Early Vitrectomy: An Effective Treatment for Acute Postcataract Surgery Endophthalmitis.

Background: Endophthalmitis is a rare but a high morbid complication after cataract surgery, and a gold standard treatment is not recommended yet. In this study, we aim to evaluate the effect of early vitrectomy on the visual acuity of patients with postcataract endophthalmitis. Materials and Methods: This study was a single-arm clinical trial on 27 patients with postcataract surgery endophthalmitis. Early vitrectomy was the intervention. Visual acuity as the primary outcome was evaluated and compared at baseline, at discharge, and 1 and 3 months after the intervention. Results: From 27 patients who included in our study, six patients gain favorable visual acuity of 5/10 and above (success rate = 22%), and four of them have no improvement in their visual acuity. Retinal detachment was reported as a complication in just one case. Negative culture was a predictor for success in terms of visual acuity after the surgery. All patients who gain favorable results, presented in the first 15 days after the cataract surgery. Conclusion: The result of our study showed that, considering complete, early vitrectomy for the treatment of postcataract surgery endophthalmitis, especially for those who presented in the first 15 days of cataract surgery and for those who have negative culture is promising.

Paracentral acute middle maculopathy and COVID-19 vaccination: Causation versus coincidence finding.

The current report is a rare case of paracentral acute middle maculopathy (PAMM) in a previously healthy man following COVID-19 vaccination.

Retinal findings of COVID-19 patients using ocular coherence tomography angiography two to three months after infection: Ocular appearance recovered COVID-19 patient.

PURPOSE: The aim of this study was to evaluate the ocular disorders in COVID-19 patients, two to three months after infection. METHODS: In this cross-sectional, historically controlled study, fifty-one COVID-19 patients were compared with thirty-seven age, and gender-matched healthy individuals. After complete ophthalmological examination, all participants underwent peripapillary and macular optical coherence tomography, and optical coherence tomography angiography (OCTA) measurements (OptoVue Inc, Freemont, CA, USA). RESULTS: The time between the initial onset of symptoms, and ophthalmologic examination was 63.31±15.21 (40-95 days). Ophthalmic examination of all the recovered COVID-19 patients was within normal range. None of the peripapillary and macular OCTA parameters were significantly different between the two groups with pairwise comparisons, but after adjusting for age, gender, axial length, and signal strength index (SSI), recovered COVID-19 eyes showed a significant increase in peripapillary retinal nerve fiber (RNFL) thickness, superficial, and deep macular vessel densities in parafoveal and perifoveal regions compared with healthy control eyes (p<= 0.05). Inner retinal thickness overall is higher in recovered COVID-19 eyes compared to healthy eyes after adjustment. CONCLUSION: Patients with moderate-intensity SARS-CoV-2 pneumonia had altered peripapillary and macular vessel density compared to healthy subjects. Further investigation is warranted to analyze the correlation of these changes with disease severity as well as evolution of these changes over time.

Comparison of peripapillary and macular vascular density in primary open-angle glaucoma, pseudoexfoliation glaucoma, and normal control eyes.

PURPOSE: To compare the optical coherence tomography angiography (OCT-A) of the macula, and optic disc in primary open-angle glaucoma (POAG), pseudoexfoliation glaucoma (PXG), and normal eyes. METHODS: In this observational, cross-sectional study, Sixty-five eyes with POAG, 61 eyes of age, and mean deviation (MD) from standard automated perimetry matched PXG patients, and 45 normal control eyes underwent OCT-A using AngioVue, and optic disc-associated vessel density (VD), macular-associated VD, Foveal avascular zone (FAZ) area, FAZ perimeter (PERIM), and vessel density within a 300 µm wide region of the FAZ (FD) were compared between groups. RESULTS: Peripapillary OCT-A parameters were significantly different among normal, and glaucomatous eyes with the highest values in the control eyes, but none of the peripapillary OCT-A parameters except inside disc VD was statistically significantly different between the PXG eyes, and POAG eyes. Correlation analysis revealed significant correlation between mean retinal nerve fiber layer (RNFL) and peripapillary VD in control (r = 0.427, P = 0.006), PXG (r = 0.82, P<0.001), and POAG (r = 0.79, P<0.001) eyes. PXG eyes exhibited significantly lower superficial, and deep macular vessel densities in parafoveal and perifoveal regions compared with POAG eyes after adjustment (p<= 0.05). Overall, moderate /severe PXG eyes had lower superficial, and deep vessel densities in parafoveal and perifoveal regions compared to mild PXG. CONCLUSION: Peripapillary VD (inside disc), and macular vessel densities (parafovea and perifovea) demonstrate a significant difference in age and glaucoma severity-matched POAG and PXG eyes. Moderate/advance glaucomatous eyes, exhibit significant damage to the superficial and deep macular vascular structures.

