Intravitreal Injection of Anti-Vascular Endothelial Growth Factors Combined with Corticosteroids for the Treatment of Macular Edema Secondary to Retinal Vein Occlusion: A Systematic Review and Meta-Analysis

PURPOSE

To evaluate the efficacy and safety of intravitreal anti-vascular endothelial growth factor (anti-VEGF) and corticosteroid combination therapy for the management of treatment-naïve or recurrent/refractory macular edema caused by retinal vein occlusion (RVO) in comparison with anti-VEGF monotherapy.

METHODS

In this systematic review and meta-analysis study, the data from publications in the electronic databases including PubMed, Embase, Cochrane Library Central Register of Controlled Trials, ISI and Scopus from January 1, 2007, through November 20, 2020, were compiled. Heterogeneity was statistically quantified by the I2 statistic, and meta-analysis was performed using a random-effects model.

RESULTS

Twenty-four related studies were identified, including a total of 1280 eyes, which consisted of 685 and 507 patients with central retinal vein occlusion (CRVO) and branch retinal vein occlusion (BRVO), respectively. This study demonstrated a greater improvement in best-corrected visual acuity (BCVA) in the combination group compared to anti-VEGF monotherapy for both CRVO and BRVO cases at 6 months after initiating therapy. The improvement in vision was more notable in BRVO cases than in CRVO cases. However, the changes in central macular thickness (CMT) did not differ significantly between the different treatment approaches, and the results were inconclusive. Including all cases with RVO, there was no inferiority in terms of BCVA improvement and CMT reduction in the triamcinolone subgroup compared with the slow-release dexamethasone implant subgroup. A greater improvement was noticed in terms of BCVA in the sequentially treated subgroup compared to the simultaneous treatment subgroup, while there was a greater reduction in CMT in the simultaneous subgroup with the highest reduction recorded at 1 month after treatment.

CONCLUSIONS

This study suggests that combination therapy with intravitreal anti-VEGF and corticosteroid (such as intravitreal or subtenon triamcinolone or dexamethasone implant) has a slightly better effect on improving BCVA in cases with BRVO or CRVO at 6 months compared to monotherapy.

Acute systemic complications of intravitreal bevacizumab and triamcinolone injections – a comparative study

Introduction: Macular edema is a common visual threatening complication in patients with diabetic retinopathy and retinal vein occlusion. The injection of intravitreal drugs, such as anti-vascular endothelial growth factor (anti-VEGF) and corticosteroids, revolutionized the treatment of these diseases.

Aim: To compare and assess the acute systemic complications of intravitreal bevacizumab and triamcinolone injections in patients with diabetic retinopathy and retinal vein occlusion.

Materials and methods: The study population included 211 patients with diabetic retinopathy and retinal vein occlusion who required intravitreal injections of bevacizumab and triamcinolone. In this study, 118 patients had generally received intravitreal injections with bevacizumab and the rest (93 patients) injections with triamcinolone. Experimental data, including demographic information, number of injections, the history of comorbidities, intraocular pressure, and systemic hypertension before and after injections, were recorded on specific forms following groups’ classification. In addition, the incidence of various complications was investigated during one month after the intravitreal injections.

Results: In the present study, we included 211 patients (mean age 62.41±11.34 years, median - 63 years). The results showed that there was no significant correlation between the injectable drug and changes in increased intraocular pressure (IOP) (p=0.66). No significant difference was detected for systemic hypertension in any of the studied groups. On the other hand, the incidence of complications of blood sugar, facial skin redness, neurological problems of TIA and CVA, myocardial infarction, vascular problems after injection, and ocular complications were estimated to be zero, 1.4, 0, 0.8, 0, and 6.1%, respectively.

Conclusions: Overall, the results indicated a prevalence of 1.4% for systemic complications and a prevalence of 6.1% for ocular complications. Accordingly, it seems that intravitreal injections of both drugs studied in the present study are placed in the group of low complication medications.

Correlation between keratometry and corneal incision before and after phaco surgery

Introduction: Cataract is a common cause of vision loss and blindness in humans. After surgical management of cataract, all efforts should be focused on reducing postoperative astigmatism thus providing an excellent vision to patients.

