Superior divisional third nerve palsy due to breast cancer metastasis to the orbital apex.

PURPOSE: To report a case of breast cancer with metastasis to the orbital apex with manifestation of superior divisional third nerve palsy. CASE DESCRIPTION: A 40-year-old female, a known case of breast cancer diagnosed 3 years ago, referred to our neuro-ophthalmology clinic with chief complaint of ptosis and diplopia. In ophthalmic examination, visual acuities of both eyes were 20/20 and there was no significant finding in the anterior and posterior segment ophthalmic examination. There was left eye ptosis with MRD1 of 2 mm. In ocular movement examination, there was limitation of motion in supraduction (-2 to -3) of the left eye. Orbital MRI with contrast was requested for the patient which demonstrated a lesion in the orbital apex of the left eye. At the end, the patient was diagnosed as having superior divisional third nerve palsy. Orbital radiotherapy was recommended for the patient. CONCLUSION: In a patient with breast cancer who presents with diplopia, metastasis to the orbital apex with manifestation of divisional third nerve palsy should be kept in mind, and appropriate orbital imaging should be considered.

Serum Selenium Levels in Patients With Graves Disease With or Without Thyroid Ophthalmopathy.

BACKGROUND: Graves disease is one of the most common autoimmune thyroid diseases. Thyroid has the highest concentration of selenium (Se) in the body. Se plays a crucial role in the functioning of some thyroid enzymes; however, there are controversial results regarding the administration of serum Se levels in patients with Graves disease. METHODS: In this study, patients with Graves disease with orbitopathy (GO group) or without orbitopathy (GD group) were recruited. Healthy individuals without a history of any disease were enrolled as the control group. Serum Se and thyroid hormone levels, including T3, T4, and thyroid-stimulating hormone (TSH), were measured using atomic absorption and radioimmunoassay techniques, respectively. RESULTS: In this cross-sectional study, 60 and 56 patients and 58 healthy subjects were included in the GO, GD, and control groups. Serum Se levels in the GO, GD, and control groups were 94.53 ± 25.36 µg/dL, 96.82 ± 30.3 µg/dL, and 102.55 ± 16.53 µg/dL, respectively (P = .193). There was a reverse association between the serum Se level and thyroid hormones, including T3, T4, and TSH, in the GO group. However, serum Se levels exhibited a significant reverse association with T4 and TSH hormones but not with T3 in the GD group. CONCLUSION: Our results showed no significant differences in the serum Se levels in the GO and GD groups compared with that in the control group. In addition, we did not detect any significant difference in the serum Se levels between the GO and GD groups.

Effect of calcium dobesilate on retrobulbar blood flow and choroidal thickness in patients with non-proliferative diabetic retinopathy.

INTRODUCTION: Diabetic retinopathy is one of the most common causes of blindness in work-aging adults and develops in one third of diabetic patients. Calcium dobesilate (CaD) treatment have protective effects on blood retinal barrier (BRB) and anti-oxidant as well as anti-inflammatory properties. OBJECTIVES: To assess effects of CaD administration on retrobulbar blood flow and choroidal thickness in patients with diabetic retinopathy. METHODS: In this quasi-experimental study, diabetic patients with diabetic retinopathy (DR) were recruited from Shahid Motahari and Poostchi ophthalmology clinic affiliated to Shiraz University of Medical Sciences. Patients were treated with CaD, 1 gr per day for seven days. Before and after CaD administration, retrobulbar blood flow and subfoveal choroidal thickness were assessed. Retrobulbar blood flow were evaluated by measuring peak systolic velocity (PSV), end diastolic velocity (EDV) and resistive index (RI) of ophthalmic artery (OA), central retinal artery (CRA) and short ciliary artery (SCA). RESULTS: In this study, 26 DR patients with a mean age of 56.15 ± 8.93 years and mean diabetes mellitus duration of 15.04 ± 7.64 years were enrolled. Subfoveal choroidal thickness was significantly increased from 316.08 ± 61.69 to 327.81 ± 58.03 after CaD treatment (P value < 0.001). PSV of CRA and EDV of all arteries were significantly increased after CaD administration. In addition, RI of all arteries was significantly reduced after CaD treatment (P < 0.001). CONCLUSION: CaD treatment may improve the ophthalmic blood flow and increase the subfoveal choroidal thickness in DR patients. These results may be suggestive of protective effects of CaD on endothelium function as well as microvascular circulation.

