Outcomes of Levator Resection at Tertiary Eye Care Center in Iran: A 10-Year Experience

PURPOSE: To assess outcomes of levator resection for the surgical correction of congenital and acquired upper lid ptosis in patients with fair to good levator function and evaluation of the relationship between demographic data and success of this operation. METHODS: In a retrospective study, medical records of patients with blepharoptosis who had undergone levator resection over a 10-year period and were followed for at least 3 months were reviewed. RESULTS: Overall, 136 patients including 60 (44.1%) male and 76 (55.9%) female subjects with a mean age of 20 +/- 13.8 years (range, 2 to 80 years) were evaluated, of whom 120 cases (88.2%) had congenital ptosis and the rest had acquired ptosis. The overall success rate after the first operation was 78.7%. The most common complication after the first operation was undercorrection in 26 cases (19.1%), which was more prevalent among young patients (p = 0.06). Lid fissure and margin reflex distance (MRD1) also increased after levator resection (p < 0.001). Age, sex, type of ptosis, amblyopia, levator function, MRD1, lid fissure and spherical equivalent were not predictive of surgical outcomes of levator resection. CONCLUSIONS: Levator resection has a high rate of success and few complications in the surgical treatment of congenital and acquired upper lid ptosis with fair to good levator function. Reoperation can be effective in most cases in which levator resection has been performed.

Bilateral Terrien's marginal degeneration and posterior polymorphous dystrophy in a patient with rheumatoid arthritis

Purpose: To report an interesting case of concomitant bilateral Terrien's marginal degeneration-like corneal ectasia and posterior polymorphous corneal dystrophy in a young man with quiescent rheumatoid arthritis

Case Report: A 24-year-old man with history of rheumatoid arthritis presented with bilateral decreased vision since four years ago. Slit lamp examination revealed bilateral circumferential peripheral corneal thinning and bulging with vascularization and lipid deposition in addition to band-like lesions in descemet's membrane. Previous records revealed no gross corneal abnormalities up to 4 years ago. Corneal lesions were compatible with bilateral circumferential Terrien's marginal degeneration concomitant with posterior polymorphous dystrophy

Conclusion: To our knowledge, this is the first report of concomitant bilateral Terrien's marginal degeneration with peripheral corneal ectasia and posterior polymorphous dystrophy in a patient with rheumatoid arthritis. Bilateral circumferential involvement, younger age at presentation and total peripheral corneal ectasia as observed in this case are not typical for classic Terrien's marginal degeneration

Topical mitomycin-C versus subconjunctival 5-Fluorouracil for management of bleb failure

To compare the efficacy and safety of topical mitomycin C [MMC] drops with that of subconjunctival 5-fluorouracil [5-FU] injections for management of early bleb failure after trabeculectomy or combined phacoemulsification and trabeculectomy with posterior chamber intraocular lens implantation [PT+PCIOL]. In a randomized comparative study, 37 eyes of 37 patients with impending early bleb failure received MMC 0.02% eye drops for 2 or 4 weeks [19 eyes] or subconjunctival 5-FU injections, 5 mg per dose [18 eyes]. Complete success was defined as 5 < IOP

Myocilin mutations are not a major cause of primary congenital glaucoma in Iranian patients

To assess the frequency of mutations in the Myocilin [MYOC] gene in Iranian patients affected with primary congenital glaucoma [PCG]. The individuals evaluated herein are among the larger cohort of 100 patients who had previously been screened for CYP1B1 mutations. Eighty subjects carried mutations in CYP1B1, but the remaining 20 patients who did not, underwent screening for MYOC mutations for the purpose of the study. MYOC exons in the DNA were polymerase chain reaction [PCR] amplified and sequenced. Sequencing was performed using PCR primers, the ABI big dye chemistry and an ABI3730XL instrument. Sequences were analyzed by comparing them to reference MYOC sequences using the Sequencher software. Four MYOC sequence variations were observed among the patients, but none of them were considered to be associated with disease status. Three of these variations were single nucleotide polymorphisms already reported not to be disease causing, the fourth variation created a synonymous codon and did not affect any amino acid change. In this cohort, MYOC mutations were not observed in any Iranian subject with PCG. It is possible that in a larger sample, a few subjects carrying disease causing MYOC mutations could have been observed. But our results show that the contribution of MYOC to PCG status in Iran is small if any

Peripapillary retinal nerve fiber layer thickness measurement by three-dimensional optical coherence tomography in a normal population