Aim: To determine the relationship between corneal incision and refraction changes before and after phacoemulsification surgery in 300 patients undergoing cataract surgery in Khatam hospital in Mashhad, Iran from January 2017 to April 2018.

Materials and methods: Three hundred patients (144 women and 156 men) with cataract undergoing phacoemulsification surgery were recruited in this cross-sectional study. Refraction, keratometry and visual acuity measurement were performed before surgery. Then, a steep-based incision in the cornea was made without stitches. A 3.2 mm corneal incision was made at two supratemporal and temporal sites. The patients were followed-up for one and six months, and one year after surgery monitoring their vision and refraction, and performing keratometric measurements.

Results: The mean age of the patients was 65.7&plusmn;9.54 years (age range, 42&ndash;84 years). No major complications were observed. The greatest mean of changes in corneal power was in the supratemporal incision (1.28&plusmn;0.6). Keratometry had a significant relation with the incision (p<0.04).

Conclusions: An incision made along the steepest meridian leads to flatness of this meridian, this effect being more pronounced at the supratemporal incision. A temporal incision is recommended in cases where there is little difference in the keratometry of the two axes.

The Prevalence of Infectious Keratitis after Keratorefractive Surgery: A Systematic Review and Meta-Analysis Study

BACKGROUND

The keratorefractive surgeries (KRS) are one of the most common ocular surgeries. One of the dangerous complications of these surgeries is infectious keratitis (IK), which is the second cause of blindness after cataract surgery. The purpose of this study was to estimate the prevalence of IK after KRS in different parts of the world.

METHODS

In order to obtain relevant studies, all national and international databases including IranMedex, SID, Magiran, IranDoc, Medlib, ScienceDirect, PubMed, Scopus, Cochrane, Embase, Web of Science, and Google Scholar were searched using standard keywords.

RESULTS

IK prevalence after KRS was 0.000496% (0.000145% for the left eye and 0.000149% for the right eye). IK prevalence after KRS in the United States, Europe, and Asia was 0.000667%, 0.000473%, and 0.000045%, respectively, in all of which the common microorganisms were Staphylococci. Meta-regression showed no significant association between IK after KRS and either sample size or publication year of the studies. IK prevalence after KRS in the right eye was more than that in the left one. Also, the probability of IK incidence after LASIK surgery was more than PRK and LASEK. In the evaluation of continents, IK after KRS in the United States was more frequent compared with Europe and Asia.

CONCLUSIONS

This study provided data as to the overall prevalence of IK following KRS and its variations according to the types of eye, surgery, pathogenic microorganism, and geographical location.

Efficacy of Honey-based Ophthalmic Formulation in Patients with Corneal Ulcer: A Randomized Clinical Trial

AIM

The aim of this study was to evaluate the efficacy of honey-based ophthalmic drop in patients with foreign body induced corneal ulcer.

BACKGROUND

Honey is traditionally used for skin, mucosal and corneal ulcers. Its use is well studied in human skin and mucosal ulcers and animal model of corneal ulcer with promising effects.

METHODS

In this randomized clinical trial, 50 patients with foreign body induced corneal ulcer were allocated to receive 70% sterile honey-based ophthalmic formulation or 0.3% ophthalmic ciprofloxacin, as the standard treatment every 6 hours. All the patients were examined for the size of corneal epithelial defect, corneal infiltration and depth and followed on a daily basis until complete healing. Duration for complete healing was considered as the outcome measure. Smear, culture, antibiogram and minimum inhibition concentration (MIC) tests were performed for honey and ciprofloxacin in all patients.

RESULTS

The average durations of complete healing of corneal epithelial defect in the honey and ciprofloxacin groups were 3.88 ± 3.44 vs. 6.32 ± 3.69days, respectively (p=0.020). No significant difference was observed between two groups regarding an average duration of healing of corneal infiltration (8.12 ±1.94 days vs. 8.64±2.15 days, p=0.375). MIC of honey for pseudomonas aeruginosa was 60%w/w, for E.Coli 40% w/w, and for staphylococcus aureus 30% w/w.

CONCLUSION

Honey based ophthalmic drop can acceleratethe corneal epithelial defect healing in patients with foreign body induced corneal ulcer, compared to ophthalmic ciprofloxacin as a standard treatment. The study was registered in Iranian registry of clinical trial center (IRCT) with registration number IRCT2015020120892N1.

