Assessing the Impact of Tropicamide on Anterior Segment Parameters in Diabetic Patients: A Randomized Clinical Trial.

INTRODUCTION: Evaluation of anterior segment parameters is crucial in ophthalmic procedures such as intraocular surgeries and contact lens fitting. However, the use of tropicamide in diabetic patients presents challenges due to its potential impact on biometric measurements. This study aims to investigate and compare the effects of 0.5% and 1% tropicamide on anterior segment parameters in diabetic patients. METHODS: This double-masked randomized clinical trial enrolled 98 patients with diabetes mellitus. Participants were randomly assigned to receive either 0.5% or 1% tropicamide. Anterior segment parameters were measured using Pentacam HR (Oculus Optikgeräte GmbH, Wetzlar, Germany) before and 30 minutes after tropicamide administration. Parameters included anterior chamber depth (ACD), anterior chamber volume (ACV), anterior chamber angle (ACA), keratometry, central corneal thickness (CCT), white-to-white distance (WTW), and pupillary diameter (PD). RESULTS: Both concentrations of 0.5% and 1% tropicamide induced significant changes in anterior segment parameters. There was a notable increase in PD (2.99 ± 0.62, 3.11 ± 0.55, respectively, both P-values < 0.001), ACD (both 0.10 ± 0.05, both P-values < 0.001), ACV (16.69 ± 9.56, 17.51 ± 9.26, respectively, both P-values < 0.001), and WTW (0.06 ± 0.14, 0.03 ± 0.30, respectively, both P-values < 0.001), along with a decrease in ACA (-3.50 ± 10.65, -3.30 ± 6.87, P-value < 0.001 and P-value=0.001, respectively), and CCT (-6.10 ± 8.06, -6.39 ± 9.97, respectively, both P-values < 0.001) post-dilation. However, no significant changes were observed in keratometry (front Km (-0.03 ± 0.19, -0.04 ± 0.21, respectively), back Km (0.01 ± 0.05, 0.004 ± 0.05, respectively), P-values> 0.05). CONCLUSION: Both concentrations of tropicamide exhibited comparable effects on anterior segment parameters in diabetic patients. These post-dilation changes should be considered for accurate intraocular lens power calculation and decision-making for cataract, phakic intraocular lens, and refractive surgeries.

The Role of Optical Coherence Tomography in the Early Detection of Chiasmal Compression: Hypophyseal Adenoma Presenting With Bitemporal Nerve Fiber Layer Thinning.

Hypophyseal adenomas can present with or without minimal visual disturbances. We present a case of a 40-year-old male with a hypophyseal adenoma, highlighting bitemporal peripapillary retinal nerve fiber layer (NFL) thinning on optical coherence tomography (OCT) as a major sign of chiasmal damage despite minimal asymmetrical nonspecific changes detected on initial visual field testing. The bitemporal NFL thinning prompted further evaluation with MRI, which confirmed the presence of a macroadenoma of the hypophysis. Despite the large adenoma, treatment with cabergoline led to regression, and the patient's visual field improved. This case underscores the importance of OCT in detecting subtle structural changes associated with pituitary tumors, as it can facilitate early diagnosis and prompt intervention for optimal visual outcomes.

Enhancing Precision: A Visual Guide to Drill-Assisted External Dacryocystorhinostomy Surgery.

This technical report aims to provide a visual guide to the drill-assisted external dacryocystorhinostomy (DCR) technique with silicone intubation. Through a step-by-step video demonstration, it addresses inherent documentation challenges and highlights crucial considerations. A critical aspect of the procedure's success lies in creating a clear space around the drilling area to prevent thermal burns and soft tissue wrapping around the burr. Additionally, it emphasizes the careful use of smaller burr diameters and the importance of drilling techniques, advocating for minimal perpendicular drilling while maintaining rotational polishing movements to minimize the risk of rapid penetration and potential nasal mucosal injury. The thermal cauterization of perforating nutrient vessels during bone drilling offers a significant advantage in reducing the risk of bleeding. A review of existing limited studies comparing drill-assisted and conventional external DCR reveals advantages such as shorter surgical duration, lower intraoperative hemorrhage rate, more regular osteotomy edges, increased ostomy patency, and potential prevention of soft tissue or mucosal injuries. Nonetheless, achieving these benefits necessitates enhanced hand and foot coordination. However, despite these benefits, a noticeable gap exists in the literature concerning comprehensive studies and comparative analyses. Furthermore, exploring the associated cost and learning curve of adopting this surgical technique is essential. This report aims to fill the existing gap in the literature and serve as a visual reference for surgeons interested in adopting drill-assisted external DCR.