To determine peripapillary retinal nerve fiber layer [RNFL] thickness values by three-dimensional optical coherence tomography [3D-OCT] in a normal Iranian population and to evaluate the concordance of these measurements with those obtained by the second generation of optical coherence tomography [OCTII]. In a cross-sectional observational study, 96 normal Iranian subjects 20-53 years old were enrolled. Peripapillary RNFL thickness in one randomly selected eye of each subject was measured by 3D-OCT and also by OCT II. Standard achromatic perimetry, corneal pachymetry and A-scan ultrasonographic biometry were also performed. Other study variables included age, gender, laterality [right versus left eye], refractive error, corneal diameter and disc area. Mean peripapillary RNFL thickness measured by 3D-OCT [75.50 +/- 8.38] micro m was significantly less than that measured by OCT II [144.10 +/- 33.32 pn] [P<0.001]. Using 3D-OCT, no significant difference in peripapillary RNFL thickness was observed by gender [P=0.90] or laterality [P=0.17]; RNFL thickness had no correlation with age [P=0.95], axial length [P=0.32], spherical equivalent refractive error [P=0.21], central corneal thickness [P=0.66] and disc area [P=0.31]. However, a positive correlation was found between peripapillary RNFL thickness and corneal diameter [P=0.03]. 3D-OCT seems to yield lower RNFL thickness values as compared to OCT II. It seems advisable to obtain separate baseline measurements when using different generations of OCT machines

Sex bias in primary congenital glaucoma patients with and without CYP1B1 mutations

To investigate variations in sex ratio among Iranian primary congenital glaucoma [PCG] patients with and without mutations in the CYP1B1 gene and to evaluate possible clinical variations associated with sex in these two groups. Phenotypical data on 104 unrelated Iranian PCG patients who had previously been screened for CYP1B1 mutations were analyzed. Emphasis was placed on analysis of sex ratios among patients with and without CYP1B1 mutations. In addition to sex, familial and sporadic incidence and clinical features including age at onset, bilateral/unilateral involvement, corneal diameter, intraocular pressure, and cup-disc ratios were compared between these two groups. Information on phenotypical parameters was available for most but not all patients. Among the 93 PCG patients whose sex was recorded, 57 were male [61.3%] and 36 were female [38.7%] [P=0.03]. Patients with CYP1B1 mutations included 37 male [66.1%] and 29 female [43.9%] subjects [P=0.30], while patients without the mutation included 20 [74.1%] male and 7 [25.9%] female individuals [P=0.013]. Our data did not provide conclusive evidence on difference in severity of the disease between those with and without CYP1B1 mutations, nor between the two sexes. Consistent with data on PCG patients from other populations, the overall incidence of PCG in Iran seems to be higher among male subjects. The difference in incidence between the two sexes was not significant among patients whose disease was due to mutations in CYP1B1. The overall higher incidence of PCG among male subjects seems to be attributable to a higher incidence in male patients not harboring CYP1B1 mutations, suggesting that other genes or factors may be involved in manifestation of PCG phenotypes in a sex dependent manner

Astigmatic outcomes of temporal versus nasal clear corneal phacoemulsification

To compare the astigmatic outcomes of phacoemulsification cataract surgery using temporal versus nasal clear corneal incisions. In a clinical trial, consecutive patients with senile cataracts underwent phacoemulsification and implantation of a hydrophobic acrylic foldable intraocular lens through a horizontal clear corneal incision [temporal in right and nasal in left eyes]. Outcome measures included keratometric astigmatism and surgically induced astigmatism [SIA] calculated by the vector analysis method using the Holladay-Cravy-Koch formula. The nasal and temporal groups consisted of 20 eyes each. Mean preoperative keratometric astigmatism was 0.63 +/- 0.48 D and 0.38 +/- 0.39 D in the temporal and nasal incision groups respectively [P=0.09]. Data on 10 eyes in each study group was available for the six-month analysis. Mean keratometric astigmatism was as follows in the temporal and nasal groups respectively: 0.85 +/- 0.47 D versus 1.95 +/- 0.45 D at 1 week [P < 0.001], 0.73 +/- 0.46 D versus 1.79 +/- 0.55 D at 4 weeks [P < 0.001], and 0.63_0.30 D versus 1.05 +/- 0.56 D at 6 months [P = 0.053] after surgery. SIA at the same follow-up intervals was 0.71 +/- 0.20 D versus 1.80 +/- 0.22 D [P < 0.001], 0.63 +/- 0.20 D versus 1.65 +/- 0.31 D [P < 0.001] and 0.26 +/- 0.46 D versus 0.92 +/- 0.36 D [P=0.002] in the temporal versus nasal incision groups respectively. Temporal clear corneal phacoemulsification induces significantly less astigmatism as compared to similar surgery using the nasal approach

