Medical Hypothesis, Discovery & Innovation (MEHDI) Ophthalmology Journal
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Safety and efficacy of topical tacrolimus 0.03% in the management of vernal keratoconjunctivitis: a non-randomized controlled clinical trial
Get PDFBackground: Vernal keratoconjunctivitis (VKC) is a bilateral, recurrent, chronic conjunctival inflammatory disease with seasonal exacerbations. This study aimed to assess the efficacy and safety of tacrolimus 0.03% eye ointment in the management of chronic VKC.
Methods: This was an open-label, prospective, non-randomized, comparative interventional study that enrolled 50 patients with chronic VKC, who were allocated to one of two groups. The first group was treated with tacrolimus 0.03% eye ointment twice daily for 2 months then once daily for 2 months, followed by once every other day for another 2 months. The control group was treated with standard anti-allergic drugs, topical fluorometholone 0.1% eye drops three times daily for 2 weeks and gradually tapered for another 2 weeks, with topical olopatadine 0.1% administered twice daily during the follow-up period. Disease severity was assessed using a four-point scale for symptoms and signs. Treatment efficacy was assessed by analyzing changes in symptoms and signs, and by clinical photography.
Results: Fifty patients with bilateral chronic VKC completed the follow-up. The mean (standard deviation) ages of the tacrolimus and control groups were comparable (16.20 [5.10] years versus 16.48 [4.19] years, P > 0.05). The most commonly reported symptom was itching, and the most common signs were papillary hypertrophy and conjunctival hyperemia. All symptoms and signs were significantly reduced after treatment in both groups. The tacrolimus group showed a more significant improvement at 3 and 6 months in the mean composite symptom score (both P < 0.05) and in the mean composite sign score (both P < 0.05). Regarding complications, one case of increased intraocular pressure occurred in the control group (4%) after 2 weeks of steroid treatment, while there were no complications in the tacrolimus group, except for some reports of stinging sensation, which was well tolerated.
Conclusions: Treatment of chronic bilateral VKC with tacrolimus 0.03% eye ointment is effective and safe. It could be considered an alternative treatment to reduce steroid-associated complications in patients with chronic VKC. Future double-blinded clinical trials with a longer follow-up period are necessary to confirm our findings and to determine the long-term safety of topical tacrolimus 0.03% ointment in VKC
rs10737680 polymorphism in complement factor H and neovascular age-related macular degeneration in Yogyakarta, Indonesia
Get PDFBackground: Neovascular age-related macular degeneration (nAMD) is one of the main causes of blindness in developed countries. Complement factor H (CFH) is one of the genes involved in the pathogenesis of nAMD. This study investigated the rs10737680 polymorphism in CFH and its conferred susceptibility to nAMD in Yogyakarta, Indonesia.
Methods: This case-control hospital-based study recruited participants consisting of 96 patients with nAMD and 101 controls without nAMD from the Eye Polyclinic of Sardjito Hospital, YAP Eye Hospital, and Hardjolukito Hospital Yogyakarta. nAMD was diagnosed when fundus examination, fundus photographs, and optical coherence tomography revealed hard or soft drusen in the macular area measuring > 63 µm that appeared below the retinal pigment epithelium, with or without macular hypo- or hyperpigmentation, and was accompanied by choroidal neovascularization. Genomic DNA was extracted using a commercial DNA isolation kit. The restriction fragment length polymorphism technique was used to identify the rs10737680 polymorphism in CFH.
Results: The mean (standard deviation [SD]) age of the nAMD group was not homogeneous with that of the control group (P < 0.05); 65.41 (9.74) years versus 68.24 (7.82) years. The number of patients with hypertension in the nAMD group was significantly higher than in the control group (P < 0.05). In the nAMD group, the genotype distribution indicated homozygous risk allele in 34.38%, heterozygous risk allele in 57.29%, and homozygous non-risk allele in 8.33%. In the control group, the genotype distribution indicated homozygous risk allele in 21.78%, heterozygous risk allele in 36.63%, and homozygous non-risk allele in 41.58%. Statistical analysis between the two study groups according to homozygous risk allele genotype (odds ratio [OR], 7.87; 95% confidence interval [CI], 2.88–22.79) and heterozygous genotype (OR, 7.80; 95% CI, 3.11–21.19) showed a significant difference (both P < 0.01).