The effect of silicone oil tamponade on retinal layers and choroidal thickness in patients with rhegmatogenous retinal detachment: a systematic review and meta-analysis.

BACKGROUND: To evaluate the effects of intravitreal silicone oil (SO) on the retinal and choroidal thickness in eyes with rhegmatogenous retinal detachment (RRD). METHODS: A literature search was performed in Web of Science, Scopus, ProQuest, Embase, Clinical Key, Science Direct, Cochrane Library, and Springer, as well as Persian databases, including IranDoc, MagIran, SID, MOH thesis, and MOH articles until June 2020. Two reviewers independently searched and extracted the data. RESULTS: Sixteen studies (n = 391) met the inclusion criteria. The meta-analysis showed that the SO tamponade could significantly reduce the central macular thickness (CMT) in patients with RRD as compared to gas tamponade WMD = - 14.91; 95% CI: - 22.23, - 7.60; P < 0.001, I2 = 71%). No significant change was found in CMT between the eye with SO tamponade (after SO removal) and the fellow healthy eye in patients with RRD (WMD = - 3.52; 95% CI: - 17.63, 10.59; I2 = 68.6%). Compared to the preoperative stage, the SO tamponade could significantly reduce the subfoveal choroidal thickness in patients with RRD (WMD = - 18.67, 95% CI: - 30.07, - 1.28; I2 = 80.1%). However, there was no significant difference in the subfoveal choroidal thickness before and after SO removal (WMD = - 1.13, 95% CI: - 5.97, 3.71; I2 = 87.6%). CONCLUSION: The SO tamponade had a significant effect on the reduction of retinal layers and the subfoveal choroidal thickness.

Clinical efficacy of inferior peripheral irido-capsulo-hyaloidotomy for pseudophakic malignant glaucoma.

PURPOSE: The present research aimed to investigate the effects of Inferior peripheral irido-capsulo-hyaloidotomy for the management of pseudophakic malignant glaucoma. METHOD: Ten pseudophakic eyes with aqueous misdirection were diagnosed between September 2017 and December 2018 (10 eyes of 8 patients), which were included in the prospective consecutive case series study. Seven eyes underwent Inferior laser peripheral irido-capsulo-hyaloidotomy, and three eyes underwent pars plana vitrectomy, zonulo-capsulo-hyaloidectomy, and inferior iridectomy. RESULTS: Eight eyes (80%) had angle-closure glaucoma. The mean duration of the follow-up was 12.25 ± 3.05 months (ranging from 10-18 months). The patients had a mean age of 69.25 ± 6 years. The IOP at the onset of malignant glaucoma was found to be 33.8 ± 5.5 mmHg, which was reduced to 13.9 ± 2.7 mmHg at the final visit (P value = 0.002). The reduction in the number ± SD of anti-glaucoma medications (3.3 ± 0.48 to 1.4 ± 0.51) and improvement in mean ± SD LogMAR visual acuity (1.2 ± 0.06 to 0.61 ± 0.26) between the onset and final visit were significant (p = 0.004 and P = 0.005, respectively). All the patients responded to Inferior peripheral irido-capsulo-hyaloidotomy (with YAG laser or with the surgical procedure), which led to a significant reduction in intraocular pressure (IOP) and deepening of the anterior chamber. CONCLUSION: The success rate of peripheral irido-capsulo-hyaloidotomy with laser or surgical procedure in the inferior quadrant was high regarding pseudophakic malignant glaucoma patients. The establishment of a patent inferior communication between the vitreous cavity and the anterior chamber was the main component in the treatment of pseudophakic malignant glaucoma patients.

Intravitreal vascular endothelial growth factor (VEGF) inhibitor injection in patient during pregnancy.

