Hemicentral retinal vein occlusion in a patient with a history of coronavirus disease 2019 infection: a case report and review of the literature

BACKGROUND

Considering the various manifestations of coronavirus disease 2019 and its imperative importance in terms of the right clinical approach and early management, we sought to present a hemicentral retinal vein occlusion case, with a history of heterozygosity of methylenetetrahydrofolate reductase (MTHFR) genes and potential for clotting complications as a late manifestation of coronavirus disease 2019, and provide a brief review of reported retinal vein occlusion cases in patients with coronavirus disease 2019.

CASE PRESENTATION

A 35-year-old Iranian patient presented with a visual impairment in the left eye 4 months after recovering from coronavirus disease 2019. He reported a mild blurring of vision in the same eye a few days after admission due to coronavirus disease 2019. The ophthalmic evaluation was compatible with hemicentral retinal vein occlusion. Systemic and laboratory workups were negative except for borderline protein C activity, homocysteine levels, and heterozygosity of MTHFR genes. The patient was scheduled to receive three monthly intravitreal antivascular endothelial growth factor injections.

CONCLUSION

We present a case of inferior hemicentral retinal vein occlusion case with an MTHFR mutation with sequential loss of vision 4 months after coronavirus disease 2019 to make clinicians aware of the possibility of late ocular coronavirus disease 2019 manifestations.

Surgical Correction of Cicatricial Lower Eyelid Retraction: A Systematic Review

BACKGROUND

Cicatricial lower eyelid retraction is a challenging condition. It involves scarring of the lower eyelid, which causes it to retract and expose the sclera. This can lead to complications such as dry eye syndrome and corneal melting. It can be caused by trauma, burns, or previous eyelid surgery. Detailed assessment and understanding of eyelid anatomy and retraction are critical for successful surgical planning. Dynamic and static examinations of the eyelid including measurements of the lower eyelid margin reflex distance (MRD2) and scleral show are also essential to determine the appropriate treatment approach.

METHODS

A systematic review was conducted using Medline, Scopus, and Cochrane databases with keywords related to cicatricial lower eyelid retraction. The publication language was limited to English after 2000. A total of 29 articles were included for data extraction and analysis.

RESULTS

The main surgical techniques include tarsoconjunctival grafts, spacers, midface lift, and lateral canthal tendon suspension, although no single procedure has been universally recognized as the gold standard. New innovations such as synthetic grafts and xenografts are being explored for their potential in eyelid reconstruction. Severe cases, defined as those with inferior scleral show greater than 2 mm, may require a combination of reconstruction methods.

CONCLUSIONS

Correcting cicatricial lower eyelid retraction is a major challenge in oculoplastic reconstruction. The surgical approach should be individualized, considering the pathologies and etiologies of lid retraction. In-depth knowledge and careful surgical planning are essential for best outcomes. There is no gold standard technique, and postoperative outcomes, complications, and management vary depending on the surgical approach used.

Pediatric ocular melanoma: a collaborative multicenter study and meta-analysis

PURPOSE

To investigate clinical manifestations and prognoses in pediatric patients (≤12 years old) with ocular melanoma.

METHODS

This was a retrospective, multicenter cohort study with individual participant data (IPD) meta-analysis pooling available published cases, and unpublished cases from an international collaboration of seven ocular oncology centers.

RESULTS

There were 133 eyes of 133 pediatric patients with choroidal or ciliary body (n = 66 [50%]), iris (n = 33 [25%]), conjunctival (n = 26 [19%]), and eyelid (n = 8 [6%]) melanoma. Overall, the mean patient age at presentation was 7 years (median, 8; range, 1-12 years), with 63 males (49%). The mean age by tumor site was 6.50 ± 3.90, 7.44 ± 3.57, 9.12 ± 2.61, and 5.63 ± 2.38 years, for choroid/ciliary body, iris, conjunctiva, and eyelid melanoma, respectively (P = 0.001). Association with ocular melanocytosis was seen in 15%, 11%, 4%, and 0%, respectively (P = 0.01). Frequency of ocular melanoma family history did not vary by tumor site (7%, 17%, 9% and 12%, resp. [P = 0.26]). After mean follow-up of 74, 85, 50, and 105 months (P = 0.65), metastasis was seen in 12%, 9%, 19%, and 13% of choroid/ciliary body, iris, conjunctiva, and eyelid melanoma, respectively. Death was reported in 5%, 3%, 8%, and 0%, respectively, with survival analysis indicating higher mortality in choroidal/ciliary body and conjunctival melanoma patients.

CONCLUSIONS

Ocular melanoma in the pediatric population is rare, with unique clinical features and outcomes. Iris melanoma accounts for about one-third of pediatric uveal melanoma cases.

Bilateral central serous retinal detachment in a patient with nephrotic syndrome: a case report

BACKGROUND

The aim of this report is to highlight the importance of considering nephrotic syndrome as a potential underlying cause of bilateral central serous retinal detachment in a patient with systemic lupus erythematosus and to underscore the significance of a comprehensive systemic workup in these patients.

