Improving diabetic retinopathy screening at the point of care: integrating telemedicine to overcome current challenges.

OBJECTIVE: To investigate the utility of point of care screening of diabetic retinopathy (DR) and the impact of a telemedicine program to overcome current challenges. METHODS: This was a retrospective study on people with type 2 diabetes mellitus (T2DM) who were screened for DR using the single-field non-mydriatic fundus photography at the point of care during routine follow-up visits at endocrinology clinic. Retinal images were uploaded and sent to a retina specialist for review. Reports indicating retinopathy status and the need for direct retinal examination were transmitted back to the endocrinology clinic. All patients were informed about DR status and, if needed, referred to the retina specialist for direct retinal examination. RESULTS: Of the 1159 individuals screened for DR, 417 persons (35.98%) were screen-positive and referred to the retina specialist for direct retinal examination. A total of 121 individuals (29.01%) underwent direct retinal examination by the specialist. Diabetes macular edema (DME) was detected in 12.1%. In addition, non-proliferative diabetic retinopathy (NPDR) and proliferative diabetic retinopathy (PDR) were detected in 53.4% and 2.6% of the patients, respectively. CONCLUSION: Integrating DR screening program at the point of care at the secondary care services improves the rate of DR screening as well as detection of sight threatening retinopathy and provides the opportunity for timely intervention in order to prevent advanced retinopathy in people with T2DM.

RETINAL VASCULAR BED AREA IN EYES WITH RETINAL VEIN OCCLUSION ON ULTRA-WIDEFIELD FLUORESCEIN ANGIOGRAPHY: WAVE Study.

PURPOSE: To compute retinal vascular bed area (RVBA) in square millimeters on distortion corrected ultra-widefield fluorescein angiography images in eyes with retinal vein occlusion (RVO). METHODS: Prospective observational study. The peripheral distortion of baseline ultra-widefield fluorescein angiography (Optos 200Tx) images of 30 patients with RVO from the WAVE study (NCT01710839) and 13 control eyes of normal subjects was corrected using the stereographic projection method to compute RVBA in square millimeters. RESULTS: In comparison with age- and sex-matched normal control eyes, eyes with RVO had a decreased global RVBA for the entire retina (50.5 ± 20.4 mm 2 vs. 62.6 ± 12.2 mm 2 , P = 0.023). Eyes with RVO and the unaffected fellow eye had a similar RVBA globally (50.5 ± 20.4 mm 2 vs. 46.2 ± 18.9 mm 2 , P = 0.523). The RVBA was observed to negatively correlate with nonperfusion area (R = -0.47, P = 0.009). However, RVBA was not related to the severity of macular edema ( P > 0.05). CONCLUSION: Eyes with RVO have a similar RVBA to the unaffected fellow eyes but with a reduction when compared with normal control eyes. Retinal vascular bed area appears to be a surrogate biomarker of retinal ischemia on ultra-widefield fluorescein angiography but not the extent of macular edema.

Optic Nerve Head Vessel Density Changes from Graves' Disease without TED to TED Dysthyroid Optic Neuropathy: Does Optic Nerve Head Ischemia Play a Role?

PURPOSE: To compare the retinal peripapillary capillary (RPC) vessel density (VD) between 5 groups of patients on the spectrum of thyroid eye disease (TED). METHOD: This is a prospective comparative study looking at 5 groups of patients who were consecutively included from January 2018 to March 2021. They were composed of: Healthy volunteers (39 eyes and 20 subjects), patients with Graves' disease without TED (26 eyes and 13 patients), mild TED (28 eyes and 14 patients), moderate-severe TED (30 eyes and 17 patients), and TED with dysthyroid optic neuropathy (DON) (21 eyes and 12 patients). Ocular and periocular examination, visual field indices, RPC-VD (with optical coherence tomography angiography), and retinal nerve fiber layer, and macular ganglion cell complex thickness were recorded. RESULT: An initial insignificant (0.5 < p < 0.9) rise in the peripapillary-VD (pp-VD) and whole image-VD (wi-VD) from the healthy subject to the Graves' disease without TED was followed by a significant (p = 0.001) fall in RPC-VD in different severity grades of the TED. Paired comparison between the 5 groups showed that the statistically significant fall from the Graves' disease group occurred in the moderate-severe and DON groups (0.001 ≤ p ≤ 0.04). No variable significantly affected the VD (0.08 ≤ p ≤ 0.9). A lower wi-VD and pp-VD were significantly (0.001 ≤ p ≤ 0.009) correlated with the impaired optic nerve functional and structural tests. The sensitivity and specificity of wi-VD (81% and 76%) and pp-VD (69% and 71%) for detecting the DON were statistically significant (p < 0.001). CONCLUSION: Despite an insignificant rise in the wi- and pp-VD from the healthy volunteers to the patients with Graves' disease without TED, VD showed a declining trend in the course of patients with TED, which was statistically significant in the moderate-severe TED and DON groups.