PURPOSE: To report the clinical course of a woman treated with intravitreal bevacizumab during pregnancy. CASE REPORT: A 27-year-old female with poorly controlled diabetes and a history of two previous miscarriage was referred to our hospital with sudden deterioration in visual acuity (VA) in her right eye. Ocular findings revealed severe Proliferative Diabetic Retinopathy (PDR) complicated with preretinal hemorrhages in her right eye, and after maximal Panretinal Photocoagulation (PRP) bilaterally, she was treated with intravitreal injection of bevacizumab (IVB) into the right eye. Twenty four hours after the bevacizumab injection, she reported vaginal bleeding, and ultrasound confirmed a 12-week pregnancy of which the patient was unaware. The patient suffered from pregnancy loss. CONCLUSION: Use of intravitreal anti-VEGF by pregnant woman may only be justified if the potential benefit outweighs the potential risk to the fetus and only if clearly needed. Intravitreal bevacizumab during pregnancy in women with a history of miscarriage should be used with caution.

Peripapillary and macular choroidal thickness in both eyes of patients with acute unilateral retrobulbar optic neuritis.

PURPOSE: The purpose of this study was to examine macular and peripapillary choroidal thickness (CT) in patients with acute unilateral retrobulbar optic neuritis. MATERIALS AND METHODS: In this cross-sectional study, 19 patients with acute unilateral retrobulbar optic neuritis were examined. A control group was matched with patients for sex and age. Enhanced depth imaging optical coherence tomography in macula and peripapillary areas in both eyes was performed for evaluation of CT. The CT was measured in subfoveal and other six points of macula and four points of peripapillary areas with a 3.4-mm scan circle centered on the optic nerve head. RESULTS: The mean subfoveal CT was 384.7 ± 101.6 µm, 380.5 ± 109 µm, and 401.2 ± 84.6 µm for affected eye, unaffected fellow eye, and healthy control, respectively. All measurements of macular CT were thinner in the patient group compared with healthy controls. Global peripapillary CT in affected eyes, unaffected fellow eyes, and healthy controls were 202 ± 43.3, 195.1 ± 42.9, and 234 ± 71.2, respectively. The difference between the three groups was statistically significant in the nasal point of peripapillary area (P = 0.023). No correlation was seen between CT and initial visual acuity or duration from symptom onset to medical survey in acute phase of retrobulbar optic neuritis. CONCLUSION: Patients with acute retrobulbar optic neuritis showed no significantly thinner macular and peripapillary CT in both eyes compared with healthy controls.

Serum Level of the Angiotensin-Converting Enzyme in Patients with Idiopathic Acute Optic Neuritis: A Case-Control Study.

PURPOSE: To evaluate the serum level of angiotensin-converting enzyme (ACE) as an important component of the renin-angiotensin system (RAS) in optic neuritis (ON) compared to the healthy control group in the context investigating the possible role of ACE in ON pathogenesis. METHODS: This case-control study was conducted on patients with ON and healthy controls. Serum ACE levels were assessed and compared between the two groups by using commercially available kits by ELISA for ACE. RESULTS: Sixty-five ON patients (75.4% female, mean age 29.70 ± 8.30 years) and 65 controls (75.4% female, mean age 29.66 ± 8.36 years) were enrolled. The median serum ACE levels were 33.5 U/L (range: 25-540) and 26 U/L (range: 22.3-72) for the ON patients and controls, respectively. Serum ACE levels were significantly higher in the patients than in the control group (P < 0.001). High level of serum ACE (defined as a serum ACE >65 U/L) was present in 9 (13.8%) patients with ON and 2 (3.1%) controls. CONCLUSION: Our results indicated that the serum level of ACE appeared to be significantly higher in acute ON than in normal controls.

Ophthalmic Artery Occlusion Following Facial Sclerosing Therapy.

