Avicenna and cataracts: a new analysis of contributions to diagnosis and treatment from the canon

Physicians in ancient Persia played an important role in the development of medicine in the medieval era. One of the most influential figures of this era was Abu Ali Sina or Ibn Sina, known as Avicenna in the western world. The author of more than 200 books on medicine and philosophy, Avicenna followed and further expanded on the tradition of western philosophy and medicine introduced by Aristotle, Hippocrates and Galen. Few researchers have looked into the different medical issues in his best known work, the Canon of Medicine, particularly with regard to ophthalmology. In this analysis, Avicenna's views on and contributions to the diagnosis and treatment of cataracts in his Canon were elucidated. We first reviewed an electronic copy of the Canon and then reviewed other important sources in traditional medicine including the Kamel-al-Sanaeh, Al-Havi [Continents] and Zakhireh-kharazmshahi, available in the Avicenna Special Traditional Medicine Library of Shiraz University of Medical Sciences. We also searched Med-line, Embase, Scopus, Iranmedex and Science Iranian Database [SID] with these keywords: "traditional medicine," "Avicenna," "cataract", "Canon", "history", "ophthalmology" and "eye disorders". According to the Canon, nozulalmaa or cataract is an obstructive disease in which external moisture accumulates between the aqueous humor and the corneal membrane and prevents images from entering the eye. Avicenna classified cataracts on the basis of size, density and color. According to size, he identified two types of cataracts including complete and partial obstruction. According to the Canon, surgical intervention was necessary only for certain indications. Avicenna believed that opacity in the initial stages of cataract could be diminished by medicines and foods, and described several medicines for cataracts. He believed that surgery should be postponed until the liquid accumulation stopped, and the cataract reached its mature state. After surgery, according to Avicenna, the patient should avoid headache-inducing situations because headaches could lead to edema of the layers of the eye. He further emphasized that the patient's psychological status played an important role in the success of surgery. An important aspect of Avicenna's contribution to the medical management of cataracts was that he believed they could be cured by medication and nutrition in their early stages without the need for surgery. He also considered the patient's mental status as an important factor contributing to the postoperative prognosis. Our review of Avicenna's writings on eye disorders in the Canon of Medicine suggests that he had a rigorous approach to the diagnosis and management of patients suffering from eye disorders

Amniotic membrane transplantation for the treatment of pseudomonas keratitis in experimental rabbits

Amniotic membrane transplantation [AMT] has been considered in combination with medical treatment in progressive infective keratitis. The purpose of this study was to evaluate the efficacy of AMT as an adjunctive treatment in the management of experimental pseudomonas keratitis. Cryopreserved AMT was performed on 12 pseudomonas rabbit corneal ulcers. After one week in one group amniotic membrane transplantation combined Poostchi Eye Research Center with topical medical treatment was done [AMT group]. At the end of the second week, the clinical and pathological findings were compared with those obtained from eight corneal ulcers in another group which had only been treated with topical medication [control group]. There was not any significant difference in clinical signs between the two groups at the end of the second week. Corneal perforation was found in three cases of the control group but in none of the cases in the AMT group. Amniotic membranes were melted in four eyes, retracted in three eyes and intact in five eyes. Pathologic examination showed no significant difference in cellular infiltration or density of organism between the two groups. AMT is effective in preventing corneal perforation in the early stage of experimental pseudomonas keratitis

Local injection of bevacizumab as an alternative method for management of recurrent pterygium

Surgery has so far been used for primary treatment of pterygium; however, one of the major limitations is its high recurrence rate. This study was performed to determine the effect of bevacizumab in recurrent pterygium. Patients with recurrent pterygium were divided into two groups, receiving bevacizumab [Group 1] or normal saline [Group 2]. They were evaluated for photophobia and any conjunctival congestion and were scored from 0 to 4 prior to any injection. The size of pterygium was assessed in relation to extension of pterygium on the cornea over the limbus. All patients were followed in regular 48 hour intervals weekly up to one month and then monthly up to 6 months after the injection. There were 50 patients in group 1 and 48 in group 2 and the mean age of the patients was 40.94 +/- 13.82 and 47.10 +/- 5.9 years, respectively with a male to female ratio of 1 2. The mean size of ptrygium was 52.84 in group 1 and 46.02 in group 2. In group 1, photophobia and conjunctival congestion were 59.53 and 61.27, respectively while in group 2, they were 39.16, and 37.24, respectively. In the first 48 hours, conjunctival congestion and photophobia were higher in group 1 but there was no significant difference regarding the size of pterygium. After one week, the scores were significantly lower in group 1 while the mean rank for the size of pterygium was 52.84 in group 1, and 46.02 in group 2. After 1 and 6 months, the scores were lower in group 1. Subconjunctival injection of bevacizumab can be considered as an effective temporary treatment in the management of recurrent pterygium in those who are not a candidate for secondary operation. It can decrease conjunctival congestion and photophobia and prevent further progression even in the long term