Prevalence of pterygium in Iran: a systematic review and meta-analysis study

Background and aim

Pterygium is one of the most prevalent pathologies involving the cornea, which can lead to various vision signs and even reduction in eyesight. No accurate estimate has been reported about the prevalence of pterygium in Iran. Hence, this study aimed to determine the pterygium prevalence in Iran by meta-analysis method.

Methods

Searching for data of the last eleven years (from 2004 to 2015) was conducted using the keywords of pterygium, eye, and Iran in International and domestic indexing services and databases including Iranmedex, Scientific Information Database (SID), Magiran, Irandoc, Medlib, IranPsych, Science Direct, Web of Science (Thomson Reuters), PubMed, and Scopus. The data were analyzed using the meta-analysis method (the random effects model). The disharmony of the studies was investigated using the I2 index. The data were analyzed by STATA Ver.11 software.

Results

In 5 studies conducted in Iran, with a sample size of 10,838 people between 2004 and 2015, the extent of the prevalence was estimated to be 11% (95% CI: 3 to 18%). Also, the prevalence of pterygium in women and men was 18% and 13%, respectively.

Conclusion

According to the published reports from Iran and its comparison with other points in the world, the prevalence of pterygium in Iran is high, especially among women.

Surgical outcome of conjunctival rotational autograft-mitomycin C (MMC) versus free conjunctival autograft-MMC for pterygium removal: A randomized clinical trial

Background

Pterygium is a common degenerative eye disease. Despite various surgical methods to treat pterygium, recurrence is the main complication. The main issue is finding a surgical method with the lowest recurrence.

Objective

to compare the complications, recurrence rate and the cosmetic effects of two surgical techniques, namely conjunctival rotation autograft (CRA) and conjunctival autograft (CA), in treating pterygium.

Methods

This randomized clinical trial was conducted at Khalili Hospital in Shiraz, Iran, from January to August 2015. Forty-five eyes from 45 patients were studied. The patients were randomly divided into two groups using the blocking method. The patients of one group were operated on by the CRA technique, while the other group was operated on by the CA method. The patients were checked for the recurrence of pterygium, and other complications at the end of the first, third, and sixth month. Finally, the data were analyzed using SPSS version 21.

Results

The mean age of the patients was 42.5 years. The recurrence of pterygium was not observed in any of the patients 6 months after the surgery. Following 6 months after the operation, graft retraction occurred during the first week for one patient (4.5%) in the CA group, and five patients (21.7%) in the CRA group. The prevalence rate of graft injection among the patients of the CA and CRA groups 6 months after the operation was 9.1% and 65.2%, respectively. There was a significant correlation between injection intensity and the dissatisfaction of the patients with the operation’s outcome (p=0.017).

Conclusion

CRA with mitomycin is considered as an effective method to reduce the recurrence of pterygium after operation. This technique can be used as an acceptable method for pterygium operation, especially for patients with insufficient conjunctiva.

Clinical trial registration

The trial was registered at the Iranian Registry of Clinical Trials (http://www.irct.ir) with the Irct ID: IRCT2016092119581N2.

Funding

The study was financially supported by Shiraz University of Medical Sciences (SUMS) (grants No. 8901).

Molecular epidemiology and characteristics of 16 cases with Stenotrophomonas maltophilia bacteraemia in pediatric Intensive Care Units

BACKGROUND

Recently, Stenotrophomonas maltophilia has increasingly been reported as an important nosocomial opportunistic pathogen. Limited therapeutic options of S. maltophilia infections demand early identification and knowledge about the probable risk factors for controlling its spread.

STUDY DESIGN

The present study aimed to investigate the risk factors and trend of antibiotic susceptibility, along with genetic analysis in bacteraemia cases at pediatric intensive care units (PICUs).

METHODS

A total of 16 S. maltophilia isolates were obtained, during 4 months from August to November 2015, from blood cultures of patients admitted to PICUs at Nemazee teaching hospital, Shiraz, Iran. S. maltophilia isolates were identified by conventional tests and confirmed by specific PCR primers. Minimum inhibitory concentrations (MICs) were determined by the MIC strip test as described by the Clinical and Laboratory Standards Institute's (CLSI) recommendation. The genetic relatedness among the isolates was assessed by ERIC-PCR.

