[Deep anterior lamellar keratoplasty: review]

Lamellar keratoplasty [LK] has been a well established technique of corneal transplantation. Recent improvements in surgical instruments have revolutionized the procedure introducing a new technique employing deeper corneal dissection. This review article describes the indications, techniques, outcomes and complications of deep anterior LK

[Effect of corneal opacity in childhood on axial globe length in adulthood]

To evaluate the effect of childhood corneal opacity on the anteroposterior length of the globe in adulthood. Twenty-three patients with significant unilateral corneal opacity which had developed before the age of 6 years and the normal fellow eyes [controls] were evaluated. A comprehensive ocular examination including measurement of anterioposterior length and anterior chamber depth was performed. Mean age was 65.9 +/- 12.9 years. Mean axial length was 25.45 +/- 2.47 mm in affected eyes vs 22.85 +/- 3.34 mm in normal fellow eyes [P=0.001]. The difference in axial length was attributed to elongation of the vitreous cavity in affected eyes [18.91 +/- 2.82 vs 15.71 +/- 2.73 mm, P<0.001]. Corneal opacity in childhood can result in axial myopia in adulthood due to elongation of the posterior segment

[ case of traumatic carotid cavernous fistula]

To describe a complicated case of traumatic carotid-cavernous fistula [CCF] and our management strategy. A 13-year-old patient was referred one month following a car accident and facial trauma with severe proptosis, chemosis and limitation of ocular movement. Presence of murmur and an enlarged superior ophthalmic vein on orbital imaging suggested an arteriovenous fistula. The patient underwent transarterial fistula ballooning which resulted in alleviation of the fistula and improvement of signs and symptoms. Orbital signs and symptoms following trauma may indicate an arteriovenous fistula

[Corneal endothelial cell loss after phacoemulsification in relation to hydrodynamic parameters: low versus high vacuum techniques]

To evaluate the effect of vacuum and flow rate on endothelial cell loss after high versus low vacuum phacoemulsification. This randomized clinical trial was performed on 60 eyes of 60 patients with moderate lens opacity [nuclear sclerosis 3+]. All surgeries were performed by one experienced surgeon using stop and chop technique with Sovereign white star machine [AMO]. Patients were randomly assigned to high and low vacuum techniques in equal numbers. The machine was set on 400 mmHg vacuum and 40 ml/min flow rate in the high vacuum group and on 200 mmHg vacuum and 20 ml/min flow rate in the low vacuum group during the chop stage. All other parameters were similar in both groups. Phacotime multiplied by average ultrasound power was defined as total ultrasound energy. Specular microscopy was performed before and 1, 6 and 12 weeks after the operation. After 12 weeks, mean endothelial cell loss was 9.0 +/- 4.0% versus 9.6 +/- 4.6% in the low and high vacuum groups, respectively [P=0.6]. Mean ultrasound power was 9.2 +/- 4.3% and 13.1 +/- 4.6% in the low and high vacuum groups, respectively [P=0.001]. Mean phacotime was 1.28 +/- 1.0 minutes in the low vacuum group versus 0.88 +/- 0.6 minutes in the high vacuum group [P=0.04]. Total ultrasound energy and total fluid volume used [turbulence] during phacoemulsification was similar between the two study groups. Total ultrasound energy was the most powerful predictor of endothelial cell loss [R2=0936, P=0.001], but turbulence was not a significant predictor [R2=0.924, P=0.1]. No significant difference in endothelial cell loss was found between low and high vacuum techniques. This study supports advice to junior surgeons to choose lower hydrodynamic phaco machine parameters; experienced surgeons can choose higher parameters to reduce phacotime

[Keratolimbal allograft in total limbal stem cell deficiency]

To investigate the outcomes of keratolimbal allograft [KLAL] for treatment of total limbal stem cell deficiency [LSCD]. Patients with total LSCD and adequate tear production were included. A total of 27 KLAL procedures were performed in 21 eyes of 20 patients with LSCD. Immunosuppression was achived using mycophenolate and cyclosporine. Main outcome measure was improvement in vision; in addition, KLAL survival and post operative complications were studied. Mean follow up period was 22.14 +/- 11.83 months [range 6-39]. Mean visual acuity improved from 2.53 +/- 0.21 to 1.49 +/- 0.77 LogMAR [P<0.0001]. Six KLALs never re-epithelialized and were considered as primary failures. Mean KLAL survival was 14.23 +/- 1.5 months. Graft survival rate was 61.9% at 1 year and 31% at 20 months. Complications included corneal ulcers in 6, glaucoma in 2 and scleral thining in 1 case. Keratolimbal allograft surgery is successful in the short term for visual rehabilitation of patients with total limbal stem cell deficiency