Evaluation of plasma Osteopontin level in relapsing- remitting multiple sclerosis patients compared to healthy subjects in Isfahan Province.

Background: Multiple sclerosis (MS) is known as a neuroinflammatory disease of the central nervous system (CNS). The neuroinflammation may induce pro-inflammatory cytokines such as Osteopontin (OPN). OPN plays an important role in the inflammation by modulating the T helper1 (Th1) and Th17 responses. Since the exact immune pathogenesis of MS is complex and not well defined and many factors are involved, the need to detect more contributing biomarkers may help in setting new therapeutic strategies.Objective: This study tried to compare plasma OPN levels in relapsing- remitting multiple sclerosis (RRMS) patients during the remission phase with healthy subjects in Isfahan province.Materials and methods: In a case-control study, plasma was collected from the 40 RRMS as well as 38 (age and sex matched) healthy individuals as a control group. PlasmaOPN level was measured and compared between the two groups by Enzyme-linked immunosorbent assays (ELISA).Result: Statistical analysis revealed that plasma OPN level was markedly higher in the case group (RRMS patients during the remission phase) compared with the control group (P- value = 0.039). Our results also showed that there was no statistically significant difference in mean of plasma OPN level among RRMS patients who were treated with interferon (IFN)-ß and those who were not (P- value = 0.332). There was also no correlation between OPN plasma level and EDSS score (r = 0.037, P- value = 0.835), age of onset (r = 0.161, P- value = 0.357) and duration of disease (r = 0.121, P- value = 0.490).Conclusion: Higher OPN plasma level in studied patients suggests that OPN increased in RRMS patients who were in remission phase. It could be hypothesized that plasma OPN level may be increased as part of the pro-inflammatory cytokine milieu taking place in MS patients. OPN may not be specific marker for MS, but targeting it might present promising therapeutic effect to MS patients.

Clinical and serological approach to patients with brucellosis: A common diagnostic dilemma and a worldwide perspective.

According to the WHO factsheet, although approximately half a million brucellosis cases are reported annually, the true incidence is always 10-25 times higher than the reported number of cases. Therefore, we face a common yet uncommonly recognized entity of brucellosis, which highlights the importance of providing precise and understandable guidelines for physician to recognize and manage the disease. Up to now, there is no distinct and clear guideline for brucellosis diagnosis. Hence, this article presents for the first time an algorithm based on our 30 years clinical experiences for brucellosis diagnosis. There are several serological patterns of brucellosis due to the insidious nature and serologic response of this disease. In contrast to most infectious diseases, the IgM response to brucellosis remains after the acute phase, IgG responses often fade after improvement and there is no lifelong positivity for IgG antibody. This diversity of serological pattern leads to seven clinical subtypes of the disease; three of those do not need any medical intervention. In endemic regions, this issue makes a challenging diagnostic puzzle for clinicians, which may consequently lead to national and international over- or underestimation of brucellosis incidence. On one hand, this may change the epidemiological landscape of brucellosis. On the other hand, drugs used in therapy are often accompanied by serious or sometimes irreversible side effects. Accordingly, we attempt to create a unique template to better identify these seven serological patterns and give a comprehensive insight into the diagnostic approach to brucellosis. Moreover, we describe in detail the appropriate use of wright, 2 ME, Coomb's WRIGHT, and ELISA tests.

Elevated serum level of IL-4 in neuromyelitis optica and multiple sclerosis patients.

Mediators have important roles in the pathogenesis of autoimmune diseases. Interleukin 4 (IL-4) is one of the most important cytokines that has a regulatory effect on immune cells. In the current study, the serum level of IL-4 was assessed in the newly diagnosed neuromyelitis optica (NMO) and multiple sclerosis (MS) patients compared to healthy subjects. ELISA technique was used for assessment of the serum level of IL-4, and data analysis was performed by SPSS software. Serum level of IL-4 was elevated in both NMO and MS patients compared with healthy individuals (P < .001), but no statistically significant difference was identified between MS and NMO patients (P = .071). Furthermore, gender (female) and AQP4-Ab had significant impacts on the level of IL-4 in NMO patients (P < .001). These data show the crucial role of IL-4 in the pathogenesis of NMO and MS diseases. However, we suggest future studies to investigate the serum level of IL-4 in NMO and MS patients to clarify more roles of this cytokine in the pathogenesis of both diseases.