Conclusions: Homozygous risk allele was less frequent than heterogeneous risk allele in patients with nAMD; however, both increased the risk for nAMD. Although the homozygous or heterozygous risk-alleles were detected in most patients, yet other important genetic or environmental factors could be involved in the pathogenesis of nAMD. Overall, we found a significant association between rs10737680 polymorphism in CFH and the susceptibility to nAMD in Yogyakarta, Indonesia; however, future studies are needed to fully delineate the mechanism
Frequency of retinopathy of prematurity at a tertiary referral center
Get PDFBackground: With advances in medical facilities and increased survival of premature infants, the prevalence of retinopathy of prematurity (ROP) has increased. This study aimed to determine the frequency of ROP and its associated risk factors.
Methods: This descriptive-analytical, retrospective study included all premature infants with a birth weight (BW) equal or less than 2,500 g and/or gestational age (GA) equal or less than 35 weeks who were referred to Imam Khomeini Hospital in Ahvaz, Iran, for ROP screening over a 7-year period from April 2013 to April 2020. Demographic criteria, associated risk factors, and findings of eye examinations were collected and analyzed.
Results: Of the 812 at-risk infants screened, 807 met the inclusion criteria. ROP was observed in 316 (39.0%) of the 807 premature infants, with types I and II in 142 (45.0%) and 174 (55.0%) infants, respectively. The mean GA (29.6 ± 2.5 weeks versus 30.7 ± 2.5 weeks) and BW (1,203.6 ± 382.8 g versus 1,333.5 ± 386.5 g) were significantly lower in infants with ROP than in those without ROP (both P < 0.001). GA (r = 0.80; P < 0.001) and BW (r = 0.85; P < 0.001) had a strong positive correlation with ROP, and the correlation increased as GA and BW decreased (all P < 0.001). Associated risk factors in infants with ROP, in order of frequency, were oxygen therapy (22.8%), respiratory distress (16.1%), phototherapy (14.6%), blood transfusion (5.7%), apnea (4.1%), mechanical ventilation (1.6%), and intraventricular hemorrhage (0.9%). Multivariate regression analyses showed low GA and BW (both P < 0.05) as independent predictors of ROP.
Conclusions: The frequency of ROP in premature infants was slightly higher than the average range reported for domestic and foreign statistics. Low BW and GA were independent predictors of ROP
Electroretinogram changes before and after silicone oil removal in eyes with macula-off rhegmatogenous retinal detachment
Get PDFBackground: Pars plana vitrectomy (PPV) with silicone oil (SO) injection for rhegmatogenous retinal detachment (RRD) repair may adversely affect electroretinographic responses. This study was aimed at assessing retinal function using electrodiagnostic testing after successful PPV with SO tamponade in the eyes with macula-off RRD.
Methods: In this interventional comparative study, eligible participants were recruited prospectively over 1 year. We included the eyes that underwent a single successful three-port PPV with SO tamponade for the primary repair of macula-off RRD. Full-field electroretinogram (ffERG) and multifocal electroretinogram (mfERG) were recorded 1 day before and 3 days after SO removal. The amplitude and implicit time of the a- and b-waves for ffERG and P1 and N1 waves for mfERG were evaluated. The unaffected fellow eyes of the patients were selected as controls.
Results: We included the ten eyes of ten patients (seven men and three women) with a mean (standard deviation) age of 58.8 (6.2) years. The mean (SD) interval between the diagnoses of macula-off RRD and PPV was 11.7 (3.6) days. The mean (SD) duration of SO tamponade was 147.8 (34.9) days. Using ffERG, significantly lower a- and b-wave amplitudes were found in the eyes before and after SO removal or compared to the unaffected fellow eyes (all P < 0.05). Using the mfERG, treated eyes had significantly lower P1 amplitudes in the central R1+R2+R3 rings and in the R4 and-R5 peripheral rings of the macular area in the eyes before and after SO removal or compared to the unaffected fellow eyes (all P < 0.05). The wave implicit time in ffERG and mfERG did not differ significantly in the eyes before and after SO removal or compared to the unaffected fellow eyes (all P > 0.05).
