Comparison of the effect of tea tree oil eye gel with standard treatment in patients with anterior blepharitis: An open-label clinical trial.

Purpose: Daily cleansing of eyelids is very important to carry out a successful blepharitis treatment. However, there are no therapeutic guidelines for blepharitis. The aim was to compare the symptomatic relief of anterior blepharitis using Blephamed eye gel, a cosmetic product, versus standard treatment. Methods: The study was a prospective, interventional open label clinical trial at a university-based hospital. The test population was subjects aged 18-65 years who presented with mild to moderate anterior blepharitis. Eyelid hygiene was applied twice a day. At each visit, a detailed assessment of symptomatology was carried out. A two-way repeated measure mixed model ANOVA was used to compare two groups by time. Results: In total, 61 patients with mean age of 60.08 ± 16.69 years were enrolled in the study including 30 patients in standard group and 31 patients in Blephamed group. Two groups did not differ in terms of age (P = 0.31) and eye laterality (P = 0.50). The baseline scores of erythema, edema, debris, and symptoms as well as total score were similar between two groups (all P values >0.50). Two groups became different for all these parameters at day 45 (all P values <0.001). Significant interaction was detected between time and intervention groups for all severity parameters of blepharitis as well as total score (all P values <0.001). Conclusion: Eyelid hygiene with Blephamed more significantly decreased symptoms of anterior blepharitis compared to standard treatment.

Local ocular safety of the subconjunctival injection of cetuximab in rabbits.

BACKGROUND: To evaluate the safety of different doses of subconjunctival cetuximab in rabbits. METHODS: After general anesthesia rabbits received a subconjunctival injection of 2.5 mg in 0.5 ml, 5 mg in 1 ml, and 10 mg in 2 ml of cetuximab in their right eyes (two rabbits in each group). A similar volume of normal saline solution was injected subconjunctivally in the left eyes. The histopathologic changes were evaluated after enucleation with the aid of H&E staining. RESULTS: No significant difference were observed between the treated and control eyes in terms of conjunctival inflammation, goblet cell density, or limbal blood vessel density for all administered doses of cetuximab. CONCLUSION: Subconjunctival injection of cetuximab with the administrated doses in rabbit eyes are safe.

A clinical decision support system for diagnosing and determining severity of dry eye disease.

INTRODUCTION: Dry eye and its related symptoms are the most common causes of referrals to the ophthalmology centers. Since people with dry eye may suffer from different levels of the disease severity, this study aimed to develop a clinical decision support system for diagnosing and determining severity of dry eye disease. METHODS: This research was carried out in two phases in 2020. In the first phase, a questionnaire was designed to identify the most important diagnostic parameters from the cornea specialists' perspectives (n = 37). In the second phase of the research, a clinical decision support system was designed and implemented by using MATLAB software. Finally, the system was evaluated using patient data which were collected in a teaching hospital (n = 50). RESULTS: The diagnostic parameters for dry eye disease were filamentary keratitis, meibomian gland dysfunction, score of ocular surface disease index, Schirmer's test result, tear meniscus height, tear breakup time, and fluorescein staining score. The system output variables were the diagnosis and severity of dry eye disease at four levels for the right and left eyes, separately. The results of the evaluation study showed that the accuracy, sensitivity and specificity of the system were 96.9%, 97.5%, and 93.7%, respectively. CONCLUSION: It seems that the system designed in this study can help ophthalmologists to diagnose dry eye disease more accurately and quickly. However, it is recommended to conduct more evaluation studies and include more patients in the future research.

Outcomes of a Single-Segment Intrastromal Corneal Ring in Early Keratoconus and Early Pellucid Marginal Degeneration.

PURPOSE: To determine the effect of a single-segment intrastromal corneal ring segment (ICRS; Intacs SK) on early keratoconus (KCN) and pellucid marginal degeneration (PMD). METHODS: It is a prospective interventional study. One hundred twenty-four eyes (99 patients) with KCN and 36 eyes (26 patients) with PMD at early stage (the maximum keratometric reading less than 55 diopters) were included to ICRS implantation using femtosecond laser at a tertiary university-based hospital and a private outpatient center. The uncorrected distance and spectacle-corrected visual acuity (UDVA and SCDVA), manifest spherical and cylindrical refractions, and keratometry indices were measured preoperatively and postoperatively, 1 week, 2 and 6 months. RESULTS: One week after surgery, significant improvements were observed in UDVA, SCDVA, cylinder and keratometry readings of both KCN and PMD groups (all P < 0.05) with no significant changes afterward. No significant change occurred in the sphere refraction of PMD group (P = 0.10) in contrast to KCN group (P < 0.001). Corneal irregularity of KCN group in central 3 and 5 mm zones increased at 1 week (both P < 0.001) and then started to decrease up to 6 months. However, the corneal irregularity of PMD group had significant reduction only at 1 week in 5-mm zone (P = 0.02) and 2 months in 3-mm zone (P = 0.01) postoperatively. The final efficacy indexes were 1.44 ± 0.71 and 0.87 ± 0.40 in KCN and PMD groups, respectively. CONCLUSION: Visual acuity, refractive errors and keratometry values have been improved after one-segment Intacs SK implantation in early KCN and PMD patients.