Anterior-Segment Optical Coherence Tomography Unlocks Novel Perspectives: Lacking Iris Anterior Limiting Layer Signal in Uveitis.

Chronic uveitis, a challenging intraocular inflammatory condition, presents complexities in diagnosis and management due to its diverse etiologies and manifestations. Anterior-segment optical coherence tomography (AS-OCT) has emerged as a pivotal tool in evaluating uveitis, offering high-resolution imaging of anterior segment structures. We present the case of a 49-year-old man diagnosed with neurosarcoidosis and chronic intermediate uveitis, where AS-OCT revealed unique findings. Clinical examination identified a Koeppe nodule. AS-OCT evaluation unveiled hyperreflectivity in the iris stroma and the adjacent nodule. Notably, AS-OCT documented the absence of the hyperreflective anterior limiting layer signal, a novel observation in uveitis assessment. This unprecedented finding underscores the significance of AS-OCT in elucidating uveitis pathophysiology and emphasizes its potential in refining diagnostic and therapeutic strategies for this complex ocular condition.

Ocular Rosacea: Don't Forget Eyelids and Skin in the Assessment of This Stubborn Ocular Surface Disease.

Ocular rosacea, a subset of rosacea affecting the ocular surface, poses a diagnostic challenge due to its elusive presentation and overlapping symptoms with other ocular surface diseases (OSDs). This report emphasizes the critical role of a comprehensive evaluation, particularly focusing on eyelid and skin assessment, in diagnosing and effectively managing ocular rosacea-related ocular surface symptoms. The case study highlights a 69-year-old female initially diagnosed with common dry eye disease, subsequently identified with ocular rosacea following a meticulous examination revealing subtle ocular and skin manifestations. Treatment encompassed a tailored approach combining systemic and local therapies, emphasizing proper eyelid hygiene. Objective improvements were observed in ocular surface parameters and patient-reported symptom scores, showcasing the significance of an integrated approach addressing ocular and dermatological aspects in managing ocular rosacea. This report underscores the importance of heightened clinical suspicion, thorough assessments, and comprehensive management strategies in optimizing outcomes for patients with OSD, particularly ocular rosacea.

Atypical Ocular Toxoplasmosis: Multifocal Segmental Retinal Arteritis (Kyrieleis Arteritis) and Peripheral Choroidal Leision.

A 45-year-old immunocompetent man with a two-week history of unilateral painful red eye was referred to the university hospital for further investigation. High intraocular pressure, corneal edema, large pigmented keratic precipitates, cells and flares in the anterior chamber, patches of iris transillumination with atrophy, multifocal segmental retinal arteritis (SRA) or Kyrieleis arteritis, and peripheral choroidal elevation with overlying vitritis without adjacent old scars were observed. Toxoplasmosis, varicella-zoster virus, herpes simplex, and cytomegalovirus serologies (IgG) were positive. More detailed history-taking revealed that the patient consumed grilled rats in Ghana where rats are eaten more regularly. Toxoplasmosis diagnosis was assumed. The patient was successfully treated according to local guidelines with azithromycin 500 mg/day for five weeks. No recurrence or new lesion was observed during the six-month follow-up period.

Accelerated Recovery: The Role of Oral Steroid in the Management of Herpes Zoster Ophthalmicus-Related Ophthalmoplegia.