RESULTS

All isolates of S. maltophilia were susceptible to ciprofloxacin, co-trimoxazole and colistin, and only 1 (6.2%) isolate was resistant against ceftazidime. The MIC50/MIC90 of ciprofloxacin, trimethoprim/sulfamethoxazole, colistin and ceftazidime was 0.25/0.38 mg/mL, 0.125/0.19 mg/mL, 0.25/0.38 mg/mL, and 2/4 mg/mL, respectively. Genotypic analysis of ERIC-PCR results revealed two distinct types of pattern. Interestingly, the only ceftazidime resistant isolate showed different patterns with other isolates.

CONCLUSIONS

Our findings indicated the importance of routine surveillance in infection control, since early detection of pathogens prevented the spread of nosocomial infections and granted effectiveness to care practices. Moreover, the results suggest that the routine drug of choice for S. maltophilia was mostly active against clinical isolates in our region.

Corneal Collagen Cross-linking for Treatment of Bacterial and Herpetic Keratitis

INTRODUCTION

Optimal management of infective keratitis is a formidable challenge and subject of ongoing studies. Recently, Collagen Cross-Linking (CXL) of the cornea has been considered to be a new effective therapeutic approach for resistant infectious keratitis.

AIM

Aim of the study was to evaluate the effectiveness of CXL with Ultraviolet-A (UV-A) and riboflavin for treatment of the refractory bacterial and Herpes Simplex Virus (HSV) keratitis.

MATERIALS AND METHODS

In this prospective interventional study, eight patients with diagnosis of infectious keratitis who were referred to Khalili Hospital eye emergency room, between 2014 and 2015 were included in the study. There were six patients with bacterial keratitis and two patients with HSV keratitis; they were resistant to conventional treatment and underwent CXL. Response to the treatment was considered as good if rapid epithelialization and rapid decrease in stromal infiltration occurred.

RESULTS

Microbial culture in the bacterial keratitis group showed coagulase negative Staphylococcus in two patients, Staphylococcus aureus in one patient, mixed infection in one patient and Pseudomonas aeruginosa in two patients. Good response and rapid epithelialization and resolution of stromal infiltration were seen in the four out of six eyes. Two patients showed no response and underwent penetrating keratoplasty for eradication of infection. Furthermore, one patient showed a good response to CXL in the HSV keratitis group and another patient had a relative response but recurrence occurred.

CONCLUSION

Although, CXL seems promising in the treatment of patients with refractory bacterial keratitis, but in some cases, it is ineffective. CXL may be an alternative treatment for refractory cases of HSV keratitis but recurrence is possible.

Effect of Intraperitoneal Injection of Saffron on the Treatment of Experimental Endotoxin Induced Uveitis in the Rabbit

INTRODUCTION

Saffron with scientific name of "Crocus sativus" from the family "Iridaceae" is a plant without stem and root. Antioxidative and immunomodulatory effects of saffron has been demonstrated in different studies.

AIM

To assess the effects of saffron in the treatment on Lipopolysaccharide (LPS) induced uveitis in the rabbit.

MATERIALS AND METHODS

Thirty healthy female New Zealand white rabbits were prepared. LPS induced uveitis was confirmed via slit lamp examination 24 hours after intravitreal injection of Salmonella typhimurium LPS endotoxin in the right eye of all rabbits. Then the animals were randomly divided into two equal groups - group 1 (controls) and group 2 (saffron). After 24 hours of intravitreal injection of LPS, 60 mg/body weight of saffron was injected intraperitoneally for Group 2. On the seventh day after intraperitoneal injection, all rabbits of both groups were euthanized with an overdose intraperitoneal injection of sodium thiopental. Immediately after euthanasia, enucleation of both groups of rabbits was done. Clinical Scoring System (CSS) and pathological severity score of uveitis was assessed for each eye.

RESULTS

No statistical difference in the CSS was found in days 3,5, and 7 after intraperitoneal injection of saffron. Also, Pathological Severity Score (PSS) did not show a significant difference between two groups. Additionally, the maximum PSS of both groups was very closed but the number was observed in the saffron group (20%) more than control group (10%).

CONCLUSION

Intraperitoneal injection of saffron was ineffective in the management of experimental uveitis. Further studies with different dosages and follow up and using other routes of administration are needed.

