODS

The records of 75 patients (76 eyes) with IRFBs were retrospectively reviewed. All eyes underwent vitrectomy. The IRFBs were removed with intraocular forceps in 45 eyes (59.2%) and by magnetic extraction in 31 eyes (40.8%), either through pars plana sclerotomy or through the sclera over the IRFB after precise localization. Laser photocoagulation or cryotherapy was performed around the IRFB before surgery in 38 eyes.

RESULTS

The average follow-up period was 34 months. Of the 75 patients, 46 (61.3%) were injured at war. The IRFBs were metallic in 71 (93.4%) eyes. Of these, 59 (83%) were ferromagnetic. In these 76 eyes, final visual acuity was 20/15-20/40 in 37 (48.6%), and 20/50-20/200 in another 10 (13%). In 19 eyes (25%), partial or total retinal detachment was present at the final follow-up examination.

CONCLUSION

Surgical management of IRFBs is a complicated procedure. The appropriate route of removal may be determined by the type and site of the embedded IRFB. Performance of a meticulous vitrectomy is mandatory, and an attempt should be made to minimize the rate of iatrogenic peripleral retinal breaks. Preoperative retinopexy around the site of the embedded foreign body is recommended, if possible, to reduce the risk of retinal detachment. The prognosis in eyes with IRFBs and rhegmatogenous retinal detachment is guarded.

Association of herpetic encephalitis with acute retinal necrosis syndrome

Bilateral acute retinal necrosis syndrome developed shortly after a severe acute encephalitis in two previously healthy adults. The clinical and laboratory data suggested that herpes simplex virus was the cause of the encephalitis and acute retinal necrosis in these patients. To the authors' knowledge, this is the first report of an association of herpetic encephalitis with acute retinal necrosis in the literature.