[Combined sutureless 25-gauge vitrectomy, phacoemulsification, and posterior chamber intraocular lens implantation for management of uveitic cataracts associated with posterior segment disease]

To report the visual outcomes and complication of one-stage surgery for management of uveitic cataracts associated with posterior segment disease. In this retrospective interventional case series, 19 eyes of 19 patients with posterior segment involvement due to chronic uveitis underwent sutureless scleral tunnel incision phacoemulsification combined with total vitrectomy using 25-gauge instruments and posterior chamber intraocular lens [PCIOL] implantation. Membrane peeling and endolaser photocoagulation were performed when indicated. Outcome measures were visual acuity, inflammatory activity, macular edema and surgical complications. After a minimum 12-month follow-up, visual acuity was >/=20/100 in 12 eyes [63.2%] and >/=20/40 in 6 eyes [31.6%]. One grade of decrease in postoperative inflammatory activity was observed in 8 eyes [42.1%]. Cystoid macular edema was present in 16 eyes preoperatively and in 12 eyes postoperatively. Early postoperative complications included transient corneal edema in 10 eyes [50.3%], posterior synechia in 9 eyes [47.3%] and fibrin reaction in 3 eyes [15.8%]. Glaucoma was the most common late postoperative complication [3 eyes, 18.8%]. Nine eyes [47.4%] needed YAG laser capsulotomy during the first year. Combined sutureless 25-gauge vitrectomy, phacoemulsification, and PCIOL implantation may be a well tolerated procedure with an acceptable complication rate for visual restoration in selected uveitic eyes with significant cataract and coexisting posterior segment disease

[Results of descemet`s stripping with endothelial keratoplasty [dsek] in patients with bullous keratopathy after cataract surgery]

To evaluate the anatomical and visual outcomes of Descemet`s stripping with endothelial keratoplasty [DSEK] in patients with bullous keratopathy after cataract surgery. The study was performed on 20 eyes of 20 patients [13 male, 7 female] with bullous keratopathy [pseudophakic=15, aphakic=5]. Donor lenticule was prepared using a micro keratome [n=12] or manual dissection [n=8]. Patients were excluded in case of extensive corneal scarring and/or vascularization. DSEK surgery was performed by removal of recipient endothelium and Descemet`s membrane, and replacement by the donor lenticule. Patients were followed at least for 6 months. Mean age at surgery was 64.6 +/- 6.7 years and mean follow up was 7.3 +/- 2.1 months. At final follow up 15 grafts were clear. Failure was seen in 5 cases. Visual acuity LogMAR was 1.96 +/- 0.38 before and 0.52 +/- 0.09 after the procedure [P<0.0001]. Mean topographic keratometry was 46.0 +/- 2.9 D before surgery which reached 44.4 +/- 1.7 D postoperatively [P=0.219]. Preoperative astigmatism was 2.5 +/- 1.7 D which decreased to 1.1 +/- 2.3 D at final follow up [P=0.229]. Mean pre- and postoperative surface regularity index [SRI] were 1.47 +/- 0.60 and 0.43 +/- 0.17, respectively [P=0.006]. No case of endothelial rejection was observed. DSEK surgery is an effective treatment modality in cases of bullous keratopathy after cataract surgery with acceptable anatomical and visual outcomes

[Sensitivity and specificity of confocal scan in the diagnosis of fungal and acanthamoeba keratitis]

To determine the sensitivity and specificity of confocal scan in the diagnosis of fungal and acanthamoeba keratitis based on the results of corneal and/or contact lens case smear and culture. Confocal scan and corneal and/or contact lens case smear and culture were performed in all patients with a clinical diagnosis of infectious keratitis who were referred to Labbafinejad Medical Center from 2004 to 2006. A total of 133 eyes of 133 patients [52% male] with mean age of 48.0+22.6 years [range 9-83] were included in the study. Previous history of contact lens wear, ocular trauma and ocular surgery was present in 21%, 21% and 38.3%, respectively. Overall, corneal and/or contact lens case smear and culture were positive in 71 eyes [53.4%] for bacteria [40 cases], fungi [16 cases] and acanthamoeba [15 cases]. Confocal scan was positive in 50 cases [37.6%] which revealed hyphalike structures in 27 cases [20.3%] and cyst and/or trophozoite-like structures in 23 cases [17.3%]. The sensitivity and specificity of confocal scan were 100% and 84% for diagnosing acanthamoeba keratitis versus 93.4% and 77.8% for diagnosing fungal keratitis, respectively. In vivo corneal confocal scan is a rapid non-invasive tool for the diagnosis of acanthamoeba and fungal keratitis with high sensitivity and specificity based on smear and culture results. It may also be helpful in excluding fungal or acanthamoeba-like structures in cases with negative bacteriological results and in early bacterial keratitis before clarification of microbiologic results

[Eye glasses]