The use of systemic steroids in managing herpes zoster ophthalmicus-related ophthalmoplegia (HZORO) remains a topic of debate. Here, a case involving third nerve HZORO is highlighted, where a regimen of oral valacyclovir followed by a brief course of oral steroids resulted in significant improvement within days and complete resolution of the palsy within a month of initiating the treatment. This case underscores the need for randomized controlled studies to definitively determine the efficacy of systemic steroids in alleviating or shortening the course of HZORO.

Comparison between 90-degree and 360-degree selective laser trabeculoplasty (SLT): A 2-year follow-up.

PURPOSE: To compare the effect of 90- and 360-degree selective laser trabeculoplasty (SLT) as primary or supplement therapy in patients with glaucoma and ocular hypertension (OHT). METHODS: Patients (>30 years old) with OHT, primary open-angle glaucoma (OAG), pigmentary glaucoma or pseudoexfoliative glaucoma were enrolled in a prospective randomized clinical trial. Patients were sequentially randomized to either 90- or 360-degree SLT. Their intraocular pressure (IOP) was monitored. RESULTS: The survival periods (in days) of the two extents (90 or 360 degrees) of treatment were not statistically significantly different (p = 0.85); only pretreatment IOP level could predict survival of treatment (p = 0.02). CONCLUSION: The 90-degree SLT is as effective as 360-degree SLT. Further studies are warranted to confirm the findings. High baseline IOP could be a factor that predicts treatment success.

An Update on Optical Coherence Tomography Angiography in Diabetic Retinopathy.

Optical coherence tomography angiography (OCTA) is a novel non-invasive imaging modality for 3-dimensional visualization of retinal and optic nerve capillary networks. In this article, a comprehensive review of relevant original articles in the PubMed database was performed using the search terms "diabetic retinopathy," "diabetic macular edema," "diabetes mellitus," and "optical coherence tomography angiography." OCTA was found to detect microvascular changes early in diabetes mellitus, even before they become clinically evident. Morphological and qualitative assessment of vascular changes can help to determine the pathophysiological processes, activity, treatment, and follow-up of diabetic retinopathy (DR). Vessel density and foveal avascular zone are the most investigated quantified indices shown to be early predictors of DR, correlated to DR severity and visual function, and useful in predicting response to treatment. OCTA has shown to be a promising alternative to fluorescein angiography in the management of DR. Further studies are warranted to determine the role of OCTA in the routine clinical management of DR.

Correlation between cystatin-C, acute phase reactants, and retinopathy severity in diabetic patients / 国际眼科杂志(Guoji Yanke Zazhi)

·AIM: To evaluate correlation of cystatin-C (Cys-C) with severity of diabetic retinopathy (DR) and acute phase reactants, including erythrocyte sedimentation rate (ESR) and high-sensitivity C-reactive protein(hs-CRP). ·METHODS: All diabetic patients who were referred for diabetic retinopathy (DR) screening during 1mo were enrolled. Demographic data were recorded. All patients have undergone full ophthalmic exam. At the same day, all patients were tested for hemoglobin A1c (HbA1c), ESR,hs-CRP,and Cys-C serum levels. · RESULTS: Sixty seven diabetics were enrolled, including 19 (28.3%) without retinopathy, 22 (32.8%) non - proliferative retinopathy, and 26 ( 38. 8%) proliferative retinopathy patients. The mean age, sex distribution, mean duration of diabetes, prevalence of hypertension and dyslipidemia, smoking status and HbA1c levels were not significantly different among the three groups. The mean levels of Cys - C increase significantly as retinopathy progress [1.1 ± 0. 48; 1. 22 ± 0.38;1.71 ± 0.92 (P=0.007), respectively]. In multiple regression analysis, just Cys - C was significantly associated with severity of DR (P=0.025). ·CONCLUSIONS: This study revealed that serum levels of Cys-C increase while DR progress independently of acute phase reactants. Therefore, it could be used as an associated marker by primary care physicians to distinguish patients at higher risk of severe DR. Larger randomized studies are warranted to confirm findings. Reviewing physiological role of the Cys-C, we proposed that the Cys-C may be a protective response to catalytic stress rather than being a pathogenic factor in microangiopathies.