Conclusions: The electrical retinal response density in ERG waveforms increased following SO removal, indicating amelioration of the electrical activity of the retina and macula. These results indicate that the adverse effects of SO tamponade on electroretinography responses may be reversible with removal. In addition, ffERG and mfERG can be used to monitor retinal function in the eyes with macula-off RRD and SO tamponade. Further clinical trials are required to verify the preliminary findings of this study
Validation of the Postnatal Growth and Retinopathy of Prematurity (G-ROP) screening criteria
Get PDFBackground: Retinopathy of prematurity (ROP) is a leading cause of irreversible blindness in infants. The Postnatal Growth and ROP (G-ROP) study proposed new screening criteria for ROP. This study aimed to validate the G-ROP screening criteria in a group of Iranian premature infants who were treated in the neonatal intensive care unit (NICU) for at least 40 days.
Methods: In this retrospective study, we extracted the data pertaining to infants admitted to the NICU from January 2020 to December 2021. We screened all the included infants for ROP based on the Iranian national screening criteria. We applied the G-ROP criteria to our study population, and if no criterion was met, the infant was exempted from ROP screening. We determined the sensitivity and specificity of the G-ROP guidelines for ROP detection, along with its capacity for predicting the requirement for ROP treatment. Moreover, we compared the G-ROP guidelines with the Iranian and North American guidelines for ROP screening.
Results: A total of 166 premature infants with complete datasets were included: 130 had ROP, of whom 61 were treated. There were 109 female infants (65.7%). The mean (standard deviation [SD]) birth weight and gestational age were 1080 (256) g and 28.28 (1.97) weeks, respectively. Applying the G-ROP criteria, 127 of 130 infants with ROP were identified (sensitivity, 97.69%; 95% confidence interval [CI], 95.11% – 100%), and of 36 infants without ROP, three were correctly excluded (specificity, 8.33%; 95% CI, 0% – 17.36%). The G-ROP criteria did not fail to identify infants who required treatment for ROP (sensitivity, 100%; 95% CI, 98.29 – 100) and had a specificity of 8.69% (95% CI, 2.04% – 15.34%). Although the Iranian and North American criteria had 100% sensitivity for infants with any stage of ROP, they could not detect infants without ROP (0% specificity).
Conclusions: The G-ROP screening criteria had a sensitivity of 100% in identifying infants requiring treatment for ROP in our high-risk group; however, specificity was not sufficiently high. Further studies with larger numbers of referred infants could confirm a decrease in the burden of retinal examinations using these criteria
Effects of mitomycin-C on tear film function following photorefractive keratectomy for mild-to-moderate myopia
Get PDFBackground: Mitomycin C (MMC) is used to prevent corneal opacity after photorefractive keratectomy (PRK). This study sought to determine the effect of MMC on tear film function after PRK in eyes with mild-to-moderate myopia.
Methods: This prospective, contralateral eye comparison was conducted on 30 eyes of 15 patients with low-to-moderate myopia referred to Alzahra Eye Hospital, Zahedan, Iran. The eyes of the control group underwent PRK with a balanced salt solution, while the fellow eyes in the intervention group underwent PRK with 0.02% MMC for 25 s. The tear breakup time test (TBUT) and basic Schirmer test results of eyes in the control and intervention groups were compared at baseline and 1, 3, and 6 months postoperatively. Tear osmolarity was recorded and compared at baseline and 3 months postoperatively.
Results: The mean ± standard deviation (SD) age of participants was 27.53 ± 7.04 years. No statistically significant differences were observed in the means ± SDs for tear osmolarity, TBUT, and basic Schirmer test values (all P > 0.05) between MMC-treated eyes and untreated fellow eyes at baseline and during postoperative follow-up. The means ± SDs for tear osmolarity, TBUT, and basic Schirmer test results were comparable in both groups between the baseline and postoperative follow-ups (all P > 0.05).