CASE PRESENTATION

A 19-year-old Iranian female patient with history of systemic lupus erythematosus presented with progressive vision loss and bilateral macular elevation. Ophthalmic examination revealed periorbital edema, chemosis, and subretinal fluid at the macula of both eyes. Optical coherence tomography confirmed the existence of subretinal fluid and serous detachment located at the macula of both eyes. On fluorescein angiography, there were no signs of subretinal leakage such as smoke stack sign or expansile dot in late phases. Laboratory tests detected hypoalbuminemia and significant proteinuria, leading to the diagnosis of nephrotic syndrome. Treatment with prednisolone and albumin infusion resulted in improved visual acuity and resolution of subretinal fluid.

CONCLUSION

Nephrotic syndrome can be a rare underlying cause of bilateral central serous retinal detachment, and its association with systemic lupus erythematosus should be considered. Hypoalbuminemia in nephrotic syndrome alters fluid dynamics in the retina, contributing to bilateral central serous retinal detachment. Early recognition and management of nephrotic syndrome are essential for vision recovery and preventing long-term complications.

Cataract surgery in patients with retinitis pigmentosa: systematic review

Retinitis pigmentosa (RP) is an inherited bilateral retinal degenerative disease with an incidence of 1 in 4000 people. RP affects more than 1 million individuals worldwide. Although night blindness and restricted visual field are the most typical symptoms of these individuals, generalized vision loss due to cataracts can be expected in the latter stages of the disease. It has been demonstrated that posterior subcapsular cataract is the most prevalent cataract in younger individuals with RP, as opposed to age-related cataracts. Although most ophthalmologists may have a negative view of cataract surgery in patients with RP, it appears that it can play an important role in the visual restoration of patients with RP. However, there are concerns about performing cataract surgery for patients with RP. Herein, a systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses on databases of MEDLINE and Scopus.

Tamoxifen retinopathy

Tamoxifen (TAM) is a selective estrogen receptor modulator that is used in the treatment of breast cancer. As there are estrogen receptors in the retina, retinal pigment epithelium, and choroid, these tissues may also be affected by TAM. We describe the reported effects of TAM on the retina and choroid. Medical databases were searched using relevant keywords and the results were extracted and pooled. The incidence of retinal/choroidal toxicity ranged from 0.9% to 12%. There was a wide range for the time of exposure before the development of TAM retinopathy (3 weeks to 13 years). While functional measurements may be appropriate for assessment of TAM retinopathy, they have not been effective for screening patients. There is no generally accepted screening modality, but serial funduscopy and optical coherence tomography imaging seem to be the most reasonable approach for detecting early TAM-induced retinal toxicity.

Automated machine learning-based classification of proliferative and non-proliferative diabetic retinopathy using optical coherence tomography angiography vascular density maps

PURPOSE

The study aims to classify the eyes with proliferative diabetic retinopathy (PDR) and non-proliferative diabetic retinopathy (NPDR) based on the optical coherence tomography angiography (OCTA) vascular density maps using a supervised machine learning algorithm.

METHODS

OCTA vascular density maps (at superficial capillary plexus (SCP), deep capillary plexus (DCP), and total retina (R) levels) of 148 eyes from 78 patients with diabetic retinopathy (45 PDR and 103 NPDR) was used to classify the images to NPDR and PDR groups based on a supervised machine learning algorithm known as the support vector machine (SVM) classifier optimized by a genetic evolutionary algorithm.

RESULTS

The implemented algorithm in three different models reached up to 85% accuracy in classifying PDR and NPDR in all three levels of vascular density maps. The deep retinal layer vascular density map demonstrated the best performance with a 90% accuracy in discriminating between PDR and NPDR.

CONCLUSIONS

The current study on a limited number of patients with diabetic retinopathy demonstrated that a supervised machine learning-based method known as SVM can be used to differentiate PDR and NPDR patients using OCTA vascular density maps.

Evaluation of the additive effect of interferon α 2b with monthly intravitreal injection of bevacizumab in refractory diabetic macular edema

Background

To evaluate the additive effect of topical or sub-tenon injection of interferon (IFN)-α 2b in the treatment of refractory diabetic macular edema.

Methods

In this prospective study patients with center-involved DME who were unresponsive to 3 monthly consecutive IVB injections were recruited. Patients were divided into three groups: group1, received IFN- α 2b topical drop at a dose of 1mIU/ml four times a day for 3 months. Group 2, received a single sub-tenon injection of 1mIU/ml IFN- α 2b at the enrollment. Group 3 received artificial tears four times a day for 3 months (control group). All groups received three consecutive monthly IVB injections and were evaluated monthly up to 1 month following the last IVB injection.

Results

In this study, 59 eyes of 35 patients with refractory DME were assessed. The final follow-up showed that although CMT decreased in all groups, only patients in Group 2 had statistically significant lower CMT compared to their baseline values (change in CMT: − 117 ± 213 µm; p-value = 0.025). Comparison of CMT changes between three groups showed no statistically significant difference, although it was higher in group 2 (change in CMT: − 117 ± 213 µm (Group2) vs. − 49 ± 173 (Group 1) vs. − 36 ± 86 (Group 3); p-value = 0.085). Considering eyes with baseline CMT > 400 µm, sub-tenon injection of IFN α2b led to a significant reduction of CMT at the first month and final follow-up visit (CMT change: − 166 ± 210, − 145 ± 231 µm; p-value = 0.018 and 0.035, respectively). In this subgroup, eyes in Group 2 had lower CMT at the first month following treatment in comparison with the control group (CMT: 444 ± 123 µm vs. 544 ± 96 µm, p-value = 0.042). Alterations of CDVA were not statistically significant among groups, although patients in Group 1 had a significant improvement in vision at second and last follow up (CDVA change: − 0.23 ± 0.39, − 0.20 ± 0.43 logMAR; p-value = 0.030 and 0.010, respectively).