PURPOSE: To describe a case of ophthalmic artery occlusion and complete ophthalmoplegia after intralesional injection of a sclerosing agent into a subcutaneous hemangioma on the forehead. CASE REPORT: A 16-year-old girl underwent direct injection of 3 mL of sodium tetradecyl sulfate (Fibrovein) emulsion 1% (10 mg/mL) with a 23-gauge needle into a subcutaneous hemangioma on the forehead. Immediately after the injection, she developed sudden loss of vision and lid swelling of the left eye. Her visual acuity in the left eye became no light perception. Her left eye also developed a dilated pupil, ptosis, and complete external ophthalmoplegia. Funduscopy of the left eye revealed signs of central retinal artery occlusion. Magnetic resonance imaging of the orbit showed thickening of the medial and lateral rectus muscles of the left eye. Magnetic resonance venography of the brain was normal with no evidence of cavernous venous thrombosis. After 3 months, her ptosis and ophthalmoplegia resolved but her visual acuity remained no light perception. CONCLUSION: Persistent total visual loss should be kept in mind as a disastrous complication of sclerosing therapy in a patient with facial hemangioma.

Intravitreal Injection of Anti-vascular Endothelial Growth Factor Agents for Ocular Vascular Diseases: Clinical Practice Guideline.

PURPOSE: To provide the clinical recommendations for the administration of intravitreal anti-vascular endothelial growth factor (VEGF) drugs especially bavacizumab for ocular vascular diseases including diabetic macular edema, neovascular age-related macular degeneration, myopic choroidal neovascularization, retinal vein occlusion and central serous chorioretinopathy. METHODS: Twenty clinical questions were developed by the guideline technical committee. Relevant websites and databases were searched to find out the pertinent clinical practice guidelines to answer the questions. The technical committee provided possible answers (scenarios) according to the available evidences for each question. All scenarios along with their levels of evidence and the supported articles were sent to the experts for external review. If the experts did not agree on any of the scenarios for one particular clinical question, the technical committee reviewed all scenarios and their pertinent evidences and made the necessary decision. After that, the experts were asked to score them again. All confirmed scenarios were gathered as the final recommendations. RESULTS: All the experts agreed on at least one of the scenarios. The technical committee extracted the agreed scenario for each clinical question as the final recommendation. Finally, 56 recommendations were developed for the procedure of intravitreal anti-VEGF injection and their applications in the management of ocular vascular diseases. CONCLUSION: The implementation of this guideline can standardize the management of the common ocular vascular diseases by intravitreal injection of anti-VEGF agents. It can lead to better policy-making and evidence-based clinical decision by ophthalmologists and optimal evidence based eye care for patients.

Simultaneous Unilateral Presentation of Three Different Ocular Manifestations of Granulomatosis with Polyangiitis.

PURPOSE: To report the simultaneous presentation of three ocular manifestations of granulomatosis with polyangiitis in one eye. CASE REPORT: A 42-year-old man with a confirmed diagnosis of granulomatosis with polyangiitis was referred to the emergency room with sudden blurred vision. Eye examination showed hyperemic conjunctiva due to necrotizing scleritis in the superior nasal quadrant of the left eye, a mass in the left superior lid, as well as central retinal artery occlusion in the same eye. CONCLUSION: This case suggests that unilateral eye involvement may be a manifestation of underlying granulomatosis with polyangiitis.

Bilateral Diffuse and Cluster Pigment Epithelial Detachment Associated with Diffuse Proliferative Glomerulonephritis.

Retinal pigment epithelium detachment (PED) is an area of retinal pigment epithelium (RPE) elevation with minimal or no sensory retinal detachment resulting from the accumulation of sub-RPE fluid. There are many etiological factors that lead to the development of PED. PED may be observed as an isolated finding or in association with ocular and systemic conditions. In this case we report a 23-year-old male with bilateral cluster PED associated with diffuse proliferative glomerulonephritis (DPGN). The importance of current report is that development of PED and DPGN is more than a simple incidental event. Patients with DPGN should have regular fundus examinations, and follow-up should be conducted by an ophthalmologist who is aware of the possible presence of these diseases.

Relationship Between Serum Uric Acid and Incident Hypertension in Patients with Type 2 Diabetes.