Conclusions: Single application of a standard dose of MMC (0.02%) for 25 s in PRK did not change tear stability, tear production, or variation in tear dynamics up to 6 months postoperatively in eyes with low-to-moderate myopia. Future longitudinal studies with a longer follow-up and a larger sample size are warranted to confirm our findings
Pars plana vitrectomy for tractional diabetic macular edema with or without internal limiting membrane peeling
Get PDFBackground: The effectiveness of internal limiting membrane (ILM) peeling in the surgical treatment of tractional diabetic macular edema (DME), although widely examined, remains controversial. This study aimed to assess the efficacy of pars plana vitrectomy (PPV) in the management of tractional DME and to highlight any benefits of additional ILM peeling.
Methods: This was an open-label, prospective, comparative, and interventional study that enrolled 50 eyes with tractional DME that underwent PPV and allocated each to one of two groups: group A consisted of 25 eyes that had no ILM peeling and group B consisted of 25 eyes that underwent ILM peeling. Postoperative assessments of best-corrected distance visual acuity (BCDVA) in the logarithm of minimal angle of resolution (logMAR) notation and central macular thickness (CMT) were performed at 1, 3, and 6 months postoperatively.
Results: At baseline, the two groups were comparable in terms of sex ratios, phakic status, insulin use, coexistence of hypertension, and mean (standard deviation [SD]) age, BCDVA, CMT, duration of diabetes mellitus, and glycosylated hemoglobin (HbA1c) levels. In group A, the mean (SD) BCDVA improved significantly from 0.89 (0.12) logMAR preoperatively to 0.64 (0.24) logMAR (P < 0.001), and the mean (SD) CMT declined significantly from 471.28 (80.83) micrometer to 228.20 (26.45) micrometer (P < 0.001), at the 6-month postoperative assessment. Likewise, in group B, the mean (SD) BCDVA improved significantly from 0.83 (0.10) logMAR preoperatively to 0.58 (0.24) logMAR (P < 0.001), and the mean (SD) CMT decreased significantly from 496.84 (89.82) micrometer to 226.20 (18.04) micrometer (P < 0.001), after 6 months. There were no significant differences between groups A and B in the changes in BCDVA (Delta BCDVA) or CMT (Delta CMT) at 1, 3, and 6 months postoperatively with respect to the baseline values (all P > 0.05). Postoperative complications were comparable between the two groups. A significant negative correlation was detected between the preoperative HbA1c level and BCDVA improvement in all participants (r = - 0.82; P < 0.001).
Conclusions: PPV is an effective treatment for tractional DME. Additional ILM peeling was not significantly associated with functional and anatomical benefits over a short period. Long-term glycemic control plays a role in vision gain after vitrectomy in patients with diabetes. Further long-term studies are required to verify our findings
Binocular vision parameters in chronic heavy alcoholics: Short-term outcomes of alcohol detoxification
Get PDFBackground: Alcohol consumption is rising in developing countries such as India, and alcohol addiction has systemic and ocular impacts. This study aimed to investigate the binocular functions of chronic heavy alcoholics before and after alcohol detoxification.
Methods: A prospective before–after study was designed and conducted at Treda De-Addiction Centre, Bengaluru, India. Males in the age range of 30–40 years who had been alcohol addicts for more than six years and met the inclusion criteria were recruited. We performed a routine optometric examination followed by detailed binocular vision assessment, including accommodative, vergence, and oculomotor tests on the first day of rehabilitation and one month after initiation of rehabilitation.
Results: Twenty-five males with of the age (mean ± standard deviation [SD]) 36.24 ± 4.33 years were evaluated. The pre- and post-detoxification mean ± SD of the monocular (right eye: 5.98 ± 3.50, 6.60 ± 3.49; left eye: 6.18 ± 3.69, 7.10 ± 3.78) and binocular accommodative facility (7.10 ± 3.93, 7.40 ± 4.51) did not change significantly (all P > 0.05). Eighteen (72%) of the participants had non-strabismic binocular vision anomalies (NSBVA), among whom the accommodative infacility and convergence insufficiency were higher in frequency and remained constant after alcohol detoxification. Furthermore, the binocular vision parameters showed no statistically significant difference between the pre- and post-detoxification values (all P > 0.05).