Conclusions

In short term, Sub-tenon injection of IFN might have an additive anatomical effect in eyes with refractory DME. Validation of this observation requires further prospective controlled studies.

Impact of Coronavirus Disease 2019 Pandemic on the Epidemiology of Intravitreal Injections

Purpose

To evaluate the epidemiologic pattern of intravitreal injections (IVIs) during Coronavirus Disease 2019 (COVID-19) pandemic.

Methods

The records of patients receiving IVIs in two 12-month periods immediately before and after the beginning of the COVID-19 epidemic were included. Age, province of residency, indication, number of injections, and number of operating room (OR) visits were analyzed.

Results

Compared to pre-COVID period, a 37.6% decrease in the number of patients receiving IVI in COVID period was seen (10518 vs. 6569). There was a parallel decrease in the number of OR visits (25590 vs. 15010: 41.4%) and injections (34508 vs. 19879: 42.4%). Regarding IVI indication, age-related macular degeneration (AMD) showed the highest decrease in IVI rate (46.3%) which was significantly higher than decrease in other indications (P < 0.001). Retinopathy of prematurity (ROP) patients showed no change after epidemic. Mean overall age in AMD group was the highest (67.7 ± 13.2 years) compared to other indication groups (excluding ROP) (P < 0.001); while the mean age of the other indications was not significantly different from each other (excluding ROP).

Conclusions

COVID pandemic decreased the number of IVIs significantly. While previous studies suggested that the AMD patients had the highest risk of visual loss due to failure to receive IVIs in a timely manner, this very same group showed the highest decrease in the IVI number after pandemic. The health systems should devise strategies to protect this most vulnerable group of patients in future similar crises.

Structural and functional outcomes of pars plana vitrectomy in patients with lamellar macular hole

PURPOSE

To investigate the short-term functional and microstructural outcomes of pars plana vitrectomy (PPV) without gas tamponade in lamellar macular holes (LH).

MATERIALS AND METHODS

In this prospective case series, LH cases diagnosed by optical coherence tomography (OCT) underwent PPV with epiretinal membrane (ERM) removal and internal limiting membrane peeling without gas tamponade. All patients underwent a complete ophthalmologic examination, including best-corrected visual acuity (BCVA) and OCT imaging preoperatively and 3 months after the surgery.

RESULTS

Among 22 eyes, 10 degenerative (Deg) LH, 8 tractional (Trac) LH, and 4 mixed-type LH were assessed. After the surgery, anatomical closure occurred in 20 eyes (91%) without any significant difference between LH subgroups. Comparing preoperative and postoperative values, no significant changes was detected regarding BCVA neither totally (P = 0.5) nor in subgroups (P for Deg = 1.0, Trac = 0.71, Mix = 0.18). The overall central foveal thickness was increased significantly after surgery (P < 0.01), but in subgroup analysis, the increase was significant only for Trac LH (P = 0.02). The tractional LH eyes had less ellipsoid zone (EZ) disruptions compared to Deg or mixed subgroups before surgery. There were no changes in EZ integrity before and after the surgery. In regression analysis, no correlation was found between demographic or clinical characteristics and anatomical closure or BCVA improvement postoperatively.

CONCLUSION

PPV resulted in 91% anatomical closure of all cases of LH but without functional improvement in short-term. Further prospective clinical trials with larger sample size and longer follow-up would be required to confirm the clinical significance of these findings.

Post-intravitreal injection endophthalmitis pattern during the COVID-19 pandemic with implementation of patients' masking

Purpose

To evaluate the role of patient facial masks on the occurrence of post-intravitreal injection (IVI) endophthalmitis in a real-word setting.

Methods

In this retrospective cohort, patients receiving IVIs between 20 February 2019 and 20 February 2021; a 12-month period before the official beginning of COVID-19 epidemic in Iran and a 12-month period thereafter were included. In the pre-COVID era, patients underwent IVI without a facial mask while in the COVID era patients wore an untaped facial mask. Physicians and staff had facial mask in both periods. IVIs were administered in a dedicated operating room without a strict no talk-policy. The main outcome measure was the rate of post-IVI endophthalmitis.

Results

A total number of 53,927 injections was performed during the study period: 34,277 in pre-COVID and 19,650 in COVID periods; with a 42.7% decrease in the number of injections. Endophthalmitis occurred in 7 eyes (0.020%) in pre-COVID and 7 eyes (0.036%) in COVID era (p = 0.40). In multivariate analysis, after adjustment for intercorrelations between the eyes and multiple injections in one patient, there was no statistically significant association between wearing facial masks by the patients and risk of endophthalmitis (relative risk = 1.47, 95% confidence interval of 0.97–2.22; p = 0.071).

Conclusion

Patients’ facial masking is not associated with an increased risk of post-injection endophthalmitis.