In spite of rapid advances in keratorefractive surgery in recent decades, the most common method for refractive error correction throughout the world is glasses, the discovery of which is attributed to the Persians. Other advantages include protection of the eye against trauma and radiations, correction of phorias and tropias and cosmetic reasons. The purpose of this article is to describe and review different components of glasses [frame, temple and lens], sunglasses, photochromic and polarizing glasses, antireflective and mirror coats, progressive additional lenses and also recommendations about frame selection

Delayed corneal perforation secondary to topical diclofenac use after LASEK

To report a case of delayed corneal perforation secondary to topical diclofenac usage after myopic LASEK and review of literature. A 25-year-old female with history of myopic LASEK 2 months before referred to her surgeon with epithelial defect, stromal thinning and infiltration. She was treated with antimicrobial medications for infectious keratitis for one week. She was then referred to Labbafinejad Medical Center because of lack of response and progressive stromal thinning. Two days after admission, corneal perforation was occurred. Smear and culture of the cornea were negative. She had used topical diclofenac for 6 weeks. After discontinuing the topical medications and conservative measures [oral acetazolamide, patching, simple eye ointment] the perforation started healing. Prolonged use of topical non-steroidal anti-inflammatory drugs after surface ablation may lead to stromal melting and corneal perforation; therefore, such medications should be used cautiously in these patients especially in high risk groups such as rheumatoid arthritis, dry eye syndrome, ocular surface disorders and neurotrophic keratopathy

Primary graft failure and systemic presentations of HSV infection following transplantation of an HSV-contaminated donor cornea

To report a case of primary graft failure [PGF] and systemic manifestations of herpes simplex virus [HSV] infection following transplantation of an HSV-contaminated donor cornea. A 28-year-old male with history of penetrating keratoplasty 12 days before, developed intraocular inflammation with marked anterior chamber reaction, graft edema and elevated intraocular pressure [IOP] together with systemic manifestations such as fever and unilateral cervical adenopathy. Systemic manifestations resolved after a few days but the graft edema was persistent. Regraft was performed after 3 months and the previous donor tissue was evaluated by PCR for cytomegalovirus [CMV] and HSV and was positive for HSV. HSV may be a cause of PGF, which can be transmitted by a contaminated donor cornea to the recipient. This condition may also lead to systemic symptoms

[Initial lacrimal probing after age 15 months]

Purpose: to evaluate the results of lacrinal probing for the first time in the age above 15 months

Methods: we studied the hospital records of 158 eligible patients with epiphora or mucopurulent discharge who underwent probing for the first time

Results: mean age was 3 +/- 4.2 years; 47% were male and 53% were female. In 78% of the cases unilateral probing and in 22% bilateral probing was required. Overall in 75% of cases, probing was successful. The success rate was 72% in unilateral and 82% in bilateral cases. Success rate was not related to age

Conclusion: probing of the lacrimal duct can be successful in congenital nasolacrimal duct obstruction even in higher age groups and if a patient with epiphora is referred for the first time at older ages, it is better to do probing as the first line of treatment; silicone intubation or DCR must be preserved only for failed cases

[Epidemiologic and etiologic characteristics of patients with paralytic strabismus]

Purpose: to evaluate the epidemiologic and etiologic characteristics of patients with paralytic strabismus at Labbafinejad Hospital during the years 2000-2001, Tehran-Iran

Method: as a descriptive study, consecutive cases with extraocular muscles paralysis [according to signs of cranial nerves 3,4, or 6 involvement and negative forced duction test] were enrolled in the study. Age, gender, duration of involvement, past medical history, intensity of muscle paralysis, deviometry, head posture, and etiology were evaluated

Results: of 119 patients [75 male and 44 female] with mean age of 30.58 +/- 22 years, 111 cases [%93.3] had unilateral involvement and 8 cases [%6.7] had bilateral involvement; 103 [%86.6] cases had isolated nerve involvement including sixth nerve paralysis [%33.6], fourth nerve paralysis [%32.7], and third nerve paralysis [%20.2]. The etiology was congenital in 32 patients [%26.9], vascular in 30 patients [%25.2], and traumatic in 27 patients [%22.7]. Mean age was 13.8 +/- 10.3, 56.4 +/- 122, and 27.4 +/- 15.6 in these subgroups, respectively. Other etiologies like unknown, infective, myasthenia gravis, migraine, multiple sclerosis, and tumoral followed in frequency. Over 60% of cases with 4th nerve palsy were operated, of which the most successful method was inferior oblique myectomy. Half of cases with 6th or 3rd nerve palsies were operated and the most common method was R and R

Conclusion: the most common nerve involvement was the 6th nerve. Fourth nerve involvement was the most common etiology in congenital disorders and 6th nerve involvement was the most common in traumatic and vascular disorders