Missing Globe: A Case of Severe Head Trauma, Eyelid Laceration, and Traumatic Enucleation.

We report an unusual periocular injury in a 19-year-old motorcycle rider during an accident. The patient had lacerations on the right upper and lower eyelids and the globe was enucleated en bloc. Despite disorganization of the eyelids and orbit, reconstruction of the eyelids and anophthalmic socket was successful. The primary reconstruction of the anophthalmic socket in the traumatic enucleation is a real challenge, especially when the conjunctival and the orbital tissues are missing or disorganized. It is proposed to utilize the optic nerve regeneration techniques in the cases of traumatic enucleation when the globe is intact. However, in the current case, the globe was unavailable.

Refractive outcomes following the treatment of retinopathy of prematurity in the anti-VEGF era: a literature review.

A growing body of evidence indicates that antivascular endothelial growth factor (VEGF) therapy is effective in the treatment of retinopathy of prematurity (ROP). We conducted a comprehensive literature review on refractive outcomes of anti-VEGF treatments compared to laser treatment or a combination of laser therapy and anti-VEGF injections. Of the 9 studies analyzed, the final mean refractive error was myopic in 3 studies (37%) with IVB monotherapy, 7 studies (87.5%) with laser photocoagulation, and 1 study (50%) with combined therapy. In comparing IVB with laser monotherapy, 6 of 7 studies (86%) reported that final refractive error was significantly more myopic (>1 D) after laser treatment. No study was graded as high quality, and only a single article provided moderate quality of evidence.

Ultra-wide-field imaging in diabetic retinopathy; an overview.

PURPOSE: To present an overview on ultra-wide-field imaging in diabetic retinopathy. METHODS: A comprehensive search of the pubmed database was performed using the search terms of "ultra-wide-field imaging", "ultra-wide-field fluorescein angiography" and "diabetic retinopathy". The relevant original articles were reviewed. RESULTS: New advances in ultra-wide-field imaging allow for precise measurements of the peripheral retinal lesions. A consistent finding amongst these articles was that ultra-wide-field imaging improved detection of peripheral lesion. There was discordance among the studies, however, on the correlation between peripheral diabetic lesions and diabetic macular edema. CONCLUSIONS: Visualization of the peripheral retina using ultra-wide-field imaging improves diagnosis and classification of diabetic retinopathy. Additional studies are needed to better define the association of peripheral diabetic lesions with diabetic macular edema.

Posterior sub-tenon's bevacizumab injection in diabetic macular edema; a pilot study.

PURPOSE: To evaluate the short-term results of sub-tenon's injection of bevacizumab in patients with clinically significant macular edema (CSME). METHODS: In this prospective non-comparative interventional case series, sub-tenon's injection of 2.5 mg/0.1 ml bevacizumab was performed for eyes with CSME. Macular thickness and best corrected visual acuity measurements were performed before and one month after injections. RESULTS: Nineteen eyes of twelve patients with a mean age of 59.8 ± 5.7 years were evaluated. Thirteen eyes (68.4%) had center-involving macular edema. No significant difference was observed between pre- and post-injection central subfield retinal thickness measurements (P = 0.3). Central subfield thickness measurements improved or remained unchanged in 13 eyes (68.4%). Baseline BCVA of 0.48 ± 0.35 LogMAR improved to 0.36 ± 0.26 LogMAR after injection (P = 0.01). Improvement of >2 lines in BCVA was found in 5 eyes (26.3%), and no eye lost >2 lines of BCVA. No complication associated with sub-tenon's injection was observed. CONCLUSION: Sub-tenon's injection of bevacizumab resulted in significant short-term visual improvement in eyes with CSME. Retinal thickness changes were not significant.

Effect of grid decentration on macular thickness measurements in normal subjects and patients with diabetic macular edema.