Efficacy of Green Tea Extract for Treatment of Dry Eye and Meibomian Gland Dysfunction; A Double-blind Randomized Controlled Clinical Trial Study

INTRODUCTION

With an incidence rate of 9%, dry eye is a common problem of the ocular surface, especially in patients more than 40-year-old. Green tea extract has anti-oxidative, anti-bacterial, anti-androgen, and immunomodulatory properties.

AIM

To evaluate the efficacy of green tea extract for treatment of patients with dry eye and Meibomian Gland Dysfunction (MGD).

MATERIALS AND METHODS

In a double-blind randomized controlled clinical trial, 60 patients were selected within the age range of 30 to 70 years, and divided into two groups by blocked randomization method. Standard treatment included artificial tear eye drops, three times a day for a month for all patients. Topical green tea extract was prescribed three times a day for one month in one of the groups. All patients were evaluated at the beginning and end of the study for clinical symptoms based on the Ocular Surface Disease Index (OSDI) score, Schirmer's test, Tear Breakup Time (TBUT), corneal and conjunctival staining and meibum score.

RESULTS

The mean age of participants in the green tea and control group was 61 and 64 years respectively. In the green tea group, the mean score of clinical symptoms was 9±0.86 that improved to 4.86±0.55 after one month (p=0.002). Scores suggesting improvement of TBUTs and the health of meibomian glands were significantly higher in the green tea group (p=0.002). Furthermore, no side effects of the treatment were observed.

CONCLUSION

Green tea extract is an effective, safe, and well-tolerated topical treatment for mild and moderate evaporative dry eyes and MGD.

Frequency of bacteria causing urinary tract infections and their antimicrobial resistance patterns among pediatric patients in Western Iran from 2007-2009

Urinary Tract infections ( UTIs) are among the most common infections in infants and neonates. The aim of the current study was to evaluate the frequency of bacteria causing UTI and their relevant drug resistance patterns among infants and neonates hospitalized in Ilam province, Western Iran during 2007-2009. A total of 220 cases of UTI were enrolled in this cross-sectional retrospective study. A standard checklist was used for demographic and clinical data to be collected from their health records. Data was then analyzed using SPSS version 16.0. More than two-thirds (64.8%) of the cases were female. E. coli (44.5%), Klebsiella spp., (18.6%), Enterobacter spp., (15%) and Staphylococcus spp. (12.7%) were the most common microorganisms isolated from UTIs, respectively. High rates of resistance to tetracycline, ampicillin, and nalidixic acid were observed among these isolates. Similar to other studies, E. coli was the most common bacteria causing UTI and showed a high rate of resistance against most of the antimicrobial agents. Determining the antimicrobial sensitivity can be helpful for physicians in choosing an appropriate treatment for patients suffering from UTI, and also to reduce the complications related to serious UTI.

Antimicrobial resistance of nosocomial strain of Acinetobacter baumannii in Children's Medical Center of Tehran: a 6-year prospective study

There are increasing reports of emergence of multiple drug resistant (MDR) Acinetobacter spp in the world; however there are a few reports in our country. 145 A. baumannii isolates from distinct wards and Children's Medical Center (CMC) in Tehran were studied in order to find the profile of antibiotic resistance among them. 40.6% (59/145) of A. baumannii isolates were identified as MDR. Overall susceptibility rates to cotrimoxazole, chloramphenicole and ciprofloxacin were 23.4%, 16.9% and 20.1%, respectively. Frequency susceptibility rates to amikacin, kanamycin, gentamycin and tobramycin decreased gradually from 81.2%, 50%, 50% and 62.5% in 2002 to 25%, 15.6%, 28.1% and 25% in 2007 respectively. Overall susceptibility rates to cephalosporines cephalotin, ceftazidime, cefteriaxon, ceftizoxime and cefixime were 9.3%, 14.7%, 16.2%, 15.9% and 18%, respectively. Susceptibility to carbapenems was assessed only in 2007. The susceptibility rates of Imipenem and meropenem were shown to be 50% and 46.8%, respectively. Our data indicates that MDR A. baumannii strains are spreading and carbapenem resistance is becoming more common in Iran. Our findings also highlight the importance of clinicians' access to updated susceptibility data regarding A. baumannii in developing countries such as Iran.