Sub retinal pigment epithelium hyporeflective spaces preceding large drusen collapse.

PURPOSE: To describe and study hyporeflective sub retinal pigment epithelium (RPE) spaces in large drusen and drusenoid pigment epithelial detachment prior to collapse. METHOD: Retrospective longitudinal study which enrolled patients with large and very large drusen due to intermediate age-related macular degeneration (AMD). The following optical coherence tomography (OCT) parameters were assessed: Drusen size (maximum width and height), OCT biomarkers of RPE atrophy, presence of intraretinal and subretinal fluid (IRF, SRF), acquired vitelliform lesion and sub RPE regions of hyporeflectivity within the PED compartment. RESULTS: Of the 50 eyes from 41 patients (mean age of 77.1 ± 9 years, 78% women) with large and very large drusen, 16 eyes progressed to collapse. Eyes with sub RPE hyporeflective spaces (n=8 eyes, 50%) were associated with greater drusen width and height than eyes without sub RPE hyporeflective spaces. At the collapse visit, eyes with sub RPE hyporeflective spaces displayed poorer visual acuity and greater iRORA (incomplete RPE outer retinal atrophy) and cRORA (complete RORA) length than eyes without sub RPE hyporeflective spaces (p=0.004 and p=0.04, respectively). CONCLUSION: Sub RPE hyporeflective spaces are a novel OCT finding of large and very large drusen that collapse to atrophy. Progressive RPE dysfunction and failure may lead to reduced drusenoid material formation and progressive degenerative hydration of the large drusen prior to collapse, but this awaits confirmation with histopathological analysis.

En Face Optical Coherence Tomography Illustrates the Trizonal Distribution of Drusen and Subretinal Drusenoid Deposits in the Macula.

PURPOSE: To analyze the topographic distribution of macular drusen and subretinal drusenoid deposits (SDDs) using single-capture en face spectral domain optical coherence tomography (SD-OCT) imaging. DESIGN: Retrospective case series. METHODS: Analysis of 33 eyes of 20 patients with evidence of SDDs. Structural en face OCT images were reconstructed using a 40-µm-thick slab positioned from 48 to 88 µm above the Bruch membrane. The Early Treatment of Diabetic Retinopathy Study (ETDRS) grid and a rod/cone density map were overlaid on the en face OCT images, and the distribution of different subtypes of SDDs and macular drusen were assessed. RESULTS: A total of 31 eyes (94%) showed a trizonal distribution pattern of drusen and SDDs. Whereas small to large drusen tended to aggregate in the central circle, dot SDDs predominated in the inner ring and the inner portion of the outer ring of the ETDRS grid and ribbon SDDs localized to the outer ring and outside the ETDRS grid. Of note, drusen colocalized to the region of greatest cone density, whereas ribbon SDDs colocalized to the area of greatest rod density. The dot SDDs mapped to the intermediate region with mixed rod and cone representation. CONCLUSION: Dot and ribbon subtypes of SDDs and macular drusen show a characteristic trizonal distribution. The locations of these lesions colocalize according to the different densities of the cones and rods in the retina and may reflect varying pathophysiological activities of these photoreceptor subtypes.

Senior medical students' attitudes toward psychiatry as a career choice before and after an undergraduate psychiatry internship in Iran.

OBJECTIVES: The study aimed to assess 1) the attitudes of medical students in the sixth and seventh years (known as interns in Iran) toward psychiatry as a career choice, and 2) the degree of attractiveness of psychiatry as a career choice, with regard to various defined aspects, before and after an undergraduate psychiatry internship (similar to the medical school psychiatry rotation in the United States, but mandatory in Iran) in three major medical schools in Tehran, the capital of Iran. METHOD: Sixth- and seventh-year medical students (locally called interns, N=347) at Tehran, Shahid Beheshti, and Iran Universities of Medical Sciences were consecutively invited to complete anonymous self-report questionnaires designed to assess their perceptions of careers in psychiatry before and after internship in psychiatry wards. Also, students evaluated psychiatry in terms of the factors that reflected the degree of attractiveness of this specialty. RESULTS: Positive responses toward choosing psychiatry as a career were seen in 18.8% before and 20.0% after psychiatry rotation. No significant differences were observed in the positive responses before and after psychiatry internship. The students' opinions changed to a more attractive degree in terms of only 3 out of the 13 defined aspects. There was also no significant difference in the total score on attractiveness of psychiatry before and after the psychiatry internship. CONCLUSIONS: The study indicated that undergraduate psychiatry internship might not induce more students to consider psychiatry as a possible career. The present pattern of psychiatry education in Iran seems not to positively affect most aspects of medical students' attitudes toward psychiatry.