[Ocular trauma in subjects older than 60 years]

To evaluate the demographic data, mechanisms of injury and complications of ocular trauma in patients over 60 year of age. We retrospectively reviewed the medical records of 91 patients older than 60 who were admitted and treated in the Ophthalmology Department of Khalili Hospital, between September 2002 and November 2008, due to ocular trauma. Data were retrieved from admission charts including demographic information, mechanisms of injury, site of penetrating or perforating trauma, associated injuries such as endophthalmitis and intraocular foreign bodies, complications of trauma, the time interval between trauma and referral to our center and the initial visual acuities. X2 analysis were performed using SPSS 11.5 program to analyze the data. Patient age ranged from 60 to 87 years with mean [ +/- SD] of 69.6 [ +/- 7.8] years. 11 patients [21.1%] were monocular. 61 patients [67%] belonged to rural and 30 patients [33%] were from urban areas. Mean [ +/- SD] time interval from trauma to referral was 102 [ +/- 130] hours [range: 1 to 480 hours]. The most common mechanisms of trauma were trauma with tree spines [24.2%], sharp trauma with wood [22%], blunt trauma with wood [11%], blunt trauma with hand [11%] and falling down [9.9%]. Three patients had intraocular foreign bodies and 14 eyes [15.4%] were complicated by endophthalmitis. The most common complications of trauma were corneal ulcer [27.5%], surgical wound dehiscence [22%] and corneal laceration [22%]. There was significant correlation between corneal ulcer and also surgical wound dehiscence and profound visual loss. There was also significant correlation between referral later than 48 hours and profound visual loss. The results of this study provide some information about elderly eye trauma. These results may be valuable in planning, education, prevention programs and surveillance of this susceptible population of the community

[Polymerase chain reaction versus conventional laboratory methods in the diagnosis of fungal keratitis]

To compare the value of conventional laboratory methods and polymerase chain reaction [PCR] in the diagnosis of fungal keratitis. This cross sectional study was conducted at Khalili Hospital, Shiraz, Iran. Samples were taken from thirty-eight patients with findings suspicious for fungal keratitis. Corneal scrapings were used for Gram, Giemsa and KOH stains, culture and PCR analysis. Of 38 enrolled eyes, 25 eyes [68.5%] were judged to have fungal infection based on positive cultures, staining, PCR or response to antifungal treatment. PCR detected fungi DNA in 17 of 25 samples [68% sensitivity]. Staining [Gram, Giemsa and KOH] and culture yielded a positive result in 40% and 24% of samples respectively. Twenty one [84%] of 25 patients showed fungal elements in at least one laboratory work up and 4 patients were diagnosed as fungal keratitis only based on response to antifungal drugs. Compared to conventional laboratory methods, PCR based methods offer higher sensitivity and a faster diagnosis in fungal keratitis

[Fuchs heterochromic iridocyclitis and pellucid corneal marginal degeneration: a co-incidence or a developmental defect?]

To report a patient with Fuchs' heterochromic iridocyclitis and pellucid corneal marginal degeneration. A 37-year-old woman referred to Poostchi Eye Clinic, Shiraz, Iran with complaint of low vision in both eyes especially in the left side since many years ago. On ophthalmologic examination, best-corrected visual acuity was 20/50 in right eye with refraction of -6.50-7.5@90 and 20/80 in left eye with refraction of -8.50-11.00x90. Slitlamp examination revealed inferior thinning of cornea in both eyes and diffuse keratic precipitates on corneal endothelium, 1+ cell and flare in the anterior chamber and posterior subcapsular cataract in left eye. There was a moderate iris hetererchromia between the eyes which beside other findings was suggestive of Fuchs' heterochromic iridocyclitis. Corneal topography was in favor of pellucid marginal degeneration. To our knowledge this is the first case of pellucid marginal degeneration associated with Fuchs' heterochromic iridocyclitis in the literature. This may be a co-incidence or might have occurred due to a defect in embryonic ocular development