Progression of retinal vascularization after intravitreal anti-vascular-endothelial growth factor therapy in retinopathy of prematurity

Background

Anti-vascular endothelial growth factor (Anti-VEGF) therapy is now considered as one of standard therapies in approaching infants with retinopathy of prematurity (ROP). The purpose of this study was to assess the time to full retinal vascularization in infants with ROP who were treated with intravitreal bevacizumab (IVB).

Methods

This retrospective cohort study evaluated premature infants with ROP who were treated with IVB between 2012 and 2019. Demographic and clinical data were collected from the medical records and analyzed. Main outcomes were defined as time to complete vascularization and time of zone shift.

Results

Eight hundred sixty-five eyes from 441 patients were included. Average gestational age and birth weight were 28 ± 4 weeks and 1121 ± 624 g, respectively. Primary treatment failure and reactivation occurred in 35 eyes (4.0%) and 33 eyes (3.8%), respectively. Recurrent ROP occurred significantly more frequently in infants with pre-treatment zone 1 ROP compared to those with zone 2 ROP (7.6% versus 3%, p < 0.01). Patients with pre-treatment zone 2 reached zone 3 faster than those with pre-treatment zone 1 (142 ± 152 days versus 181 ± 174 days, p < 0.01); however, the time until full retinal vascularization did not significantly differ between the groups (p = 0.10).

Conclusion

This study revealed that pre-treatment ROP zone was associated with ROP reactivation rate but not with time to full vascularization in those treated with IVB.

Trial registration Retrospectively registered; IR.TUMS.FARABI.REC.1399.040

Histological and ultrasonographic alterations in skin and soft tissue in upper eyelid excised blepharoplasty due to ipsilateral eyebrow tattooing: (preliminary findings)

BACKGROUND

Eyebrow tattooing (ET) is a relatively common cosmetic procedure for middle-aged women which can hide age-related ptosis.

AIMS

We aimed to evaluate the periocular soft tissue changes following ET and its effects on upper eyelid blepharoplasty (UEBL).

PATIENTS/METHODS

In this non-randomized prospective case-controlled study, 28 subjects recruited, 14 with ET for at least 5 years and 14 without ET. Eyebrows ultrasonography was performed to measure the periocular soft tissue thickness including skin and subcutaneous tissue on the medial and lateral side of the eyebrow. Then, UEBL was performed with extended eyelid skin incisions. So, the excised tissues being evaluated histopathologically.

RESULTS

The mean age of patients was 50.6 ± 0.6 and 51.2 ± 5.59 years in non-eyebrow tattooing (NET) and ET groups, respectively (P = .78). In the ET group, soft tissue thickness was, respectively, equal to 5.90 ± 1.10 and 6.3 ± 0.95 mm on the lateral and medial side of the eyebrow, which were significantly thicker compared to the NET group (4.68 ± 0.69 and 4.78 ± 0.56 mm, respectively)(P = .001). Histopathological findings were ranging from edema-congestion to chronic inflammation and dermal fibrosis which were more frequently seen in ET group. However, this difference was statistically significant only for dermal fibrosis (P = .02). Surgical wound complications were observed in 3 patients who were in the ET group (P = .22).

CONCLUSION

Subjects with eyebrow tattooing, as compared to a control group, showed a thicker eyebrow skin on ultrasonography and higher upper eyelid dermal fibrosis on histopathological examination.

Test characteristics of focused assessment with sonography for trauma (FAST), repeated FAST, and clinical exam in prediction of intra-abdominal injury in children with blunt trauma

PURPOSE

In children with blunt abdominal trauma (BAT), focused assessment of sonography in trauma (FAST) has been reported with low sensitivity, on the whole, in the detection of intra-abdominal injuries (IAI). The aim of the present study was to assess test characteristics of FAST using different strategies including repeated FAST (reFAST), and physical exam findings.

METHODS

This retrospective study evaluated BAT pediatric patients with stable hemodynamics who underwent computed tomography (CT). Demographic data, initial physical examination, and results of FAST, reFAST (if done), and CT imaging were recorded. Different strategies of FAST were cross-tabulated with CT as the gold standard and test characteristics including sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were interpreted.

RESULTS

129 patients with a mean age of 8.6 ± 4.7 were studied and 74% were male. Comparing CT-positive and -negative groups, from the demographic and clinical findings, only positive physical exam (tenderness or ecchymosis) was significantly higher in the CT-positive group (59% vs. 17%; p < 0.01). In a multivariate analysis, positive FAST modality and clinical exam remained independent predictors for a positive CT result (likelihood ratios of 34.6 and 6.4, respectively). Out of the different diagnostic strategies for the prediction of IAI, the best overall performance resulted from the FAST-reFAST-tenderness protocol with sensitivity, specificity, PPV, NPV, and accuracy of 87%, 77%, 70%, 91%, and 81%.

CONCLUSION

For children with blunt abdominal trauma, physical examination plus FAST and reFAST as needed, seems to have reasonable sensitivity, specificity, and accuracy in detecting intra-abdominal injuries and may reduce the need for CT scans.

Modified Encircling Scleral Buckle Technique Without Subretinal Fluid Drainage or Retinopexy

Introduction

Scleral buckling (SB) tends to be more challenging and time-consuming for compared to the pars plana vitrectomy for repairing rhegmatogenous retinal detachments (RRDs). This study characterizes a novel and simplified technique for SB.