Spatial distribution of diabetic capillary non-perfusion.

OBJECTIVE: To evaluate the distribution of capillary non-perfusion (CNP) in superficial and deep capillary plexuses (SCP and DCP) in eyes with diabetic retinopathy (DR). METHODS: In this retrospective case series, macular optical coherence tomography angiography (OCTA) images were obtained from eyes with DR without diabetic macular edema (DME). The area of CNP in SCP and DCP was delineated using an automated approach after excluding the foveal avascular zone (FAZ) and major retinal vessels. The distribution and spatial correlation of the CNP in each layer were analyzed. RESULTS: Forty-three eyes of 27 patients with DR with a mean age of 59.10 ± 9.05 years were included. The mean CNP area in SCP was statistically significantly higher than DCP (0.722 ± 0.437 mm2 vs. 0.184 ± 0.145 mm2 , respectively, p < .001). There was a statistically significant association between mean BCVA (0.28 ± 0.21 logMAR) and CNP area in DCP (p = .01). After automated subtraction of CNP areas in DCP from SCP, 25.43 ± 15.05% of CNP areas in the DCP had co-localized CNP areas in SCP. The CNP percentage was statistically significantly different between the concentric rings on foveal center, both in SCP and in DCP (both p < .001) showing a decreasing trend from the outer ring toward the center. CONCLUSION: In DR, SCP is more ischemic than DCP. This is in contrast to the previously described oxygenation-dependent ischemic cascade following acute retinal vascular occlusions. This study provides further insight into the retinal ischemia in DR.

Postoperative Blepharoptosis After Pars Plana Vitrectomy Procedure.

PURPOSE: To describe the frequency of blepharoptosis and factors affecting it after the pars plana vitrectomy (PPV) procedure. METHODS: In a prospective study, patients were recruited consecutively from October 2016 to June 2018. Upper eyelid margin reflex distance 1 and 2 (MRD1 and 2), upper eyelid crease height, and levator function were measured before, 1 and at least 6 months after surgery by the same investigator. Clinical and Clinically significant ptosis were defined as ≥0.5 and ≥2 mm drop of MRD1. RESULT: There were 60 eyes from 57 patients. The majority of surgeries were performed by the fellows (63.3%, 38/60) and under general anesthesia (95.0%, 57/60). Clinical and clinically significant ptosis following PPV were 47.2% (25/53) and 11.3% (6/53) at the last follow up (at least 6 months), respectively. MRD2 (p = 0.389) and eyelid crease height (p = 0.057) did not significantly change. Surgeons' level, time of the procedure and other variables were not significantly impacting the frequencies. CONCLUSION: Persistent clinically significant ptosis was observed in 11% of patients undergoing PPV. No variable was significantly associated with persistent postoperative ptosis after PPV.

SEVERITY OF DIABETIC MACULAR EDEMA CORRELATES WITH RETINAL VASCULAR BED AREA ON ULTRA-WIDE FIELD FLUORESCEIN ANGIOGRAPHY: DAVE Study.

PURPOSE: To quantify retinal nonperfusion area and retinal vascular bed area (RVBA) in mm on ultra-widefield fluorescein angiography in eyes with diabetic macular edema (DME) and explore their relationship with the severity of DME. METHODS: Prospective, observational case series. Baseline ultra-widefield fluorescein angiography images of 40 eyes from 29 patients with treatment-naive DME who participated in the DAVE study (NCT01552408) were stereographically projected at Doheny Image Reading Center. The retinal vasculature was automatically extracted to calculate RVBA. Nonperfusion area was manually delineated by two masked certified graders. Retinal vascular bed area and nonperfusion area were computed in mm automatically by adjusting for peripheral distortion and then correlated with the severity of DME. RESULTS: The global RVBA for the entire retina in eyes with DME was increased compared with healthy controls (54.7 ± 16.6 mm vs. 37.2 ± 9.9 mm, P < 0.001) and correlated with the severity of DME (P < 0.05). Retinal ischemia (nonperfusion area) was nonuniformly distributed and not related to DME extent (P > 0.05). CONCLUSION: Eyes with DME have an increased RVBA compared with healthy controls. The severity of DME appears to be related to global RVBA, but not to retinal ischemia.