[Local injection of bevacizumab for treatment of primary active pterygium]

To report subconjunctival injection of bevacizumab [Avastin] for treatment of primary active pterygium. Patients with primary active pterygia without other ocular disease, pregnancy or diabetes mellitus were enrolled. Patients were randomly allocated into two groups to receive injection of Avastin or placebo. Patients were evaluated for changes in photophobia, conjunctival congestion and size of the pterygium. In the first 48 hours, conjunctival congestion was greater in the treatment group as compared to the placebo group [125.76 vs 73.98, P<0.001]. The same was observed for photophobia [139.01 vs 69.18, P<0.001], but there was no difference in the size of pterygium between the two groups [105.86 vs 94.08, P= 0.130]. After one week, conjunctival congestion [90.98 vs 108.20, P= 0.01] and photophobia [85.08 vs 114.36 P<0.001] were less marked in the treatment group; however, mean pterygium size did not differ between the two groups [105.89 vs 94.06, P= 0.120]. This trend continued up to 6 months after the injection, the time at which the results regressed to become similar to those observed 48 hours after injection. Local injection of bevacizumab may be effective in treatment of pterygium; however, repeat injections should be considered

[Microbial inhibitional in non-inflamed human aqueous after oral antibiotic intake]

To investigate the penetration of cefixime, cephalexin and ciprofloxacin into the human eye based on microbial inhibition by human aqueous samples after oral administration. Sixty patients aged 40 to 75 years who were scheduled for cataract surgery were divided into three equal groups. One group received 500 mg oral ciprofloxacin 24, 12 and 2 hours preoperatively; another group received 500 mg oral cephalexin 24, 18, 12, 6 and 2 hours before the operation and the third group received 400 mg oral cefixime 24, 12 and 2 hours prior to surgery. Immediately before opening the anterior chamber, 0.1 ml of aqueous was taped with an insulin syringe. A 4 ml sample of the patient's blood was obtained simultaneously. Aqueous and serum specimens as well as a standard antibiotic disc were placed on the culture media of a known bacterium which was completely sensitive to the respective antibiotic. After 48 hours microbial inhibition zone of each sample was compared to the standard antibiotic disc. No microbial inhibition zone was seen by aqueous samples, however very large zones of inhibition were seen by discs of serum samples and antibiotics. It seems that oral cefixime, cephalexin and ciprofloxacin do not achieve effective concentrations in human aqueous for microbial inhibition

Comparative evaluation of visual acuity and complications in ECCE+P/C IOL and phacoemulsification+ P/C IOL in Senile Cataract

The age related cataract surgery is most common ophthalmic surgery. Today the method of choice for cataract surgery is phacoemulsification. This study was conducted to compare the visual acuity, pre-operation and post operation ECCE and Phacoemulsification complication in patients referring to Khalili and Dastgheib Hospital in Shiraz during 1380-1381. This prospective non randomized concurrent control study was conducted on 100 cases [52 case of ECCE and 48 case of Phaco]. Pre-operative evaluation included age, sex, visual acuity, astigmatism according to keratometry difference and type of cataract. The patients were evaluated during the operation for size, site of incision, posterior capsular rupture, vitreous loss and nucleus dropped in vitreous. Then in 1, 5, 14, 90,180 days post operation, they were examined for BCVA, UNCVA, astigmatism [keratometry and refraction], inflammation, corneal edema, posterior capsular opacity and clinical CME. In this study 100 cases [48 phacoemulsification, 52 ECCE] aged 48-76 for cataract surgery were included. Patients were followed for 6 months after operation. Mean age in phacoemulsification was 58.27 +/- 7.26 and in ECCE was 64.71 +/- 6.84. On the fifth day after ECCE, UNCVA >/= 30.60 was 15.3% and in phaco was 62.5%. On the fifth day mean UNCVA in phaco was 30.60 and in ECCE, 20.60. Mean astigmatism on the first day post-operation according to keratometry difference in ECCE was 4.84 +/- 2.08D and in phaco was 2.27 +/- 1.67D and according to refraction in ECCE was 3.62 +/- 2.08D and in phaco was1.91 +/- 1.34D. Posterior capsular rupture in ECCE was 7.6% and in phaco was 12.5%. Vitreous loss in ECCE was 5.7% and in phaco was 10.7%. Corneal edema in the first day post-operation in ECCE was 19.2% and in phaco was 43.8%. Two weeks after operation in all patients who underwent phacoemulsification, corneal edema was cleared, but in ECCE 3.8% corneal edema continued for 6 months after operation. Nucleus dropped in vitreous occurred only in phaco [2.1%] IOL dislocation after phacoernulsification was 4.1% and 2.1% [1 case] need to IOL removal, but this complication was not visible in ECCE. Success rate, Intra operative and post-operative complications in phacoernulsification in comparison to other studies were in an acceptable range. We recommend further study in this case for more documented results