Methods

In this single-masked randomized interventional study, patients with RRDs who were eligible for SB were randomly assigned to either the standard (S) or modified (M) technique of SB. In the modified approach, neither intraoperative break localization nor cryopexy or subretinal fluid drainage was done. A large tire (276/279) was placed where preoperative retinal breaks had been localized with a 240 encircling band placed for support of the remaining retina. Patients were followed for 12 months and the primary outcomes were differences between the surgical groups in operative time, anatomical success, visual acuity, and complication rate.

Results

Thirty-six eyes were included in the study (18 in each arm). There were no differences in baseline patient demographics or characteristics including gender, age, lens and macular status, preoperative vision, and symptom duration. The mean length of surgery was 72.2 ± 13.2 and 56.2 ± 9.5 min in groups S and M, respectively (P = 0.001). Complete retinal reattachment at the end of month 12 after single surgery was 80.6% overall; 77.8% (14/18) in group S and 83.3% (15/18) in group M (P > 0.999). After 12 months, both groups achieved similar final best-corrected visual acuity (BCVA): 0.26 ± 0.23 and 0.23 ± 0.17 logMAR in groups S and M, respectively (P = 0.231). Controlling for preoperative BCVA on ANCOVA testing, there were no significant differences in visual improvement between the two groups [F (1,26) = 0.02, P = 0.966 (95% CI) − 0.128 to 0.123)]. Scleral perforation (2:1), vitreous hemorrhage (3:2), and transient rise of intraocular pressure (3:4) all occurred at a low and similar rate between the two groups (S:M).

Conclusion

Modified SB technique was non-inferior compared to the standard approach for anatomical and visual outcomes. Shortening surgical time while maintaining low complication rates makes this an appropriate approach to SB, especially for vitreoretinal surgery trainees.

Electronic supplementary material

The online version of this article (10.1007/s40123-020-00279-1) contains supplementary material, which is available to authorized users.

Simultaneous photorefractive keratectomy and accelerated collagen cross-linking in high-risk refractive surgery (Tehran protocol): 3-year outcomes

PURPOSE

To evaluate safety and efficacy of performing simultaneous photorefractive keratectomy (PRK) and collagen cross-linking (CXL) in myopic patients with preoperative risk factors for developing keratectasia.

METHODS

Seventeen eyes of 15 patients with at least one of the following risk factors were recruited: central keratometry (K_max) between 48 and 50, difference between inferior, superior corneal power (I-S value) between 1.4 and 1.9 and corneal thickness between 450 and 480 µm. Upon final stage of standard PRK, 0.02% mitomycin was applied for 30-50 s, and then, accelerated CXL was performed for 5 min. Pre- and postoperative Oculus Pentacam^® imaging for keratometry values, measurement of uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA) were done for all patients.

RESULTS

Mean follow-up time was 32.08 ± 7.79 months (range 25-49 months). Mean age of patients was 28.78 ± 3.80 years. Mean postoperative spherical equivalent was + 0.19 ± 0.42 (- 0.5 to + 1.0 [D]). Mean UDVA and CDVA improved from 0.9062 ± 0.485 log MAR and 0.0148 ± 0.043 log MAR to 0.0173 ± 0.040 log MAR and 0.0057 ± 0.023 log MAR, respectively (P = 0.011, P = 0.735). Mild degree of early postoperative stromal haze was seen which did not persist more than 6 months. There was no late stromal haze, corneal ectasia or other major postoperative complication in the follow-up period.

CONCLUSION

Combined PRK and accelerated CXL is an efficient and safe procedure for high-risk refractive surgery candidates, with no increased risk of persistent corneal haze.

Electroretinogram Changes Following Sequential Panretinal Photocoagulation for Proliferative Diabetic Retinopathy

Purpose

To evaluate changes in electroretinogram (ERG) response over the course of multiple sessions of panretinal photocoagulation (PRP) in patients with proliferative diabetic retinopathy (PRP).

Methods

A prospective cohort study of 11 patients with PDR who required PRP was conducted. PRP was completed over three sessions. Each patient had five ERGs done: baseline, 1 week after each PRP session, and 6 weeks after the last session of PRP. Dark-adapted 0.01 ERG, Dark-adapted 3 ERG, Dark-adapted 10 ERG, Light- adapted 3 ERG, and Light-adapted 30 Hz flicker ERG were done. The mean change in a- and b-wave amplitudes as well as implicit times compared to baseline was analyzed.

Results

A significant reduction in peak amplitudes of both a- and b-waves and delay in latencies were observed in all responses (p<0.05). The absolute amplitude reduction and delay in latency were higher for scotopic b-waves (p<0.05). The root mean square (RMS) of Dark-adapted 10.0 ERG (p<0.05) and total mean amplitude changes of a- and b-waves (p<0.001) were reduced after each laser session; however, the magnitude of change was not different between the first, second, or third sessions of PRP, and each session showed a similar deterioration rate of ERG parameters comparing to each other (p=0.4 for RMS and p=0.2 for total mean amplitude changes). In addition, the results indicated recovery of the amplitude and latency of ERG waves after 6 weeks from the final treatment (p<0.001) although not to baseline levels.

Conclusion

ERG findings following PRP show reduced retinal function after each session which partially recovers by 6 weeks after the completion of therapy. Clinicians should be mindful of these changes when planning the treatment course for patients with PDR.