Serum level of interleukin 36 in patients with multiple sclerosis.

INTRODUCTION: Multiple sclerosis is a chronic autoimmune demyelinating disorder of central nervous system with unknown origin. In MS disease, T cells are pointed to myelin antigens and it leads to myelin loss and axonal degeneration. Cytokines are important regulators of immune system and has critical roles in MS pathogenesis. Interleukin 36, a member of interleukin 1 family, has been shown having important roles in some autoimmune disorders due to its proinflammatory actions and its role in host immunity. METHODS AND MATERIALS: In the current study, 49 relapsing remitting multiple sclerosis patients and 41 healthy individuals were recruited. IL36 measurement was performed using enzyme-linked immunosorbent assay technique. RESULTS: Mean age of RRMS patient and control group were 31.84 ± 6.89 and 34.27 ± 8.83 years, respectively. Serum level of IL36 were 61.91 ± 16.29 in MS patients and 42.26 ± 17.54 in healthy group (P < 0.001). CONCLUSION: in this study for the first time, significantly higher serum level of IL36 was determined in RRMS patients comparing healthy individuals. This data may suggest important roles of this cytokine in MS pathogenesis.

The effects of smoking on corneal endothelial cells: a cross-sectional study on a population from Isfahan, Iran.

PURPOSE: The aim of this study is to compare the effect of smoking in corneal endothelial cell number and morphology by specular microscopy on a non-smoker population. METHODS: Our cross-sectional study was performed on 150 participants from a non-smoker population. Non-contact specular microscopy (Tomey Corporation Inc., Nagoya, Japan) was performed in the center of the cornea of all subjects. The cell density (CD), average cell size (AVG), percent of hexagonality (HEX%) and central corneal thickness (CCT) were calculated and compared in both groups. RESULTS: Totally, 76 eyes of 76 smokers and 74 eyes of 74 non-smokers were enrolled in the study from 2015 to 2016. The mean age of smokers and non-smokers were 48.61 ± 17.04 and 46.39 ± 13.02, respectively. The mean number of pack/year among the smokers was 17.36 ± 14.68. Also, the mean values of AVG and CD were significantly different for these two groups (p = 0.011 and p = 0.039, respectively). Other corneal endothelial variables did not show a significant difference between smokers and non-smokers (p > 0.05). However, smokers with severe nicotine dependency had significantly greater AVG and lower CD in comparison with the non-smokers (p = 0.004 and p = 0.013, respectively). CONCLUSION: Our study showed that smoking can cause significant changes in some of the corneal endothelial variables, but not all of them.

Hyperimmunoglobulin E syndrome: Genetics, immunopathogenesis, clinical findings, and treatment modalities.

The hyperimmunoglobulin E syndromes (HIESs) are very rare immunodeficiency syndromes with multisystem involvement, including immune system, skeleton, connective tissue, and dentition. HIES are characterized by the classic triad of high serum levels of immunoglobulin E (IgE), recurrent staphylococcal cold skin abscess, and recurrent pneumonia with pneumatocele formation. Most cases of HIES are sporadic although can be inherited as autosomal dominant and autosomal recessive traits. A fundamental immunologic defect in HIES is not clearly elucidated but abnormal neutrophil chemotaxis due to decreased production or secretion of interferon γ has main role in the immunopathogenesis of syndrome, also distorted Th1/Th2 cytokine profile toward a Th2 bias contributes to the impaired cellular immunity and a specific pattern of infection susceptibility as well as atopic-allergic constitution of syndrome. The ophthalmic manifestations of this disorder include conjunctivitis, keratitis, spontaneous corneal perforation, recurrent giant chalazia, extensive xanthelasma, tumors of the eyelid, strabismus, and bilateral keratoconus. The diagnosis of HIES is inconclusive, dependent on the evolution of a constellation of complex multisystemic symptoms and signs which develop over the years. Until time, no treatment modality is curative for basic defect in HIES, in terms of cytokines/chemokines derangement. Of note, bone marrow transplant and a monoclonal anti-IgE (omalizumab) are hoped to be successful treatment in future.

Photorefractive keratectomy in the management of postradial keratotomy hyperopia and astigmatism.