TIME COURSE OF CHANGES IN OPTIC DISK NEOVASCULARIZATION AFTER A SINGLE INTRAVITREAL BEVACIZUMAB INJECTION.

PURPOSE: To evaluate the longitudinal changes in optic disk neovascularization (NVD) after intravitreal bevacizumab injection using optical coherence tomography angiography. METHODS: In this prospective, interventional, case series, eyes with NVD secondary to diabetic retinopathy were enrolled. En face optical coherence tomography angiographic images were obtained from the optic disks before and 3 hours, 6 hours, 24 hours, 7 days, and 30 days after intravitreal bevacizumab injection. The size and flow area of the neovascularization were measured by two graders. RESULTS: Eleven eyes of 9 patients with a mean age of 52.11 ± 9.48 years were included. The reduction in the NVD size and flow area was statistically significant at 24 hours, 7 days, and 30 days after injections compared with the baseline measurements (all P < 0.05). The decremental regression in the NVD size and flow area continued during the study course. The changes were not statistically significant in 3-hour and 6-hour measurements (all P > 0.05). CONCLUSION: In this study, statistically significant regression in the NVD size and flow area was observed as early as 24 hours after a single intravitreal bevacizumab injection, with a continued decreasing trend for at least a 1-month period.

The spectrum of Vogt-Koyanagi-Harada disease in Iran.

PURPOSE: To report the spectrum of Vogt-Koyanagi-Harada (VKH) disease in Persians. MATERIALS AND METHODS: This is a retrospective chart review of patients diagnosed with VKH disease at four referral centers in Iran. Patients' demographics, ocular and extraocular manifestations, treatment modalities, complications, and visual outcomes were collected and analyzed. RESULTS: Eighty-eight patients with a mean age of 32.1 ± 12.6 years (range 7-79 years) were studied. Fifty-nine patients (67.0%) were female. Sunset glow fundus was seen in 40.9%, and nummular peripheral chorioretinal scars in 55.7% of eyes. Integumentary findings were noticed in 14.8% of the patients. In patients with acute presentation, exudative retinal detachment was the most common ocular finding (87.8%) followed by optic disk swelling (71.4%). Anterior uveitis and vitritis each were found in about half of the studied eyes. Auditory symptoms were reported by 38.8% of the patients. Overall, immunomodulatory agents were used in 72.7% of the patients. Ocular complications occurred in 36.4% of eyes (mean follow-up 3.8 years, range 6-228 months). Final visual acuity was 20/40 or better in 73.3% of eyes. Four patients (4.5%) were classified as having 'complete' type of the disease, 36 (40.9%) 'incomplete' type, and 48 (54.5%) 'probable' type. CONCLUSION: In our series, there are clinical features that differ from those reported in other studies. While auditory symptoms occurred in more than one-third of patients, integumentary findings were rather rare. Most patients exhibited the 'probable' type of VKH disease. The overall visual prognosis was favorable.

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY OF THE FOVEA IN CHILDREN BORN PRETERM.

