The Role of Inferior Turbinate Fracture in the Management of Congenital Nasolacrimal Duct Obstruction.

PURPOSE: To evaluate the effect of inferior turbinate fracture in the treatment of congenital nasolacrimal obstruction combined with first attempt probing in children younger than 36 months. METHODS: This prospective case-control study was conducted on 230 eyes from 176 children aged 12 to 36 months with congenital nasolacrimal duct obstruction. All patients underwent simple probing under general anesthesia. Inferior turbinate fracture was performed in case group combined with first probing. Patients were followed up 1, 3, and 6 months after surgery. RESULTS: Total success rate was 91.2% for patients with turbinate fracture and 86.4% for patients without turbinate fracture. The difference between success rates was not statistically significant (p = 0.269). The authors did not find significant difference between cases and controls in age subgroups. Success rate in combined case and control groups in patients younger than 24 months (success rate: 91.7%) was significantly higher than those older than 24 months (success rate: 71.9%; p = 0.001). In univariate logistic regression analysis, age ≥24 months showed a negative association with the success rate (odds ratio = 0.232; 95% confidence interval: 0.91-0.59; p = 0.002). Other factors like sex, bilaterality of nasolacrimal duct obstruction, method of probing were not significantly associated with response to treatment. CONCLUSIONS: Inferior turbinate fracture does not improve the outcomes of simple probing and is not recommended during the first attempt in treatment of congenital nasolacrimal duct obstruction. Late probing (after 24 months of age) may have a higher failure rate, and increased age is the important factor that predicts failure in probing simple congenital nasolacrimal duct obstruction.

Accuracy of different lens power calculation formulas in patients with phacomorphic glaucoma.

PURPOSE: The purpose of the study was to determine the most accurate formula for intraocular lens (IOL) power calculation among five currently used formulas in eyes with phacomorphic glaucoma (PG) undergoing cataract extraction surgery. MATERIALS AND METHODS: In this prospective interventional case series Patients diagnosed with PG were undergone uneventful phacoemulsification and IOL implantation. After 3 months, the refractive outcome for each formula was evaluated with mean prediction error (PE), mean absolute error (MAE), and the percentages of eyes within 0.25 D and 0.5 D of predicted error. RESULTS: Twenty-three patients completed the study. PEs were significantly different among the 5 formulas (P = 0.019), and Holladay I had the least error (-0.02 ± 1.11). Haigis formula had the highest hyperopic shift (0.37 ± 1.22), highest MAE (0.99 ± 0.78) and the lowest percentages of desired PEs, while the SRK II produced the greatest percentages. The overall differences in MAE between the 5 formulas were statistically insignificant (P = 0.547). CONCLUSION: In some extreme situations like patients with PG, lower generation of IOL power calculation formulas may still produce more acceptable refractive outcomes.

Evaluation of the additive effect of interferon α 2b with monthly intravitreal injection of bevacizumab in refractory diabetic macular edema.