Corneal Pachymetry using Ultrasound Vs Orbscan II in Normal and Post-LASIK Eyes

To compare orbscan II [0 II] and ultrasound [US] pachymetry in normal and post-LASH[eyes. In a comparative prospective study, central corneal thickness [CCT] was measured in 168 eyes of 84 normal subjects and 42 eyes without corneal opacity of 21 post-LASIK patients by 0 II and US. Paired t test was used to identify significant differences between the two methods and Pearson test was used to identify the correlation of measurments between the two methods. Mean CCT measured by ultrasound [538.7 +/- 47.4 gm] was less than that of 0 II [542.7 +/- 52.2 gm] in the normal eyes [P<0.04], but mean CCT measured by ultrasound [477.8 +/- 38.2 lam] was greater than that of 0 II [469.5 +/- 47.2 gm] in the post-LASIK eyes. [p<0.02] There was significant linear correlation between US and 0 II in both groups. [r=0.87, P=0.000 and r=0.88, P=0.000, respectively]. Mean difference of CCT measurements between 0 II and US in normal and post LASIK clear cornea is not clinically significant and interchangeable use of data in planning or assessing corneal surgery is possible

[Topical cyclosporine A 2% in management of endothelial corneal allograft rejection]

To determine whether adding 2% topical cyclosporine [CSA] to local and systemic steroids in treatment of endothelial corneal allograft rejection improves the outcome. A prospective randomized treatment trial was carried out on 40 consecutive corneal graft recipients, presenting with the first episode of endothelial graft rejection in two groups. Group one [20 patients] received topical steroid eye drops and oral prednisolone [1mg/kg]. Group two [20 Patients] received the same topical and systemic therapy plus 2% cyclosporine eye drops. The patients were followed up for three months and their clinical outcomes were evaluated by the rates and time for reversal of rejection. In group one, 14 [70%] cases had total reversal of graft rejection episode which started within a mean period of three days, but in the CSA group, it occurred in 18 [90%] cases which started within a mean period of 1.5 days [P=0.21]. Among patients who sought treatment early [< 6 days], survival rates were 85% and loo%, respectively [P=0.2]. In high risk patients, the rejection reversal rate was 66% in CSA group and 25% in the control group [P=0.5]. Addition of 2% CSA eye drop to topical and systemic steroids may improve the rates of graft rejection reversal. It may also decrease the interval between initiation of treatment and improvement of clinical signs

[Amniotic membrane transplantation in trabeculectomy]

To evaluate the effect of amniotic membrane transplantation in trabeculectomy. The study was conducted on 25 eyes of 25 patients with advanced and medically uncontrolled glaucoma. All patients underwent trabeculectomy with a fornix based conjunctival flap, amniotic membrane was than placed under the scleral flap and fixed using 10-0 nylon suture. Amniotic membrane was retrieved from healthy pregnant women during elective cesarean section. Preoperative intraocular pressure was 33.5 +/- 5.0 mmHg [26-50 mmHg] with full medication, which decreased to 12.4 +/- 1.8 mmHg [9-15 mmHg] post-operatively [P=0.0001]. intraocular pressure was less than 21 mmHg after surgery in all eyes, with [8%] or without [92%] use of antiglaucoma medications after six months. The use of amniotic membrane in trabeculectomy can increase the chance of success in terms of maintenance of a functional bleb and prevention of failure. This method may be superior to antimetabolites due to lack of complications

In-vitro susceptibility of infective keratitis causative bacteria to topical povidone iodine