PURPOSE: To compare the foveal avascular zone (FAZ) area measured by optical coherence tomography angiography in children who had been born preterm with age-matched controls. METHODS: In this cross-sectional observational comparative case series, 43 eyes of 26 children (28 eyes of 15 former preterm infants and 15 eyes of 11 former term infants) between the ages of 4 and 12 years old were included. Optical coherence tomography angiography with a scan size of 3 × 3 was performed for all eyes. Foveal avascular zone area was measured using the Optovue RTVue AVANTI instrument (Optovue Inc, Fremont, CA) software. Inner and outer retinal thicknesses were measured with the instrument caliper. RESULTS: A distinct FAZ was absent in 12 eyes (42.8%) of children with a history of preterm birth, however, it was present in all (100%) control eyes. The FAZ area was significantly correlated with gestational age (r = 0.82, P < 0.001) and birth weight (r = 0.80, P < 0.001). The gestational age was less than 29 weeks and birth weight was less than 1,480 grams in eyes with no distinct FAZ. Mean central foveal vessel density in the superficial capillary plexus was 41.8 ± 4.4% in the preterm group and 32.8 ± 5.8% in the control group (P < 0.001). In all eyes, a significant negative correlation was found between the central foveal vessel density and gestational age (r = -0.63, P = 0.001) and birth weight (r = -0.59, P = 0.002). On spectral domain optical coherence tomography examination, the foveal depression was absent and the inner retinal layers were preserved in all eyes with absent FAZ. In all eyes, a significant negative correlation was found between the inner retinal thickness and gestational age (r = -0.68, P < 0.001) and birth weight (r = -0.61, P = 0.001). Ten eyes of 6 preterm children had a history of laser therapy for retinopathy of prematurity. A distinct FAZ was absent in six eyes (60%) with retinopathy of prematurity with history of laser therapy, and six eyes (33.3%) with preterm birth without laser therapy. Eyes with history of laser therapy had a statistically significantly higher inner retinal thickness and central foveal vessel density and smaller FAZ compared with the eyes with preterm birth without laser therapy (P < 0.001, P = 0.04 and P = 0.03, respectively). CONCLUSION: Optical coherence tomography angiography is a novel modality for noninvasive visualization of the retinal vasculature in pediatric patients and expands our knowledge of foveal abnormalities in retinopathy of prematurity. A small or absent FAZ seems to be a distinct sign of prematurity.

Intravitreal injection of methotrexate in persistent diabetic macular edema: a 6-month follow-up study.

PURPOSE: To evaluate the efficacy of intravitreal injection of methotrexate (MTX) in patients with persistent diabetic macular edema (DME) nonresponsive to intravitreal bevacizumab. METHODS: In this prospective, interventional study, intravitreal injection of 400 µg MTX was performed in eyes with persistent center-involving DME unresponsive to at least three consecutive bevacizumab injections or two consecutive bevacizumab injections plus macular photocoagulation. Best-corrected visual acuity (BCVA), central subfield thickness (CST), and maximum retinal thickness (MRT) were recorded before and 1, 3, and 6 months after injections. RESULTS: Eighteen eyes of 16 patients with a mean age of 61.1 ± 6.7 years were included. Mean number of intravitreal bevacizumab injections was 3.9 ± 1.8 (range 2-8). The mean change in BCVA was -0.09 ± 0.19, -0.1 ± 0.19, and -0.1 ± 0.19 LogMAR at 1, 3, and 6 months after intravitreal MTX injections, respectively (all P = 0.04). Three eyes (16.6 %) had improvement of at least two lines of BCVA and no eye lost visual acuity. Mean change in CST was -23.7 ± 66.7, -28.7 ± 82.2 and 26.5 ± 83.4 µm at 1, 3, and 6 months after MTX injections, respectively (all P = 0.1). A decrease in CST was found in 13 eyes (72.2 %) at 1 and 3 months, and seven eyes (38.8 %) at 6 months of follow-up. Other eyes showed an increase in CST measurements. Mean change in MRT was -35.1 ± 76.4, -40.6 ± 86.3, and 29.8 ± 68.6 µm at 1, 3, and 6 months after MTX injections, respectively (P = 0.06, P = 0.06, and P = 0.08, respectively). No complication attributable to intravitreal MTX occurred. CONCLUSION: In this study, intravitreal injection of MTX resulted in anatomical improvement in a significant proportion of eyes with persistent DME. Significant visual improvement was found in 16.6 % of eyes.

Determination of the toxicity of intravitreal minocycline in rabbit eyes.

PURPOSE: To evaluate the retinal toxicity of intravitreal minocycline in rabbit eyes. METHODS: Intravitreal injection of minocycline with concentrations of 1000, 500, 250, 125 and 62.5 µg in 0.1 ml was performed in 10 New Zealand albino rabbits. Each concentration was injected into two rabbit eyes. For each dose, normal saline was injected in one contralateral eye and the other fellow eye remained non-injected. Electrophysiologic testing was performed before and 4 weeks after injections. The eyes were enucleated 4 weeks after injections and examined using light microscopy. RESULTS: The clinical examination was unremarkable after injections. Electroretinography recordings were significantly affected at all doses in at least one of the a- or b-waves of photopic or scotopic responses. Histopathologic examination revealed marked atrophy and loss of integrity in all retinal layers in all minocycline injected eyes. Contralateral eyes were normal. CONCLUSION: In our study, intravitreal minocycline was toxic to the retina in albino rabbits even at a concentration of 62.5 µg/0.1 ml.