Improvement of pseudophakic cystoid macular edema with subconjunctival injections of interferon α2b:a case report.

Purpose: To report a patient with resistant cystoid macular edema after an uneventful phacoemulsification cataract surgery who responded to subconjunctival interferon α2b injections. Observations: This report describes a 60-year-old male patient with pseudophakic cystoid macular edema that was unresponsive to multiple courses of topical non-steroidal anti-inflammatory drugs and steroids during the follow-up period. Weekly subconjunctival interferon α2b (5 MIU/ml) was administered four times. Cystoid macular edema completely resolved after the 4th injection.During a six-month follow-up period, cystoid macular edema did not recur. No adverse local and systemic side effects were observed. Conclusions and importance: Weekly subconjunctival interferon α2b injections might be a safe and effective treatment modality in the treatment of stubborn pseudophakic cystoid macular edema to conventional treatment.

Short-term changes of cornea and tear film after ruthenium-106 plaque therapy for intraocular tumors.

PURPOSE: Plaque therapy is a well-recognized treatment for intraocular tumors. In current study, we aimed to prospectively investigate the short-term effects of ruthenium 106 (Ru-106) plaque therapy on the cornea and ocular surface parameters. METHODS: Twenty-five patients diagnosed with choroidal melanoma which undergone Ru-106 plaque therapy from 2016 to 2018 were included. Tear osmolarity, tear film break-up time, Schirmer test I, fluorescein dye staining based on Oxford staining method; Ocular Surface Disease Index (OSDI) questionnaire and corneal specular microscopy were performed. These tests were assessed preoperatively and then 3 months postoperatively. RESULTS: The mean (±SD) age of subjects was 48.52 ± 15.18 years. The patients were followed for a mean(±SD) period of 3.64 ± 2.40 months. Total mean (+SD) delivered radiation dose to the tumor apex and total received radiation by the sclera was 83.20 ± 26.31 and 640.65 ± 472.69 Gray (Gy), respectively. In longitudinal analysis, OSDI score and Oxford staining score increased significantly (P = 0.002 for both variables) and the prevalence of dry eye disease (DED) increased from 20% preoperatively to 72% at 3 months postoperatively (P = 0.001).The changes in the all specular microscopy parameters were statistically nonsignificant (all P values > 0.05). CONCLUSION: There is a considerable increase in the rate of DED following plaque therapy for the treatment of choroidal melanoma in short-term follow-up. The OSDI questionnaire and fluorescein staining test are valuable tools for early detection of DED postoperatively.

Long-Term Visual and Refractive Stability and Ocular Biometric Changes after Laser-Assisted Subepithelial Keratomileusis for Correction of Myopia: An 8-Year Follow-Up.

PURPOSE: To assess the long-term visual and refractive stability and ocular biometric changes in low to moderate myopic subjects treated by laser-assisted subepithelial keratomileusis (LASEK). METHODS: It is a prospective, interventional study. Included were 70 eyes of 35 patients who underwent LASEK for correction of ≤6 diopters (D) myopia. The uncorrected and corrected distance visual acuity (UDVA and CDVA), manifest refractions, and ocular biometric indices (by Lenstar-LS900, Haag-Streit AG, Koeniz, Switzerland) including keratometry, anterior chamber depth (ACD), aqueous depth (AD), axial length (AL), central corneal thickness (CCT), and lens thickness (LT) were assessed preoperatively and after 6 months and 8 years. RESULTS: Mean preoperative spherical equivalent was -3.99 (standard deviation [SD] =1.38) D which improved to 0.02 (SD = 0.27, P < 0.001) D and -0.10 (SD = 0.31, P < 0.001) D at 6 months and 8 years, respectively. The preoperative AL was not different from postoperative measures at 6 months (P = 0.15) and 8 years (P = 0.47). The ACD and AD decreased during 8 years, while LT increased (all P ≤ 0.001). The changes of LT inversely correlated with changes of ACD (rs = -0.67, P = 0.001 at 6 months and rs = -0.87, P < 0.001 at 8 years) and AD (rs = -0.76, P < 0.001 at 6 months and rs = -0.86, P < 0.001 at 8 years). The CCT and keratometry values reduced at 6 months postoperatively (all P < 0.001) and then did not change up to 8 years (0.21 ≤ P ≤ 0.87). CONCLUSIONS: The post-LASEK myopic regression is 0.1 D over 8 years. Ocular biometric values like keratometry, CCT, ACD, AD, and LT have been changed for a long period after LASEK in low to moderate myopia except AL.