Purpose: To evaluate the in-vitro susceptibility of bacterial isolates from the cases of corneal ulcer to povidone iodine. Setting: Department of ophthalmology, and clinical microbiology research center, Shiraz University of Medical Sciences, Shiraz, Iran. Patients and The in-vitro susceptibility and Minimum Inhibitory Concentration [MIC] of the bacteria isolated from the cornea of 50 cases of bacterial corneal ulcer to povidone iodine was determined by broth dilution method. Concentrations of 1%, 2%, 5% and 10% of povidone iodine were tested. Bacterial isolates included 50% S. epidermidis, 20% P. aerogenosa, 10% S. aureus, 4% Acintobacter, 4% S. pneumoniae, 4% E-coli, 2% Proteous, 2% S. viridance, 2% Diphtheroid and 2% Bacillous. Povidone iodine bactericidal efficacy for gram positive bacteria was at least 82.36%, 91.2%, 100% and 100% in 1%, 2%, 5% and 10% concentrations after 5 minutes exposure time. The bactericidal efficacy of this agent over the gram negative bacteria was at least 62.5%, 87.5%, 100% and 100% in 1%, 2%, 5% and 10% concentrations after 5 minutes exposure time, respectively. Povidone iodine was shown to have a broad spectrum in- vitro bactericidal efficacy in cases of bacterial keratitis. If further invivo studies confirm the efficacy of this agent over the bacterial keratitis, it would be suggested as a broad spectrum medication for the treatment of these cases

Correlation of corneal allograft rejection with tumor necrosis factors-alpha gene polymorphism

Correlations between bone marrow, heart, kidney, liver, skin and lung transplant rejection or survival with human cytokine gene polymorphisms have been described. There are also reports about the role of cytokines and Tumor Necrosis Factors-Alpha [TNF-alpha] on corneal transplant in animal models. Further studies are needed to clarify the role of cytokines in corneal allograft rejection in humans. To study whether corneal allograft rejection is associated with TNF-alpha gene polymorphism. A total of 105 cases of corneal transplant were followed for a mean period of 25.9 months and the episodes of rejections recorded. We determined allele-specific PCR [ASPCR] TNF-alpha gene polymorphism of the patients and evaluated their association with rejection. Results; The overall incidence of corneal graft rejection and its subsequent recovery were 21% and 63.6% respectively. Rejection was more common in the vascularized corneas [5.4 folds; P<0.001], and in eyes with anterior synechia [3.9 fold; P<0.05]. There was no correlation between TNF-alpha gene polymorphism and the chance of allograft rejection. No association was found between human TNF-alpha 308 G/A promoter gene polymorphism and corneal allograft rejection in our cases of uncomplicated penetrating keratoplasty

In vitro susceptibility of fungal isolates of keratomycosis to antiseptic agents

Fungal corneal ulcer is the most dangerous and challenging type of infective keratitis. Since most of the ophthalmic antifungal drops are scarce and expensive in developing countries, attempts have been made to study fungicidal property of some readily available antiseptic agents as a substitute. Povidone iodine [PI] and chlorhexidine gluconate [CHx] has been postulated to be effective against fungi. To study in vitro antifungal efficacy of PI and CHx. Fungi isolated from cases of keratomycosis were entered in a prospective study from June 2001 to March 2002. In vitro susceptibility of these fungi was tested by broth dilution method of NCCLS Standard to PI [1%, 2%, 5%, 10%] and CHx [0.04%, 0.1%, 0.2%] after 5 minutes, 1 hr, 24 hrs and 48 hrs exposure times. From a total of 16 culture-proven cases of fungal keratitis, the isolated fungi were 8 Aspergillus sp, 3 Fusarium sp, 2 sterile hyphae, 1 Candida sp, 1 Drechslera sp, 1 Rhodotorula sp. PI showed 100% fungicidal effect with all tested concentrations, after 5 minutes of exposure to all fungal species. CHx. 0.1% and 0.2% after 1 hr exposure were as effective as PI [p>0.34]. The fungicidal efficacy of CHx 0.1% and 0.2% was significantly less than PI after 5 minutes [p<0.001]. Both PI and CHx have strong in vitro fungicidal effect. The kill rate of CHx, however, is less than PI. Since in vitro efficacy of topical ophthalmic preparations is affected by multiple factors, our study provides a good idea for further in vivo investigations about this subject