Conjunctival bacterial flora in nasolacrimal duct obstruction and its changes after successful dacryocystorhinostomy surgery.

PURPOSE: To evaluate the results of conjunctival culture in patients with nasolacrimal duct obstruction (NLDO) and its changes after successful dacryocystorhinostomy surgery. METHODS: In this prospective study, 71 adult patients with NLDO and 41 age- and sex-matched controls without NLDO were evaluated. The patients were divided in 2 groups based on clinical examination; group A with purulent regurgitation and group B without purulent regurgitation. Dacryocystorhinostomy surgery was performed, and the silicon tube was inserted in patients with upper lacrimal drainage system stenosis and when the lacrimal sac or nasal mucosal flap was inadequate for suitable anastomosis. Before surgery, microbiologic specimens were taken from the conjunctiva. Postoperative conjunctival sampling was continued weekly until the culture became negative or the colony count reached to the range of the control group. RESULTS: There were 38 and 33 patients in groups A and B, respectively. Silicone tube was inserted for 17 patients (23.9%). The culture was positive for bacterial growth in all cases. The conjunctival culture in the control group was positive in 17 eyes (41.4%). The mean count of colonies in a sample unit was 5274 ± 6300, 1167 ± 1504, and 9.5 ± 1.5 for group A, group B, and controls, respectively. The mean time of normalization of specimens was 3.3 ± 1.3 weeks (range 1-7). Pathogenic bacterial growth, higher colony counts, the presence of silicone tube, and purulent regurgitation were significantly associated with longer normalization time (p = 0.007, p = 0.0001, p = 0.0001, and p = 0.01, respectively). CONCLUSIONS: This study suggests that after successful dacryocystorhinostomy surgery, a waiting period of 7 weeks is enough for conjunctival bacterial cultures to become negative or reach the level of the normal eyes.

Improvement of Tamoxifen Induced Foveal Cavitation with Topical Dorzolamide Therapy.

PURPOSE: To present a case of severe foveal cavitation and near complete macular hole secondary to tamoxifen toxicity that improved after tamoxifen cessation and topical dorzolamide therapy. METHODS: A 45-year-old female referred with bilateral tamoxifen maculopathy. Bilateral foveal cavitation, worse in the right eye (OD) with draping of the internal limiting membrane, was noted with baseline optical coherence tomography. RESULTS: After discontinuing tamoxifen therapy and administering topical acetazolamide drops, cavitation remarkably improved OD with near resolution of the macular hole, and without recurrence 4 months after discontinuation of the topical drops. CONCLUSION: A short course of topical dorzolamide drop therapy may be beneficial in cases with severe foveal cavitation due to tamoxifen toxicity.

Clinical predictive factors and imaging biomarkers of treatment response to half dose PDT in patients with chronic central serous chorioretinopathy.

PURPOSE: To determine the clinical and imaging biomarkers of the response to half-dose photodynamic therapy (HD-PDT) in patients with central serous chorioretinopathy (CSC) METHODS: Clinical records and baseline ophthalmic images of 67 chronic CSC patients who underwent HD-PDT were assessed. In addition to demographic data, optical coherence tomography (OCT), fluorescein angiography (FA) and fundus autofluorescence (FAF) images were analyzed for specific biomarkers. The patients were categorized to early responder and late responder based on the time needed for complete resolution of subretinal fluid after PDT (less than 1 month vs. more than 1 month). The baseline clinical and imaging biomarkers were compared between the two groups. RESULTS: Seventy-three eyes of 67 patients were included in the study. The mean response time to PDT was 1.63 ± 1.48 months with 82.2% (60/73) of eyes categorized as early responder. The mean response time to PDT in delayed-response group was 4.15±1.51 months. In multivariate analysis, delayed response to PDT was associated with lacking history of systemic corticosteroid consumption, lacking history of pretreatment with eplerenone or acetazolamide before PDT and presence of hyperreflective foci in baseline OCT images (all p values < 0.05). There was no association between final visual outcome and late response to PDT. CONCLUSION: The presence of inflammatory biomarkers such as hyperreflective foci in baseline OCT images might be indicative of resistance to PDT. Moreover, the effect of pretreatment with mineralocorticoid antagonist on the response to PDT in chronic CSC should be explored in future prospective studies.