Parenteral Fish-Oil Lipid Emulsions in Retinopathy of Prematurity: A Retrospective Comparative Study

Purpose

To evaluate the effects of a fish oil-containing regimen on the severity of retinopathy of prematurity (ROP) in preterm infants.

Methods

In this retrospective, observational study, 82 preterm infants with documented retinal examinations were evaluated. Patients' demographic data, associated morbidities, the worst ROP zone, stage, and the presence of plus disease during the follow-up examinations, and the need for ROP treatment in the two groups were recorded and analyzed.

Results

Forty-three infants were treated with INTRAlipid®, and 39 infants were treated with 20% SMOFlipid. There were no differences in gestational age, birth weight, and associated morbidities between the two groups. No differences were observed among the two groups in their need for treatment (P = 0.51), ROP zones (P = 0.62), and plus disease (P = 0.38). Although no difference was seen in ROP stages between the groups (P = 0.41), in subgroup analysis, Stage 3 (severe ROP) occurred significantly lower in the SMOFlipid group (P = 0.04) and Stage 0 occurred significantly higher in the SMOFlipid-treated infants (P = 0.05).

Conclusions

This study showed no difference between the two groups regarding the need for the treatment. The lower prevalence of severe ROP in preterm infants receiving SMOFlipid emulsion was observed comparing to the INTRAlipid-treated infants.

Comparison of Three Different Techniques of Inverted Internal Limiting Membrane Flap in Treatment of Large Idiopathic Full-Thickness Macular Hole

Purpose

To evaluate and compare three different techniques of inverted internal limiting membrane (ILM) flap in the treatment of large idiopathic full-thickness macular hole.

Methods

In a comparative interventional case series, 72 eyes from 72 patients with large (> 400 µm) full-thickness macular hole were randomly enrolled into three different groups: group A – hemicircular ILM peel with temporally hinged inverted flap; group B – circular ILM peel with temporally hinged inverted flap; and group C – circular ILM peel with superior inverted flap. Best-corrected visual acuity (BCVA), anatomical closure rate, and ellipsoid zone (EZ) or external limiting membrane (ELM) defects were evaluated preoperatively, at week 1, and months 1, 3 and 6 after surgery.

Results

There were 24 eyes in group A, 23 in group B, and 25 in group C. In all three groups, larger diameter macular hole was associated with worse preoperative visual acuity (r=0.625, P<0.001). Mean BCVA improved significantly in all three groups 6 months after surgery (0.91vs 0.55, p<0.001). 6 months after surgery, mean BCVA improved from 0.91 logMAR to 0.52±0.06 in group A, 0.90 to 0.53±0.06 in group B, and 0.91 to 0.55±0.11 in group C. In group A vs. B vs. C, improvement of BCVA was 0.380±0.04 vs. 0.383±0.04 vs. 0.368±0.11 logMAR, with no statistically significant difference between groups (P=0.660). The rate of successful hole closure was 87.5% vs. 91.3% vs. 100%. Although the closure rate was 100% in Group C (circular ILM peel with superiorly hinged inverted flap), this difference was not statistically significant (P=0.115).

Conclusion

ILM peel with an inverted flap is a highly effective procedure for the treatment of large, full-thickness macular hole. Different flap techniques have comparable results, indicating that the technique can be chosen based on surgeon preference.

Multifocal electroretinogram in diabetic macular edema and its correlation with different optical coherence tomography features

PURPOSE

To evaluate multifocal electroretinogram (mfERG) parameters in eyes with diabetic macular edema (DME) and its correlation with vision and optical coherence tomography (OCT) features.

METHODS

Fifty-four eyes of 27 subjects with DME due to nonproliferative diabetic retinopathy were evaluated. MfERG responses were measured in three concentric rings. Macular thickness was measured by OCT in each segment of the three concentric rings, and mfERG rings were superimposed on the macular thickness map. The correlation between macular thickness in specific points of the thickness map and changes of the mfERG parameters in the corresponding points of the mfERG field map was evaluated and the relationship between the OCT and mfERG changes and changes of best-corrected visual acuity (BCVA) was investigated. The central foveal B-scans of SD-OCT were used to evaluate any correlation between the external limiting membrane (ELM) status, ellipsoid zone (EZ) status, presence of cysts or disorganization of retinal inner layers (DRIL), and mfERG parameters at the central corresponding area.

RESULTS

The mean of BCVA was 0.5 ± 0.3 in logMAR, and the central macular thickness was 392.6 ± 123.4 microns. The central ring P1 and N2 amplitudes had a significant correlation with BCVA in univariate and multivariate analyses (P = 0.001 for both, r = - 0.346 and r = - 0.646, respectively). There was a significant correlation between retinal thickness and the N1 amplitude in the central ring (P = 0.02, r = - 0.343). Outer retinal layer disruption (ELM and EZ) correlated with prolonged P1 implicit time at the corresponding location (P = 0.005, r = 0.068). The presence of the DRIL was associated with reduced P1 and N2 amplitudes (P = 0.037, r = - 0.284 and P = 0.019, r = - 0.562, respectively). A significant correlation was also found between the presence of cysts and a lower central P1 amplitude (P = 0.033, r = - 0.376).