BACKGROUND: Little is known about the relationship between high baseline serum uric acid (SUA) and incident hypertension in patients with type 2 diabetes (T2D). OBJECTIVES: To evaluate the ability of baseline SUA to predict the incidence of hypertension in non-hypertensive patients with T2D. METHODS: The association between SUA and mean 20-year incidence of hypertension was examined in 1,666 non-hypertensive patients with T2D from Isfahan Endocrine and Metabolism Research Center outpatient clinics, Iran. The primary outcome was incident hypertension defined as systolic blood pressure (BP) of 140 mmHg or higher and/or diastolic BP 90 mmHg or higher and/or use of antihypertensive medications. The mean (standard error (SE)) age of participants was 49.4 years (0.25 years) with a mean (SE) duration of diabetes of 6.1 years (0.15 years) at initial registration. We used multiple logistic regression to estimate the odds ratio (OR) for the incidence of hypertension across quartiles of SUA, and plotted a receiver operating characteristic (ROC) curve to assess discrimination. RESULTS: The highest quartile of SUA was not associated with hypertension compared with the lowest quartile in multivariable adjusted models (OR: 1.22, 95% CI: 0.87, 1.73). The area under the ROC curve for SUA was 51.7% (95% CI: 48.9, 54.5). CONCLUSIONS: High initial SUA levels are not a predictor of incident hypertension in an Iranian T2D population.

Single-dose Intravitreal Bevacizumab after Complete Panretinal Photocoagulation in Proliferative Diabetic Retinopathy: an Effective Adjunctive Treatment.

Patients with proliferative diabetic retinopathy (PDR) who are refractory to complete panretinal photocoagulation (PRP) have a high risk of severe vision loss. The aim of this study was to evaluate the effectiveness of single-dose intravitreal bevacizumab (IVB) after complete PRP in patients with refractory PDR. Patients with retinal neovascularization (NV) secondary to diabetes mellitus and refractory to complete PRP were enrolled in this study. All patients received a single dose of 1.25 mg IVB at 3 months after completing the PRP. Patients underwent complete ophthalmic evaluation and fluorescein angiography (FA) at baseline and 1 month after injection. The main outcome measure was a reduction in the areas of leakage (mm2) on FA. All patients were evaluated at baseline and on every visit at 1 day, 1 week, and 1 month after the injection. A total of 21 consecutive patients (32 eyes) with PDR completed this study. Thirteen (61.9%) patients were female. The mean ± standard deviation (SD) age was 64.1 ± 5.6 years. Complete and partial response of angiographic leakage of NV was noted in 7 (21.9%) and 18 (56.2%) of 32 eyes after a single IVB injection, respectively. No satisfactory response of retinal NV was observed in 7 eyes (21.9%) at 1 month after the injection. No significant ocular or systemic adverse events were observed. A single-dose of IVB could be associated with a satisfactory response of retinal NV, secondary to PDR, in patients who are refractory to complete PRP.

Intravitreal Diclofenac plus Bevacizumab versus Bevacizumab alone in treatment-naive diabetic macular edema: a randomized double-blind clinical trial.

The aim of this study is to evaluate the short-term effects of a single intravitreal injection of 1.25 mg Bevacizumab combined with 300 lg/0.1 mL Diclofenac (IVB/D) versus 1.25 mg intravitreal Bevacizumab (IVB) alone in the treatment of naive diabetic macular edema (DME). In this prospective, randomized clinical trial, 80 eyes were included in the final analysis; 42 and 38 of which in the IVB and IVB/D groups, respectively. The primary outcome measure was a change in best-corrected visual acuity (BCVA) in logMAR at week 4. The secondary outcomes included changes in central macular thickness (CMT), macular volume, and potential injection-related complications. Significant improvement of BCVA was demonstrated in both study arms (mean reductions in LogMAR: -0.088 ± 0.278, -0.228 ± 0.330 for IVB and IVB/D, respectively). The difference in BCVA changes was in favor of IVB/D; however, not to a statistically significant level (P = 0.160). Significant reduction of CMT was documented in both study arms (mean reductions: 82.43 ± 160.09 and 153.26 ± 163.85 for IVB and IVB + IVD, respectively). Comparison of CMT changes between groups showed that IVB/D reduced CMT more than that of IVB (P = 0.04). Effects on macular volume corresponded to those of CMT. No injection-related complications or significant alterations in intraocular pressure were observed in any of the study arms. In treatment-naive DME, superiority of IVB/D combination therapy over IVB monotherapy may exist; especially as regards anatomical features. In our therapeutic arsenal for DME, IVD can be added as an adjunct to Bevacizumab.

Intravitreal vascular endothelial growth factor (VEGF) inhibitor injection in unrecognised early pregnancy.