BACKGROUND: To evaluate the additive effect of topical or sub-tenon injection of interferon (IFN)-α 2b in the treatment of refractory diabetic macular edema. METHODS: In this prospective study patients with center-involved DME who were unresponsive to 3 monthly consecutive IVB injections were recruited. Patients were divided into three groups: group1, received IFN- α 2b topical drop at a dose of 1mIU/ml four times a day for 3 months. Group 2, received a single sub-tenon injection of 1mIU/ml IFN- α 2b at the enrollment. Group 3 received artificial tears four times a day for 3 months (control group). All groups received three consecutive monthly IVB injections and were evaluated monthly up to 1 month following the last IVB injection. RESULTS: In this study, 59 eyes of 35 patients with refractory DME were assessed. The final follow-up showed that although CMT decreased in all groups, only patients in Group 2 had statistically significant lower CMT compared to their baseline values (change in CMT: - 117 ± 213 µm; p-value = 0.025). Comparison of CMT changes between three groups showed no statistically significant difference, although it was higher in group 2 (change in CMT: - 117 ± 213 µm (Group2) vs. - 49 ± 173 (Group 1) vs. - 36 ± 86 (Group 3); p-value = 0.085). Considering eyes with baseline CMT > 400 µm, sub-tenon injection of IFN α2b led to a significant reduction of CMT at the first month and final follow-up visit (CMT change: - 166 ± 210, - 145 ± 231 µm; p-value = 0.018 and 0.035, respectively). In this subgroup, eyes in Group 2 had lower CMT at the first month following treatment in comparison with the control group (CMT: 444 ± 123 µm vs. 544 ± 96 µm, p-value = 0.042). Alterations of CDVA were not statistically significant among groups, although patients in Group 1 had a significant improvement in vision at second and last follow up (CDVA change: - 0.23 ± 0.39, - 0.20 ± 0.43 logMAR; p-value = 0.030 and 0.010, respectively). CONCLUSIONS: In short term, Sub-tenon injection of IFN might have an additive anatomical effect in eyes with refractory DME. Validation of this observation requires further prospective controlled studies.

Pulled versus Pushed Monocanalicular Silicone Intubation in Adults with Lacrimal Drainage System Stenosis: A Comparative Case Series.

PURPOSE: To compare the success rate and complications of pulled versus pushed monocanalicular intubation in adults with incomplete lacrimal drainage system obstruction (lacrimal drainage system stenosis). METHODS: Patients with lacrimal drainage system stenosis (Munk grade ≥3), including both nasolacrimal duct (NLD) stenosis and common canalicular stenosis, were recruited in this prospective comparative case series. Patients underwent probing and either Monoka (51 eyes) or Masterka (48 eyes) intubation under general or local anesthesia. Tubes were removed 4-14 weeks after the procedure. Six months after tube removal, Munk grades 0 and 1 were defined as a complete success, Munk grade 2 was defined as a partial success, and Munk grade ≥3 was defined as failure. All complications were recorded. RESULTS: Ninety-nine eyes from 89 patients with lacrimal drainage system stenosis who underwent either Monoka (51 eyes) or Masterka (48 eyes) intubation were included. The mean (SD) age of the patients was 55.4 (12) years in the Monoka group and 53.5 (12.9) in the Masterka group. Groups were matched on demographics. Masterka intubation could not be performed in one eye. Complete and partial successes were observed in 52.9% (27/51) and 17.6% (9/51) of eyes in the Monoka group and 42.6% (20/47) and 12.8% (6/47) of eyes in the Masterka group, respectively (p=0.29). There was a trend toward a higher total success rate in patients with NLD stenosis treated with Monoka 66.7% (26/39) than Masterka 45.5% (15/33) intubation (p=0.07). This trend also existed in patients with common canalicular stenosis (83.3% (10/12) vs. 76.6% (11/14), p=0.75). Age, sex, bilateral involvement, and duration of intubation did not have a significant impact on the success rate. Early tube loss, slit puncta, and temporary superficial punctate keratopathy were observed complications. CONCLUSION: Intubation with the pulled monocanalicular silicone tube was associated with a slightly but not significantly higher success rate in adults with lacrimal drainage system stenosis. Patients with NLD stenosis may achieve better results with pulled silicone tubes.

Closantel Retinal Toxicity: Case Report and Literature Review.