PURPOSE: To evaluate the effect of optical coherence tomography (OCT) grid decentration on macular thickness measurements in healthy subjects and patients with diabetic macular edema. METHODS: In this prospective study, 3D spectral-domain OCT images of 51 eyes with clinically significant diabetic macular edema and 29 healthy eyes were assessed. In each eye, the macular Early Treatment Diabetic Retinopathy Study grid was evaluated for decentration. After grid adjustment, changes in central subfield thickness (CST) and central subfield volume (CSV) measurements were recorded. Changes >1 µm and >8.5 µm in CST were considered as grid decentration and clinically significant grid decentration, respectively. RESULTS: Grid decentration was found in 10 normal eyes (34.6%) and 32 clinically significant macular edema (CSME) eyes (62.7%, p = 0.01). Clinically significant CST changes were found in 3 normal eyes (10.3%) and 23 CSME eyes (45%, p = 0.001). The mean change in CST after grid adjustment was 6.4 ± 5.8 µm and 24.7 ± 27 µm in normal and CSME eyes (p = 0.04). Age, sex, and CST had no statistically significant effect on grid decentration in normal and CSME eyes. Best-corrected visual acuity was significantly worse in eyes with grid decentration (0.75 ± 0.55 vs 0.42 ± 0.22 logMAR, p = 0.02) and clinically significant grid decentration (0.81 ± 0.6 vs 0.45 ± 0.27 logMAR, p = 0.01). Change in CSV was detected in 3 normal eyes (10.3%) and 24 CSME eyes (47%, p = 0.001). CONCLUSIONS: Grid decentration occurs in a large number of OCT thickness maps and leads to significant error in macular thickness measurements. The effect is more prominent in patients with CSME.

Macular thickness measurement in clinically significant macular edema before and after meal.

PURPOSE: To evaluate the macular thickness changes in diabetic macular edema after meal. METHODS: In this prospective case series, macular thicknesses of diabetic patients with clinically significant macular edema (CSME) were measured after 7 h of fasting and repeated 2 h after breakfast. RESULTS: Thirty six eyes of 20 diabetic patients were evaluated. The mean central subfield thickness (CST) and maximum retinal thickness (MRT) significantly decreased after meal (mean change of -10.3 ± 14.3 µm and -13.1 ± 12.7 µm, respectively, both P < 0.001). A decrease in CST and MRT values was found in 23 (63.8%) and 28 (77.7%) eyes, respectively, and no eye had an increase in retinal thickness measurements. Significant correlation was found between CST and MRT change and fasting thickness measurements (P = 0.001 and P = 0.01, respectively) and intraretinal cystic spaces (P = 0.001 and P = 0.03, respectively). Mean MRT change was significantly higher in the presence of subretinal fluid (P = 0.01). CONCLUSION: Retinal thickness measurements may change after meal. So, fasting state of diabetic patient should be considered in measurement of macular thickness of patients with CSME.

Physicians awareness on primary immunodeficiency disorders in Iran.

Primary immunodeficiency diseases (PIDs) consist of a group of genetic disorders that predispose the patients to immune-mediated complications. The aim of this study was to assess the knowledge of Iranian general practitioners and pediatricians about PIDs.A questionnaire consisting 52 closed questions on clinical symptoms, laboratory data, associated syndromes and management of PIDs patients was made valid and reliable by a pair pilot study. Then the questionnaire was filled by pediatricians, general practitioners and pediatric residents from different regions of Iran. Totally, 333 physicians (50 general practitioners, 52 pediatric residents, 182 pediatric specialists, and 49 pediatric sub specialists) participated in this study. The mean total score was 55.9±14.3 (i.e. about 29 correct answers out of 52 questions). One hundred and five participants (31.9%) answered correctly more than two third of all questions. In order to qualitatively compare the groups a ranking system was used. Total scores was significantly different between physicians groups (p<0.01). Pediatric subspecialties gained the highest rank, which was significantly over the other participants (p<0.05). This study showed that there is a considerable lack of awareness on PIDs in physicians. This may be one of the major reasons in late diagnosis and the delay in adequate treatment deteriorating patients' morbidity and mortality. Retraining classes and reconsidered educating schedules are needed as an efficient strategies and improving physicians' knowledge about PIDs.