The use of intravitreal vascular endothelial growth factor (VEGF) inhibitor medications has widened considerably to include indications affecting females of reproductive age. Our patient was inadvertently exposed to bevacizumab within the first trimester when placental growth and fetal organogenesis take place and patient suffered pregnancy loss. There is insufficient information to suggest that such use is safe, nor is there definitive evidence to suggest that it causes harm. We advise that ophthalmologists discuss pregnancy with women of childbearing age undergoing intraocular anti-VEGF injections and in pregnant woman counselling is needed to explain the potential risks and benefits.

Bilateral optic nerve head drusen with chorioretinal coloboma in the right eye.

Chorioretinal coloboma is a congenital defect of the eye caused by improper closure of the embryonic fissure. Optic nerve head drusen (ONHD) are white calcareous deposits that are generally asymptomatic. We report a very rare association of both in a healthy patient with no any systemic syndrome. A 16-year-old man was referred to our clinic from suffering blurred vision. Best corrected visual acuity of the right eye was 6/10 and 10/10 in the left one. External ocular and slit lamp examination were normal. Dilated ophthalmoscopy showed marked swelling in both optic nerves and chorioretinal coloboma in the right eye inferiorly. Ultrasonography showed an echodense structure with acoustic shadowing in both eyes consistent with buried ONHD. Visual field testing showed normal field in the left eye and moderate superior field depression in the right eye corresponding to inferior coloboma in funduscopy. Results of general medical and neurologic, cardiologic, and other examinations were normal. To the best our knowledge combination of bilateral ONHD and unilateral chorioretinal coloboma in a healthy patient with no any systemic syndrome has not been published in the literature. We reported this very rare association and recommended examine eyes and other body organs. In such cases that coloboma is associated with ONHD, we should keep in mind Noonan syndrome. The diagnosis of Noonan syndrome is clinical and confirm by the consultant pediatricians and clinical geneticists.

Intravitreal bevacizumab for treatment of choroidal neovascularization secondary to toxoplasmic retinochoroiditis: a case series.

PURPOSE: To evaluate the efficacy and safety of intravitreal bevacizumab (Avastin) in treatment of choroidal neovascularization (CNV) secondary to toxoplasmic retinochoroiditis. DESIGN: Prospective case series. METHODS: Four patients affected by CNV secondary to inactive toxoplasmic retinochoroiditis received 1.25 mg intravitreal bevacizumab and were followed for at least six months. Patients underwent a full ophthalmic examination and fluorescein angiography (FA) and optical coherence tomography (OCT), revealing an active subfoveal CNV close to an old chorioretinal scar. All the patients were positive for toxoplasma immunoglobulins. Outcome measures were changes in best-corrected visual acuity (BCVA) and central macular thickness (CMT) and any adverse event related to the therapy. RESULTS: CNV regressed at eight weeks of follow-up and remained stable at six months of follow-up. Best-corrected visual acuity improved from mean 0.05 to 0.25. After six months, the BCVA improved in all patients (p < 0.05) and CMT decreased from 396 +/-7 micron to 253+/-17 micron. Metamorphopsia was resolved in all cases. CONCLUSIONS: Intravitreal bevacizumab seems to be an effective treatment for the long-term control of juxta/subfoveal CNV secondary to toxoplasmic retinochoroiditis. Further trials are mandatory to validate the data of our case series.

Clinical Patterns of Uveitis in an Iranian Tertiary Eye-care Center.

PURPOSE: This study aimed to analyze the clinical patterns and etiology of uveitis in Isfahan, Iran. METHODS: In this descriptive research, the records of 2016 patients with uveitis referred to a tertiary eye care centers were examined. Age, sex, clinical and anatomical features, and etiology of disease were recorded and analyzed. RESULTS: The mean age of onset of uveitis was 33.76 years and the women/men ratio was 1.2/1.0. Anterior uveitis was the most common (42.9%) type followed by posterior (21.4%), intermediate (19.3%), and pan uveitis (16.31%). Noninfectious causes had more roles (76.5%) in the etiology of uveitis. A total of 43.9% of the patients had unknown etiology (idiopathic). The most common known etiologies were toxoplasmosis, Behçet disease and Fuchs heterochromic iridiocyclitis (FHI), respectively. In 15.6%, there was an underlying systemic disease. CONCLUSION: There were some differences in the clinical and etiologic pattern of uveitis in Isfahan. Environmental, genetic, and geographical factors may contribute to this difference.