Population based estimates of non-fatal injuries in the capital of Iran.

BACKGROUND: Fatal injuries are at the top of the injury pyramid; however, non-fatal injuries are quite common and impose huge medical expenses on the population. Relying on hospital data will underestimate the incidence of non-fatal injuries. The aim of this study was to estimate the annual incidence and out of pocket medical expenses of all injuries in urban population of Tehran (the capital city of Iran). METHODS: Using the cluster random sampling approach, a household survey of residents of greater Tehran was performed on April 2008. At randomly selected residential locations, interviewers asked one adult person to report all injuries which have occurred during the past year for all household members, as well as the type of injury, place of occurrence, the activity, cause of accidents resulting in injuries, the amount of out of pocket medical expenses for injury, and whether they referred to hospital. RESULTS: This study included 2,450 households residing in Tehran during 2007-8. The annual incidence of all injuries was 188.7 (180.7-196.9), significant injuries needing any medical care was 68.8 (63.7-74.2), fractures was 19.3 (16.6 - 22.4), and injuries resulted in hospitalization was 16.7 (14.2 - 19.6) per 1000 population. The annual incidence of fatal injuries was 33 (7-96) per 100,000 Population. In children aged 15 or less, the annual incidence of all injuries was 137.2 (120.0 - 155.9), significant injuries needing any medical care was 64.2 (52.2 - 78.0), fractures was 21.8 (15.0 - 30.7), and injuries resulted in hospitalization was 6.8 (3.3 - 12.5) per 1000 population. The mean out of pocket medical expense for injuries was 19.9 USD. CONCLUSION: This population based study showed that the real incidence of non-fatal injuries in the capital of Iran is more than the formal hospital-based estimates. These injuries impose non trivial medical and indirect cost on the community. The out of pocket medical expense of non-fatal injuries to Tehran population is estimated as 27 million USD per year. Effective strategies should be considered to minimize these injuries and decrease the great financial burden to public and the health system.

Modified Encircling Scleral Buckle Technique Without Subretinal Fluid Drainage or Retinopexy.

INTRODUCTION: Scleral buckling (SB) tends to be more challenging and time-consuming for compared to the pars plana vitrectomy for repairing rhegmatogenous retinal detachments (RRDs). This study characterizes a novel and simplified technique for SB. METHODS: In this single-masked randomized interventional study, patients with RRDs who were eligible for SB were randomly assigned to either the standard (S) or modified (M) technique of SB. In the modified approach, neither intraoperative break localization nor cryopexy or subretinal fluid drainage was done. A large tire (276/279) was placed where preoperative retinal breaks had been localized with a 240 encircling band placed for support of the remaining retina. Patients were followed for 12 months and the primary outcomes were differences between the surgical groups in operative time, anatomical success, visual acuity, and complication rate. RESULTS: Thirty-six eyes were included in the study (18 in each arm). There were no differences in baseline patient demographics or characteristics including gender, age, lens and macular status, preoperative vision, and symptom duration. The mean length of surgery was 72.2 ± 13.2 and 56.2 ± 9.5 min in groups S and M, respectively (P = 0.001). Complete retinal reattachment at the end of month 12 after single surgery was 80.6% overall; 77.8% (14/18) in group S and 83.3% (15/18) in group M (P > 0.999). After 12 months, both groups achieved similar final best-corrected visual acuity (BCVA): 0.26 ± 0.23 and 0.23 ± 0.17 logMAR in groups S and M, respectively (P = 0.231). Controlling for preoperative BCVA on ANCOVA testing, there were no significant differences in visual improvement between the two groups [F (1,26) = 0.02, P = 0.966 (95% CI) - 0.128 to 0.123)]. Scleral perforation (2:1), vitreous hemorrhage (3:2), and transient rise of intraocular pressure (3:4) all occurred at a low and similar rate between the two groups (S:M). CONCLUSION: Modified SB technique was non-inferior compared to the standard approach for anatomical and visual outcomes. Shortening surgical time while maintaining low complication rates makes this an appropriate approach to SB, especially for vitreoretinal surgery trainees.