Conclusions: The binocular vision parameters did not change significantly after one month of alcohol detoxification in the chronic heavy drinkers. Most long-term alcoholics had NSBVA with no change after rehabilitation, indicating that short-term alcohol detoxification may not aid in the recovery of binocular parameters. However, further validation is required. Assessing the impact of vision therapy in addition to a longer period of abstinence can confirm or refute the persistence of observed effects of chronic alcohol consumption on binocular functions and NSBVA in this population
Corneal endothelium, retinal nerve fiber layer, ganglion cell complex, and perimetry measurements in normal eyes and those with primary open-angle glaucoma
Get PDFBackground: Corneal endothelial cell (CEC) loss in glaucoma can be attributed to the direct compressive effect of elevated intraocular pressure. Herein, we aimed to evaluate specular microscopic changes in CEC count and morphology in correlation to retinal nerve fiber layer (RNFL) changes detected by spectral-domain optical coherence tomography (SD-OCT) in early and advanced primary open-angle glaucoma (POAG).
Methods: This descriptive-analytical study involved patients with medically controlled POAG versus non-glaucomatous patients of the same age group. Specular microscopy, visual field testing, and SD-OCT of the RNFL and macular ganglion cell complex (GCC) were performed. Eyes with POAG were further subcategorized into early and advanced stages.
Results: The study included 130 eyes of 130 participants; 70 were eyes with POAG (40 eyes with early-stage POAG, 30 eyes with advanced-stage POAG), and 60 were healthy eyes. The groups were comparable regarding mean age and sex. No significant difference was found in corneal parameters between healthy eyes, eyes with early POAG, and eyes with advanced POAG (all P > 0.05). In eyes with early-stage POAG, a significant negative correlation was found between the coefficient of variation (CV) and superior RNFL thickness (r = - 0.5; P = 0.018), and between the percentage of hexagonal cells (hexagonality) and vertical cup-to-disc ratio (r = - 0.43; P = 0.035). A significant positive correlation was found between hexagonality and superior as well as inferior RNFL thickness (r = + 0.53; P = 0.008 and r = + 0.50; P = 0.015, respectively). However, in the advanced glaucomatous eyes, no significant correlation was found between RNFL thickness and CEC parameters.
Conclusions: CEC parameters were not affected in eyes with early or advanced POAG compared with healthy eyes, despite a significant thinning of RNFL and macular GCC. In eyes with early-stage POAG, a significant correlation was found between morphological characteristics of CECs, such as CV and hexagonality, with superior and inferior RNFL thickness in the optic nerve head on SD-OCT images. Future longitudinal studies with larger sample sizes are needed to verify our results
A brief review of Valsalva retinopathy
Get PDFBackground: Valsalva retinopathy is a specific type of retinopathy that appears following an acute rise in intrathoracic or intra-abdominal pressure. This review focuses on current literature and future directions for the diagnosis and management of Valsalva retinopathy.
Methods: In this brief review, the literature was searched to provide an extensive general and updated description of Valsalva retinopathy, focusing on its management and prognosis. Selected articles are summarized to present the etiology, general pathology, pathophysiology, symptoms, signs, diagnosis, differential diagnosis, treatment, and prognosis of Valsalva retinopathy.
Results: The main symptom of Valsalva retinopathy is loss of visual acuity following exertion. This is caused by the rupture of small superficial vessels in the macula and perimacular areas, leading to extravasation of blood. No link between age, sex, or race has been found, although fundus vessel abnormalities pose some predisposition to the disease. During fundoscopy, Valsalva retinopathy appears most frequently as well-defined preretinal hemorrhages confined to the sub-internal limiting membrane (ILM) or subhyaloid space. If ILM rupture occurs, hyaloid hemorrhage can appear. Diagnosis is based on the patient’s medical history and a standard examination. Usually, only observation of the patient is required, with the hemorrhage resolving within weeks to months. In cases of large premacular hemorrhage or large sub-ILM/subhyaloid hemorrhage, vitrectomy or Nd:YAG krypton laser membranotomy can be performed.
Conclusions: Of all the aspects of Valsalva retinopathy that might trouble the physician, the most challenging features are differential diagnosis and the choice of optimal treatment. Therapeutic strategies for Valsalva retinopathy can be either conservative or based on Nd:YAG laser membranotomy and/or vitrectomy. All methods seem to have good outcomes. However, physicians should not be afraid of advancing beyond conservative therapy, especially in the event of persistent premacular hemorrhage, which could lead to permanent retinal damage if valuable time is lost, even after vitrectomy