Retinal nerve changes in patients with tremor dominant and akinetic rigid Parkinson's disease.

Parkinson disease is a multisystem neurodegenerative disease which involves not only basal ganglia and extrapyramidal system but also many other neurologic systems such as retinal ganglion cells. Optical coherence tomography (OCT) is a non-invasive method for assessment of retinal nerve fiber layer (RNFL) thickness and its changes in different diseases. To evaluate the RNFL thickness in patients with Parkinson disease (PD), we performed OCT in patients with PD and compared it with a control group. From October 2010 to July 2011, 27 PD patients (54 eyes) and 25 healthy persons (50 eyes) were entered to this analytical cross-sectional study according to the defined criteria. PD patients were categorized into two groups "akinetic rigid (AR) and tremor dominant (TD)". RNFL was divided into four quadrants and was assessed by OCT. Afterwards; the data were analyzed by bivariate and multivariate models. The RNFL thickness in PD was significantly lower than the control group. Also, the thicknesses of inferior and nasal quadrants of RNFL in TD group were significantly more than AR group. According to these findings, OCT can be used as a sensitive and objective marker for assessment of early neurodegenerative changes of PD and early initiation of neuroprotective treatments. Future studies with adequate sample sizes are recommended to investigate interactions between age, distribution of the disease and type of PD as well as the effects of individual factors.

Incidence of acute endophthalmitis after intravitreal bevacizumab injection in a single clinical center.

PURPOSE: To assess the rate of infectious endophthalmitis in a single clinical center in Iran and to compare the rate of endophthalmitis in patients receiving postinjection antibiotics with those who did not. METHODS: A retrospective chart review of patients who received intravitreal injections of bevacizumab was undertaken. Cases of clinical diagnoses of endophthalmitis were reviewed. Bevacizumab was obtained at the time of injection from a commercially available vial after aseptic cleansing of the rubber cover. RESULTS: Five patients (six eyes) developed clinical endophthalmitis after the intravitreal bevacizumab injection. The risk per injection was 0.10% (6/5,901). One culture-positive case was found overall. Postinjection antibiotic drops were prescribed for 68% of eyes. All endophthalmitis cases were among those who received postoperative antibiotic eye drops. The difference in the rates of endophthalmitis between those receiving postinjection antibiotics and those who did not was not statistically significant (P = 0.18). CONCLUSION: A low risk of endophthalmitis consistent with the range of previous studies was observed notwithstanding the usage of multiple use of a single vial. Postinjection antibiotic drops may not be necessary.

Effects of local anesthesia with bupivacaine plus epinephrine on blepharoptosis and levator palpebrae muscle function.

PURPOSE: To evaluate the effect of local anesthesia with bupivacaine plus epinephrine on the extent of blepharoptosis and levator palpebrae muscle function. METHODS: : In this prospective interventional case series, patients with blepharoptosis who were candidates for aponeurotic surgery were included. After initial preparations in the operating room, a total of 1 ml of a mixture of bupivacaine 0.5% plus epinephrine 1:100,000 were injected into the upper eyelid. The margin reflex distance 1 (MRD1) and the extent of levator muscle function were measured before and 2, 5, 10, and 15 minutes after injection. RESULTS: A total of 36 eyes including 21 men (58.3%) and 15 women (41.7%) with an average age of 41.81 ± 23.09 (17-83 years) were studied. There were 21 eyes with myogenic and 15 eyes with aponeurotic blepharoptosis. The mean MRD1 was 1.18 ± 1.06 mm before injection and -0.02 ± 0.85, 0.52 ± 0.98, 0.98 ± 1.05, and 1.02 ± 1.06 mm at 2, 5, 10, and 15 minutes after injections, respectively. The changes in the MRD1 measurements were statistically significant at all time points. The MRD1 values decreased during the first 2 minutes after injection in 88.8% of eyes, but returned to initial value after 15 minutes in 84.3%. The change in the levator muscle function measurements was statistically significant at 2 and 5 minutes after injections; however, the differences were clinically negligible. CONCLUSIONS: : The local anesthesia of the eyelid with 1 ml bupivacaine plus epinephrine causes a temporary increase of blepharoptosis within the first few minutes with minimal effect on levator muscle function measurements.