Short-term Results of Trabeculectomy Using Adjunctive Intracameral Bevacizumab Versus Mitomycin C: A Randomized Controlled Trial.

PURPOSE: To compare the outcome of trabeculectomy using adjunctive intracameral bevacizumab versus intraoperative mitomycin C (MMC). MATERIALS AND METHODS: In this double-blind, randomized clinical trial 87 eyes of 87 patients with primary open-angle or pseudoexfoliation glaucoma were assigned to each treatment group (44 cases received 1.25 mg intracameral bevacizumab at the end of operation and in 43 cases MMC was applied during surgery). Success was defined as intraocular pressure (IOP) between 6 and 21 mm Hg and at least 30% IOP drop with (qualified) or without (complete) glaucoma medications without additional glaucoma surgery. RESULTS: The follow-up time was 17.12±2.58 months in the bevacizumab group and 17.23±2.42 months in the MMC group (P=0.845). The preoperative IOP was 29.17±3.94 and 28.8±4.08 mm Hg in the bevacizumab and MMC groups, respectively (P=0.689). Last visit IOP was 17.41±3.11 mm Hg in the bevacizumab group and 15.34±3.62 mm Hg in the MMC group (P<0.009). Compared with baseline, IOP drop at last visit was 11.76±5.51 and 13.43±5.92 in the bevacizumab and MMC groups, respectively (P=0.207). At last visit, complete success was achieved in 25 cases (61%) of bevacizumab group and 23 cases (66%) of MMC group (P=0.669). Early filtering bleb leak was more prevalent in bevacizumab group (29% vs. 11%). CONCLUSIONS: A single 1.25 mg dose of intracameral bevacizumab improves the success of trabeculectomy comparable with MMC; however, it increases the risk of early filtering bleb leakage.

Short-term Results of Trabeculectomy Using Adjunctive Intracameral Bevacizumab: A Randomized Controlled Trial.

PURPOSE: To investigate the outcome of trabeculectomy with or without adjunctive intracameral bevacizumab. MATERIALS AND METHODS: In this prospective, double-blind, randomized clinical trial, 71 patients with primary open-angle or pseudoexfoliation glaucoma were randomly assigned to receive either 1.25 mg intracameral bevacizumab (n=36) or balanced salt solution as placebo (n=35) at the end of trabeculectomy. Success was defined as at least a 30% drop in intraocular pressure (IOP) compared with baseline values and an IOP between 6 and 21 mm Hg at the last postoperative visit with (qualified) or without (complete) glaucoma medications. RESULTS: Thirty-two patients in bevacizumab group and 33 in placebo group completed a mean follow-up of 10.7±2.1 and 10.5±2.5 months, respectively (P=0.731). The mean preoperative IOP was 28.25±5.64 and 29.11±4.65 mm Hg in the bevacizumab and placebo groups, respectively (P=0.485). Last visit IOP was 14.5±3.7 mm Hg in the bevacizumab group and 18.55±3.64 mm Hg in the placebo group (P<0.001). At last visit, complete success was achieved in 26 cases (81.3%) of bevacizumab group and 16 cases (48.5%) of placebo group (P<0.006). Filtering bleb leak during the first postoperative month was seen in 11 (34%) and in 3 (9%) cases of bevacizumab and placebo groups, respectively (P=0.013). CONCLUSIONS: A single 1.25 mg dose of intracameral bevacizumab significantly improves the success of trabeculectomy; however, it increases the risk of early filtering bleb leakage.

Topical cyclosporine a for mustard gas induced ocular surface disorders.