A 57-year-old shepherd was referred with a 2-week history of decreased visual acuity in both eyes. Optical coherence tomography (OCT) (Heidelberg Engineering GmbH, Heidelberg, Germany) revealed diffuse outer nuclear layer hyperreflectivity and indistinguishable external limiting membrane and ellipsoid zone. The patient announced to us that he took two 500 mg of closantel tablets (15.15 mg/kg) three days before the initiation of visual problems for sore throat as an antibiotic. Electroretinography displayed severely attenuated responses in both eyes. We decided to admit the patient with the presumed diagnosis of closantel retinal toxicity and treated him with intravenous methylprednisolone 1 g per day and intravenous erythropoietin 10000 IU twice a day, and reevaluation of the patient proved no change in his visual acuity on the third day of admission. Closantel is a veterinary drug with serious side effects in the human retina and central nervous system even in previously reported doses. Public awareness and appropriate drug labeling about its side effects could prevent accidental toxicity. OCT is a noninvasive and rapid diagnostic modality that should be done in suspected toxic retinopathy.

Sickle Cell Trait Presenting as Unilateral Proliferative Retinopathy and Macular Thinning in a Pregnant Woman.

BACKGROUND: To report a case of a pregnant woman with sickle cell trait (SCT) who presented with unilateral proliferative sickle cell retinopathy. Case Presentation. A 26-year-old otherwise healthy pregnant woman presented with the complaint of visual loss in her left eye. The funduscopic examination showed vitreous hemorrhage, sea fan neovascularization, and pale optic disc. Optical coherence tomography revealed macular inner retinal layer thinning and foveal splaying (saucerization of the foveal pit). The investigations, including hemoglobin electrophoresis, verified the diagnosis of sickle cell trait. Blood pressure, fasting blood glucose tests, and tuberculin skin tests were normal. We treated the patient by peripheral retinal photocoagulation over the area of nonperfusion. CONCLUSION: Even though the sickle cell trait is generally considered as a milder form of sickle cell disease without severe retinal manifestations, pregnancy should be considered as a trigger that can induce proliferative changes and foveal splaying in this group of patients.

Lens exchange for management of accommodative intraocular lens tilting.

Accommodative intraocular lens (IOL) tilting, the so-called Z syndrome, is a rare complication of Crystalens (Bausch and Lomb) implantation. We report a significant IOL tilting and subsequent high lenticular astigmatism due to posterior capsular fibrosis 2 months after uncomplicated cataract surgery and Crystalens (AT50AO) implantation. The attempt to correct IOL position with neodymium-yttrium-aluminum garnet laser was unsuccessful, and Crystalens exchange with in-the-sulcus, three-piece monofocal IOL was performed. Accommodative IOL tilting could occur early after the surgery. Laser capsulotomy may be the first intervention to restore IOL position, but patients with a higher amount of lenticular astigmatism may require surgical intervention and IOL exchange.

Surgical outcome of a new modification to muscle belly union surgery in heavy eye syndrome.

OBJECTIVES: To report the clinical outcomes of a new modification to muscle belly union surgery in heavy eye syndrome. METHODS: Muscle belly union was performed in patients with large-angle esotropia and characteristic findings of heavy eye syndrome on orbital imaging. After isolation of superior and lateral rectus muscle and passing a single armed suture in each muscle belly, approximation was achieved via tying of both arms of separate sutures together. Medial rectus (MR) was also recessed considering the results of the intraoperative force duction test. RESULTS: Surgery was conducted in 24 eyes of 16 patients. The mean preoperative esotropia was 93.71 ± 23.1 prism diopters (PD), which improved significantly after the operation (final esotropia: 11.53 ± 15.59 PD, P value = 0.001). Six patients also exhibited mild hypotropia preoperatively (9.33 ± 6.88 PD), which resolved completely after surgery in all cases. Evaluation of preoperative abduction limitation (minus 3.1 ± 1.83) showed a significant improvement postoperatively (minus 0.95 ± 0.68, P value = 0.000). Additionally, mild limitation of adduction (minus 1) was seen in nine patients due to large MR recession. However, none of the patients reported postoperative diplopia. CONCLUSION: Our new approach in muscle belly union surgery resulted in favorable outcomes compared with previous studies. It seems that the two-suture technique presented in this study yields more convenient approximation of muscle bellies and acts as a safety suture upon spontaneous loosening of the first applied suture.