The Correlation of Global Burden of Vision Impairment and Ambient Atmospheric Fine Particulate Matter.

Purpose: To assess the correlation between the worldwide burden of vision impairment (VI) and fine particulate matter (PM) 2.5. Methods: In this retrospective cross-sectional study, global and national prevalence and disability-adjusted lost year (DALY) numbers and rates of total VI, glaucoma, cataract, and age-related macular degeneration (AMD) were obtained from the Global Burden of Disease database. The global and national levels of PM2.5 levels were also extracted. The main outcome measures were the correlation of PM2.5 levels with total VI and three ocular diseases in different age, sex, and socioeconomic subgroups. Results: In 2019, the worldwide prevalence of total VI and exposure level of PM2.5 was 9.6% (95% uncertainty interval: 8.0-11.3) and 42.5 µg/m3, respectively. The national age-standardized prevalence rates of total VI (r p = 0.52, P < 0.001), glaucoma (r p = 0.65, P < 0.001), AMD (r p = 0.67, P < 0.001), and cataract (r p = 0.44, P < 0.001) have a positive correlation with PM2.5 levels. In addition, the national age-standardized DALY rates of total VI (r p = 0.62, P < 0.001), glaucoma (r p = 0.62, P < 0.001), AMD (r p = 0.54, P < 0.001), and cataract (r p = 0.45, P < 0.001) significantly correlated with PM2.5 levels. The correlations remained significant in different age, sex, and sociodemographic subgroups. Conclusion: National prevalence rates of VI and three major ocular diseases correlate significantly with PM2.5 exposure levels, worldwide.

Delayed-Onset Endophthalmitis after Intravitreal Aflibercept Injection.

Purpose: To describe delayed-onset infectious endophthalmitis 4 months after intravitreal aflibercept injection. Methods: An 80-year-old female was referred with signs and symptoms of clinical endophthalmitis 4 months after intravitreal injection of aflibercept for choroidal neovascularization. Noninfectious causes of panuveitis were excluded and she was diagnosed with delayed-onset postinjection infectious endophthalmitis. Vitreous and aqueous specimens were prepared and antibiotics (vancomycin and ceftazidime) were injected intravitreally. Results: Vitreous culture was positive for Staphylococcus epidermidis. During the 1st month after the antibiotic injections, symptoms and signs of the patient improved and became stable during the 6-month follow-ups. Conclusions: Delayed-onset infectious endophthalmitis can be presented following intravitreal injections. Late presentation of uveitis in postinjected eyes needs complete investigations to rule out infectious endophthalmitis as an ophthalmic emergency.

Age-Related Macular Degeneration Prevalence and its Risk Factors in Iran: A Systematic Review and Meta-Analysis Study.

Purpose: To estimate the prevalence of age-related macular degeneration (AMD) and determine its risk factors in Iran. Methods: A comprehensive electronic search was conducted in PubMed, Scopus, Web of Science, and Google Scholar, with no restrictions on time or language of publication. Eleven studies meeting the eligibility criteria were included. Six studies with a total sample size of 9930 were included in the meta-analysis to calculate the overall prevalence of AMD in Iran. Meta-analysis was performed using Stata/MP version 15.0. Risk of bias assessment was carried out based on the Newcastle-Ottawa Scale. Results: All participants in the studies were over 40 years old. The pooled prevalence of AMD was estimated to be 9.9% (95% confidence interval [CI]: 6.3%-13.5%). After accounting for publication bias, this estimated decreased to 6.4% (95% CI: 4%-10.2%). Smoking (odds ratio [OR]: 1.781; 95% CI: 1.152-2.756), hypertension (HTN) (OR: 1.512; 95% CI: 1.119-2.044), diabetes mellitus (DM) (OR: 1.545; 95% CI: 1.088-2.194), and hyperlipidemia (OR: 1.512; 95% CI: 1.055-2.165) were identified as AMD risk factors. Conclusion: Based on the results of the present review, the prevalence of AMD in the Iranian population over 40 years of age is estimated to be 6.4%, and having a history of smoking, HTN, DM, and hyperlipidemia are identified as risk factors of AMD in Iran. Further original studies are needed to draw more accurate conclusions.