PURPOSE: To evaluate the effectiveness of topical cyclosporine A 0.05% for treatment of mustard gas-induced ocular surface disorders with special attention to conjunctival goblet cell density in patients with severe dry eye. METHODS: This prospective clinical study included 20 eyes of 20 patients previously exposed to mustard gas with dry eye syndrome unresponsive to artificial tears. Before and after treatment with topical cyclosporine A 0.05% twice daily for 3 months, subjects were evaluated for improvement in symptoms using the ocular surface disease index (OSDI) and signs by tear breakup time (TBUT), Schirmer test and measurement of superior bulbar conjunctival goblet cell density. Limbal stem cell deficiency (LSCD) and the degree of corneal squamous cell metaplasia were also assessed before and after treatment. RESULTS: Before treatment, mean OSDI score, Schirmer test I value and mean TBUT were 42.8 ± 6.1, 4.2 ± 1.2 mm and 2.5 ± 1.3 s, respectively. After 3 months of treatment with topical cyclosporine A, these scores reached 36.4 ± 5.2, 5.8 ± 1.6 mm and 4.9 ± 2.1 s, respectively showing a statistically significant improvement (P < 0.001) in all parameters. Mean goblet cell density was 23.3 ± 17.1/high power field (hpf) at baseline which was significantly increased to 47.7 ± 16.1/hpf at the end of the study (P < 0.001). There was no improvement, however, in corneal conjunctivalization, LSCD and the degree of corneal squamous cell metaplasia based on impression cytology reports (P > 0.05). CONCLUSION: Treatment with topical cyclosporine A 0.05% in patients with severe dry eye due to mustard gas injury increases goblet cell density in the bulbar conjunctiva and improves symptoms of the disease.

Topical cyclosporine a for treatment of dry eye due to chronic mustard gas injury.

PURPOSE: To evaluate the efficacy of topical cyclosporine A (tCsA) for treatment of dry eye disease in patients suffering from chronic ocular complications of mustard gas (MG) injury. METHODS: This interventional case series included patients with MG injury suffering from severe dry eye despite receiving artificial tears and punctal plugs. Patients were administered tCsA 0.05% twice daily for 3 months. Severity of the condition was evaluated by measuring tear osmolarity, ocular surface disease index (OSDI), tear break-up time (TBUT), and Schirmer's test at baseline and at the end of study. RESULTS: A total of 34 patients with chronic MG injury and mean age of 47.1 ± 6.5 years were studied. Compared to baseline values, tear osmolarity (301.7 ± 11.5 vs. 286.3 ± 7.9 mOsmol/L, P < 0.001) and OSDI (47.5 ± 7.2 vs. 42.7 ± 7.1, P < 0.001) were significantly improved. Likewise, Schirmer's test (4.6 ± 1.3 vs. 5 ± 1.3 mm, P < 0.001) and TBUT (1.9 ± 1.4 vs. 2.7 ± 1.5 s, P < 0.001) also significantly recovered at the end of the study. CONCLUSION: TCsA 0.05% reduces tear osmolarity and improves dry eye symptoms and can serve as an efficacious treatment for ocular complications in patients with chronic MG injury.

Clinical characteristics and causality of eye lid laceration in iran.

OBJECTIVE: The aim of this study was to assess the etiological characteristics and visual outcomes of ocular trauma with more attention to eyelid laceration. METHODS: In a cross-sectional study, 98 cases of isolated traumatic eyelid laceration were consecutively studied and its epidemiology, etiology and association with visual outcome were evaluated. The findings of this study could be used to develop healthcare related precautions and work place safety recommendations. RESULTS: Of the 98 patients included in the study, men exhibited a greater vulnerability and they were mostly aged around 29 years old. In terms of the place of trauma, 40 (43.5%) cases occurred in the street, 27 cases (29.3%) occurred at home, and 17 cases (18.5%) occurred at the workplace, while 4 cases (4.3%) happened in entertaining environments like parks. For 3 patients (3.3%), the incident took place at a public pathway, and in 1 patient (1.1%), the case occurred at school. As the most common cause of trauma, 41 patients (42.3%) had an object hit their eyes. In addition, assaults were a major cause of injury. The right eye and the upper lid were also the most common sites of injuries. Although no blindness occurred due to trauma causing eyelid laceration, the visual outcomes were correlated with severity of the incident defined based on the presence of open globe injuries. CONCLUSION: This study could possibly highlight the risk factors of eyelid laceration and provide the healthcare community with the essential recommendations regarding the safety precautions in dangerous settings, including daily / routine work places.