CONCLUSION

In diabetic patients, discrete changes of some parameters in the central ring of the mfERG field map (e.g., P1 and N2 amplitudes) have a significant correlation with both structural OCT abnormalities in the corresponding points of the thickness map (like DRIL, intraretinal cyst and ELM/EZ disruption) and BCVA. Predictive models such as those described in this report may make it possible to identify the relationship between specific anatomical and functional characteristics in diabetic retinopathy.

Intravitreal Medications for Retinal Vein Occlusion: Systematic Review and Meta-analysis

Purpose

To evaluate the outcomes of different intravitreal injections for the treatment of retinal vein occlusion including central retinal vein occlusion (CRVO) and branch retinal vein occlusion (BRVO).

Methods

PubMed, Cochrane, the metaRegister of ControlledTrials, and ClinicalTrials were searched for intravitreal anti-Vascular Endothelial Growth Factor (VEGF) and steroids with relevant keywords and date limitation of 2009-2018. Meta-analysis was performed on studies that met the defined inclusion criteria. Main outcomes were visual acuity (VA) and central macular thickness (CMT).

Results

Out of 681 studies, 36 articles (including 21 reporting CRVO and 15 dealing with BRVO) were selected for systematic review. All five intravitreal drugs including triamcinolone, dexamethasone, ranibizumab, bevacizumab, and aflibercept showed improvement of CMT and VA as compared to placebo or laser treatment. Six randomized controlled trials were selected for meta-analysis in RVO patients. The pooled mean difference of visual improvement between sham and ranibizumab was 12.7 Early Treatment for Diabetic Retinopathy Study (ETDRS) letters (95%CI: 11.00 to 13.2), and the pooled mean difference in CMT reduction was 221μm (95%CI: 153 to 284); both changes were significantly in favor of ranibizumab. The pooled mean difference of visual improvement between bevacizumab and triamcinolone was 5.3 ETDRS letters in favor of bevacizumab (95%CI: 16 μm to 17.5 μm). Triamcinolone led to 68.1 μm greater CMT reduction than bevacizumab (95%CI: 58 μm to 76 μm). However, none of these differences were statistically significant.

Conclusion

Treatment with anti-VEGF agents in RVO is superior to observation. No significant difference was seen between the eyes treated with bevacizumab or triamcinolone based on these results.

Management of Idiopathic Macular Telangiectasia Type 2

Macular telangiectasia type 2 (MacTel) is a relatively rare disease without established treatments. Although MacTel was previously considered a primarily vascular condition, the thinking on its pathogenesis has shifted to it now being considered principally a neurodegenerative disease. This has resulted in a subsequent change in the approach to treatment toward neuro-protection for the non-proliferative phase of this disease. Carotenoid supplementation has had mixed results. Ciliary neurotrophic factor (CNTF) has demonstrated some promising early results, but further study is necessary to determine its actual effect. Some structural improvements have been seen in the non-proliferative phase with oral acetazolamide but without accompanying functional improvement. Anti-vascular endothelial drugs have been studied and not found to have benefit in the non-proliferative phase of disease but have demonstrated significant structural and functional value in the treatment of secondary neovascularization. There is no level I evidence for the various proposed MacTel treatments, and efforts need to be directed toward conducting multicenter randomized trials to better understand possible treatments for this condition.

Special Care in Lichen Planus Patients Undergoing LASIK: A Review Article

Laser-Assisted in Situ Keratomileusis (LASIK) is a common surgery for the correction of refractive errors. The majority of patients who undergo this procedure often have excellent results. However, uncontrolled autoimmune disorders and dry eye have both been listed as contraindications to this surgery. Lichen planus (LP) is an autoimmune, inflammatory disorder that characteristically affects mucocutaneous membranes. The etiology is unknown, but it most commonly affects middle-aged adults and presents with bilateral, purple papules. Clinical presentation is used to diagnose the condition, and a punch biopsy is confirmatory. LP may present with multiple different symptoms depending on the type, with ocular manifestations being rare. Multiple viruses and autoimmune conditions have been associated with the disorder, and physicians should take care when gathering a full history of the patient. Exacerbation of symptoms may happen if mood disorders such as depression and anxiety are not well controlled. There are several additional factors physicians must carefully consider before recommending LASIK to patients with LP. These include lichenoid reactions, current medications, and past or present ocular lesions. LASIK may be carefully considered in patients with well-controlled LP in the absence of ocular manifestations. Patients with ocular LP are not candidates for LASIK.

Comparison of Intravitreal Bevacizumab and Laser Photocoagulation in the Treatment of Retinopathy of Prematurity

PURPOSE

To compare the outcomes of patients with type I retinopathy of prematurity (ROP) treated with either intravitreal bevacizumab (IVB) or retinal laser photocoagulation (RLP).

DESIGN

Retrospective case series.

PARTICIPANTS

Infants treated for type I ROP with IVB or RLP.

METHODS

Patients who were born between January 2011 and December 2014 and were treated in Farabi Eye Hospital were included. The outcomes were stratified and analyzed, based on the treatment type and ROP zone.

MAIN OUTCOME MEASURES

Need for retreatment, time to regression, refractive errors, retinal adverse anatomic outcomes, and rate of complications.