Steroid induced ocular hypertension following myopic photorefractive keratectomy

To determine the incidence of steroid induced ocular hypertension following myopic photorefractive keratectomy [PRK]. Myopic PRK was performed on 506 eyes of 269 patients. Preoperatively, spherical equivalent refractive error ranged from -1.00 to -5.00 diopters [D] and cylinder was less than 4 D. Baseline intraocular pressure [IOP] before PRK and at different time intervals after the procedure was measured by Goldmann applanation tonometry. IOP readings were corrected according to central corneal thickness as measured by Orbscan pachymetry. For the purpose of the study, corrected IOP >21 mmHg was considered as ocular hypertension. Ocular hypertension developed in 40 [7.9%] eyes overall, which occurred in 16 eyes [40%] 2-3 weeks postoperatively [mean IOP = 23.5 +/- 3.0mmHg], in 20 eyes [50%] after 4-6 weeks [mean IOP = 25.1 +/- 4.2 mmHg] and in 4 eyes [10%] 8-12 weeks following PRK [mean IOP = 29.0 +/- 3.1 mmHg]. There was no correlation between the level of IOP rise and preoperative spherical equivalent refractive error. IOP recovered to normal in all eyes after discontinuation of topical steroids and initiation of anti-glaucoma medications. Mean duration of IOP normalization was 28.5 +/- 27.7 [range 7-108] days and no instance of steroid-induced glaucoma was observed in any patient. Topical steroids may cause ocular hypertension following PRK. Early detec-tion, prompt treatment and close follow-up are recommended. We suggest measuring IOP in post-PRK patients no later than 10 to 14 days after initiation of corticosteroid treatment

Short-term results of two treatment regimens in ocular toxoplasmosis: trimethoprim/sulfamethoxazole versus pyrimethamine and sulfadiazine

To compare the efficacy of classic treatment for ocular toxoplasmosis [pyrimethamine, sulfadiazine and prednisolone] with a regimen consisting of trimethoprim/sulfamethoxazole [TMP/SMX] [co-trimoxazole] plus prednisolone. In a prospective randomized single-blind clinical trial, 59 patients with active ocular toxoplasmosis were randomly assigned to two treatment groups: 29 were treated with pyrimethamine/sulfadiazine and 30 patients received TMP/SMX. Treatment consisted of six weeks of treatment with antibiotics plus steroids. Anti-toxoplasmosis antibodies [IgM and IgG] were measured using ELISA. Outcome measures included changes in retinochoroidal lesion size after six weeks of treatment, visual acuity before and after intervention, adverse drug reactions during follow up and rate of recurrence. Active toxoplasmosis retinochoroiditis resolved in all patients over six weeks of treatment with no significant difference in mean reduction in retinochoroidal lesion size between the two treatment groups [61% reduction in the classic treatment group and 59% in the TMP/SMX group, P=0.75]. Similarly no significant difference was found in visual acuity after treatment between the two groups [mean visual acuity after treatment was 0.12 LogMAR [20/25] in classic treatment group and 0.09 LogMAR [20/25] in TMP/SMX group, P=0.56]. Adverse events were similar in both groups with one patient in each suffering from any significant drug side effects, The overall recurrence rate after 14 months of follow up was 6.7% with no significant difference between the treatment groups [P = 0.48]. Drug efficacy in terms of reduction in retinal lesion size and improvement in visual acuity was similar between a regimen of TMP/SMX and the classic treatment of ocular toxoplasmosis with pyrimetbamine and sulfadiazine. Therapy with TMP/SMX appears to be an acceptable alternative for the treatment of ocular toxoplasmosis

Comparison of two methods for upper lid fascia lata sling in congenital blepharoptosis: a randomized clinical trial

To compare the results of two different methods of upper lid sling with autogenous fascia lata in the treatment of congenital ptosis. In a randomized clinical trial, patients with congenital upper lid ptosis and poor levator function [<4mm] were randomly assigned to two different methods of upper lid sling: group A, bitriangular fascia sling [modified Crawford method] and group B, monotriangular fascia sling [modified Fox method]. This study included 30 upper eyelids [15 eyelids in each surgical group] of 19 patients [8 unilateral and 11 bilateral cases] with congenital ptosis. Mean increase in eyelid fissure height was 2.7 +/- 2.3 mm in group A and 3.4 +/- 2.2 mm in group B, respectively. Change in eyelid fissure in both groups was significant [P<0.001, paired t-test] but intergroup difference was not [P=0.4, independent sample t-test]. Early complications such as corneal epithelial defects and entropion, and late complications such as undercorrection were comparable in the two groups. No patient experienced recurrent ptosis requiring reoperation in either group. The monotriangular method of upper lid fascia sling can be used instead of the more popular bitriangular method. Advantages include less need for fascial tissue, less periocular scar formation and a shorter period of anesthesia

Intravitreal bevacizumab [avastin] injection for neovascular glaucoma

To report two cases with neovascular glaucoma secondary to ischemic central retinal vein occlusion [CRVO] who were treated with intravitreal bevacizumab. Two patients were referred for neovascular glaucoma following CRVO. Visual acuity was light perception. Both eyes had extensive iris neovascularization [NVI], synechial angle closure and high intraocular pressure [IOP] in spite of anti-glaucoma medications. After obtaining informed consent both eye received an intravitreal injection of 2.5 mg [0.1 ml] bevacizumab [Avastin]. Both eyes demonstrated dramatic IOP reduction together with decreased severity and extent of NVI during 4 weeks of follow up. Visual acuity remained unchanged. Despite the dramatic short-term response in terms of IOP reduction and regression of neovascularization, due to limited clinical experience, one should consider this novel indication for bevacizumab cautiously