BACKGROUND: The aim of this study is to evaluate the results of photorefractive keratectomy (PRK) in the management of postoperative hyperopia and astigmatism in patients with history of radial keratotomy (RK). MATERIALS AND METHODS: This prospective nonrandomized noncomparative interventional case series enrolled consecutive eyes treated with PRK after RK. In cases, in which (1) wavefront (WF) scan was undetectable during primary examinations; and/or, (2) WF data were not transferable to the excimer laser device, patients were treated with the tissue-saving (TS) mode. Patients with detectable/transferable WF were assigned to WF-guided advanced personalized treatment (APT). RESULTS: Thirty-two and 47 eyes were managed by APT and TS modes, respectively. Pooled analysis of both APT and TS groups showed improvement in uncorrected distant visual acuity and corrected distant visual acuity. The amount of sphere, cylinder, corneal cylinder, spherical equivalent, defocus equivalent, and total aberration showed improvement as well. CONCLUSION: PRK seems to bring favorable outcome and safety profile in the management of post-RK hyperopia and astigmatism. It is crucial for practitioners to warn their patients about the fact that they may still have progressive refractive instability regardless of their choice on the laser method of vision correction.

Role of rs7903146 polymorphism and adropin serum level in patients with diabetes mellitus; a case-control study from Isfahan, Iran.

BACKGROUND: Type-2 diabetes mellitus (T2DM) is the common endocrinopathy which characterised by insulin resistance, insufficient expression or secretion of insulin and decrement of insulin effectiveness. Although T2DM has unknown aetiology, the strongest susceptible gene in this disease is TCF7L2. Adropin peptide may have roles in T2DM pathogenesis due to several roles in glucose tolerance, decrement of insulin resistance, lipid metabolism and energy homoeostasis. AIM: To evaluate the serum level of adropin in T2DM patients and comparing with healthy individuals as well as assessing frequency of rs7903146 genotypes/alleles in patients and control groups. METHODS: We analysed the frequency of rs7903146 genotypes/alleles in 93 patients with T2DM disease and 53 healthy individuals by the method of polymerase chain reaction-restriction fragment length polymorphism analysis. The serum level of adropin was measured by using enzyme-linked immunosorbent assay technique. RESULTS: The mean serum level of adropin was 12.32 ± 2.98 and 9.51 ± 2.73 in patients and control groups, respectively (p value < .001). Also, there were significant difference in frequency of genotypes and alleles of rs7903146 in patients and controls groups (p < .001). The rs7903146T/T and rs7903146C/T genotypes increased risk of T2DM disease (OR: 6.035 and OR: 3.082, respectively). Interestingly, the highest level of adropin was detected in T2DMpatients with rs7903146T/T genotype. CONCLUSION: Our analysis showed higher level of adropin in T2DM patients and increased risk of T2DM with rs7903146T/T and rs7903146C/T genotypes.

Corneal Biomechanical Changes after Corneal Cross-Linking in Patients with Keratoconus.

Purpose: To evaluate the changes in biomechanical properties of the cornea using the Corvis ST device after the treatment of keratoconus patients with ultraviolet-A/riboflavin corneal cross-linking (CXL). Methods: Thirty-seven eyes from 37 consecutive patients with progressive keratoconus were included in this prospective observational case series. Corneal biomechanical parameters including the length of the applanated cornea (L1 and L2), corneal movement velocity during applanation (V1 and V2) at the moment of the first and second applanation, deformation amplitude (DA), distance between bending points of the cornea points of the cornea (PD), and concave radius of curvature (R) at the point of the highest concavity were recorded using the Corvis ST at baseline, 3 months, and 1 year after CXL. Results: The mean age of the patients was 23.27 years (range, 19-31 years). Among CorVis ST corneal biomechanical parameters, L1, DA, PD, and R at the point of the highest concavity did not change significantly. The length of the applanated cornea at the moment of second applanation (L2) showed a significant change 3 months after CXL, but no significant difference was found between the 3-month and 1-year values of this parameter. Corneal movement velocity during applanation (V1 and V2) did not change 3 months after doing CXL, but the changes in these parameters were significant 1 year after CXL. Conclusions: Although the CorVis ST device may detect changes in some biomechanical properties of cornea after the treatment of keratoconus patients with CXL, many parameters remain unchanged, and this device cannot readily be used to find the effects of CXL.