RESULTS

Five hundred twenty-three patients were treated for type 1 ROP, of whom 493 (986 eyes) met inclusion criteria. Seven hundred twenty-four eyes (73.4%) received IVB, and 262 eyes (26.5%) received RLP. Re-treatment (because of recurrent or persistent retinopathy) occurred in 14.4% (106/724) of eyes initially treated with IVB and in 8.8% (23/262) eyes initially treated with RLP (P = 0.065). Re-treatment was not significantly different between the 2 groups for patients with zone I disease (P = 0.978). Re-treatment rate was considerably higher in patients with zone II disease treated with IVB (69/558 [12.3%]) compared with those treated with RLP (20/251 [7.9%]; P = 0.017). In the IVB group, 82.8% and 53.4% of eyes showed an avascular area in zone III (despite ROP regression) at 1 and 2 years after treatment, respectively. The spherical power and the spherical equivalent were significantly higher in eyes treated with RLP (-1.31±2.83 diopters [D] and -2.84±2.77 D, respectively) than eyes treated with IVB (0.19±3.21 D and -1.26±3.19 D, respectively; P = 0.016 and P = 0.007, respectively). Differences in astigmatic power were not significant.

CONCLUSIONS

Both IVB and RLP are effective treatments for type 1 ROP. Longer follow-up time is necessary for infants treated with IVB. More patients with zone II disease treated with RLP achieved disease regression after a single treatment than those who received IVB, although outcomes after re-treatment were comparable except for a greater refractive error in patients treated with RLP.

Smartphones, tele-ophthalmology, and VISION 2020

Telemedicine is an emerging field in recent medical achievements with rapid development. The "smartphone" availability has increased in both developed and developing countries even among people in rural and remotes areas. Tele-based services can be used for screening ophthalmic diseases and also monitoring patients with known diseases. Electronic ophthalmologic records of the patients including captured images by smartphones from anterior and posterior segments of the eye will be evaluated by ophthalmologists, and if patients require further evaluations, they will be referred to experts in the relevant field. Eye diseases such as cataract, glaucoma, age-related macular degeneration, diabetic retinopathy, and retinopathy of prematurity are the most common causes of blindness in many countries and beneficial use of teleophthalmology with smartphones will be a good way to achieve the aim of VISION 2020 all over the world. Numerous studies have shown that teleophthalmology is similar to the conventional eye care system in clinical outcomes and even provides more patient satisfaction as it saves time and cost. This review explains how teleophthalmology helps to improve patient outcomes through smartphones.

Myeloid-derived suppressor cells in gastrointestinal cancers: A systematic review

BACKGROUND AND AIM

Gastrointestinal (GI) cancers are a heterogeneous group of cancers originating from the digestive system. Considering key roles of myeloid-derived suppressor cells (MDSCs) in the immunosuppression network, levels of MDSCs in patients with cancer are assumed to be of prognostic and predictive value. In this systematic review, we aimed to evaluate the clinical relevancy of MDSCs and their relationship with clinical features and prognosis of GI malignancies in patients with GI cancers.

METHODS

We searched Medline, Scopus, DART, OpenGrey, and ProQuest without applying any language filter up to 1 August 2015. Two of the authors independently reviewed search results for irrelevant and duplicate studies and extracted data from studies. We used tabulation to synthesize the findings of the studies and transformed data into a common rubric and calculated a weighted treatment effect across studies using Review Manager.

RESULTS

We found 1238 references in five databases, and after exclusion of irrelevant and duplicate studies, 17 studies with a total number of 1115 patients with GI cancers were included. A meta-analysis of three studies showed associations of high MDSC levels with higher mortality during follow-up periods (hazard ratio = 3.35; 95% confidence interval = 1.46-7.68, P = 0.0004). A meta-analysis of four studies showed that patients with higher levels of MDSC had higher odds of having an advanced cancer (odds ratio = 2.64; 95% confidence interval = 1.53-4.53; P = 0.0004). There were also significant associations between MDSC levels and relapse, tumor progression, lymph node involvement, and metastasis.

CONCLUSION

In conclusion, results of this systematic review based on the available literature suggest that MDSC levels are of clinical relevancy and prognostic and predictive value.

Autoimmune phenotype in patients with common variable immunodeficiency

BACKGROUND AND OBJECTIVE

Autoimmune disorders occur with a higher incidence in common variable immunodeficiency (CVID) patients than in the general population. To describe the clinical features of the autoimmune phenotype in patients with CVID.

METHODS

The hospital records of all diagnosed CVID patients referred to the Children's Medical Center Hospital in Tehran, Iran between 2000 and 2010 were reviewed. Patients were also classified according to the presence or absence of autoimmune disease.

RESULTS

Of 52 patients studied, 26.9% (n=14) had shown at least 1 autoimmune manifestation during the study period. Autoimmune cytopenias and juvenile rheumatoid arthritis were the most common form of autoimmunity in our series. Autoimmunity was significantly associated with polyclonal lymphocytic infiltrative disorders (P = .017), increased serum Immunoglobulin (Ig) M levels (P < .001), decreased IgE values (P = .04) and diminished switched memory B-cell count (P < .001).

CONCLUSIONS

Because autoimmunity is one of the first manifestations in CVID, humoral immune system tests should be considered in autoimmune patients with a history of recurrent infection. The presence of polyclonal lymphocytic infiltrative disorders and decreased switched memory B-cells may predispose CVID patients to autoimmunity.