Abobotulinum toxin A for periorbital facial rejuvenation: impact on ocular refractive parameters.

CLINICAL RELEVANCE: Botulinum toxin is commonly used for cosmetic facial rejuvenation and can result in pain at the injected site, bruising and ecchymosis, erythema and oedema, headache, diplopia, blurred vision, focal facial weakness. This study evaluates the impact of botulinum toxin on refractive error and binocular vision. BACKGROUND: Botulinum toxin (trade name: Dysport) is a neurotoxic protein which is made from a Gram-positive anaerobic bacterium known as Clostridium botulinum. In this study, we aimed to evaluate the impact of Dysport injection on refractive error, near point of accommodation and convergence, and palpebral fissure height. METHODS: Twenty-eight subjects were treated for facial wrinkles, using Dysport. A 500-unit vial of Dysport was diluted with 2.5-ml preserved normal saline, and injected doses were 30-units for crow's feet, six units for lower eyelid wrinkles, 25 to 50-units for glabellar lines (five points), and 20 to 40 for forehead creases on four points. The refractive error, near point of accommodation and convergence and palpebral fissure heights were assessed before and two weeks after injection. RESULTS: The participants comprised 23 women and five men at a mean age of 53.51 ± 14.1-years. The means of the equivalent sphere before and after injection were -0.07 ± 1.34 and -0.08 ± 1.35 (p = 0.36). The means of near point of accommodation monocularly before and after injection were 29.75 ± 6.16-cm and 26.75 ± 6.00, respectively. The means of near point of convergence before and after injection were 16.03 ± 5.27-cm and 15.55 ± 6.14, respectively (p = 0.30). The means of palpebral fissure height before and after injection were 10.33 ± 1.69-mm and 10.20 ± 1.46-mm, respectively. The changes in equivalent spherical refractive error, binocular near point of accommodation and convergence were not statistically significant. CONCLUSION: Dysport injection for the correction of upper face animation lines, if performed at the appropriate sites and the appropriate concentration, has no significant impact on refractive error, near point of accommodation and convergence, and palpebral fissure height.

Disruption of blood-aqueous barrier in dry eye disease.

PURPOSE: To evaluate level of flare in aqueous humor of dry eye disease (DED) and compare it with normal controls. METHODS: In this cross-sectional study, we compared the anterior chamber flare between 28 patients with DED (the DED group) and 27 normal age- and gender-matched controls (the control group). DED group was divided in SjÓ§gren's syndrome dry eye (SDE, n = 10) and non- SjÓ§gren's syndrome dry eye (non-SDE, n = 18) groups. RESULTS: This study enrolled 55 participants including 28 patients with DED and 27 normal controls. The mean age was 53.4 ± 14.7 years in the DED group and 48.5 ± 14.7 years in the control group (P = 0.086). Mean flare was significantly higher in DED group (12.1 ± 10.2 ph/ms, range 2.7-68.3) compared to the control group (5.0 ± 3.9 ph/ms, range 1.30-30.0, P < 0.001). There was no statistically significant difference in the flare intensity between the SjÓ§gren syndrome dry eye (SDE) group (14.5 ± 14.4 ph/ms) and the non-SjÓ§gren dry eye (non-SDE) group (10.8 ± 6.9 ph/ms, P = 0.330). A significant correlation was observed between the flare intensity and the ocular surface staining in the SDE group (r = 0.62, P = 0.018). CONCLUSION: There is a significant increase in aqueous humor flare in patients with DED. Such finding, which is a marker of disruption of blood-aqueous barrier, demonstrates deeper tissue involvement than ocular surface in these patients.

Accuracy and safety of C2 pedicle or pars screw placement: a systematic review and meta-analysis.

STUDY DESIGN: Systematic review and meta-analysis. AIM: The purpose of this study was to compare the safety and accuracy of the C2 pedicle versus C2 pars screws placement and free-hand technique versus navigation for upper cervical fusion patients. METHODS: Databases searched included PubMed, Scopus, Web of Science, and Cochrane Library to identify all papers published up to April 2020 that have evaluated C2 pedicle/pars screws placement accuracy. Two authors individually screened the literature according to the inclusion and exclusion criteria. The accuracy rates associated with C2 pedicle/pars were extracted. The pooled accuracy rate estimated was performed by the CMA software. A funnel plot based on accuracy rate estimate was used to evaluate publication bias. RESULTS: From 1123 potentially relevant studies, 142 full-text publications were screened. We analyzed data from 79 studies involving 4431 patients with 6026 C2 pedicle or pars screw placement. We used the Newcastle-Ottawa Scale (NOS) to evaluate the quality of studies included in this review. Overall, funnel plot and Begg's test did not indicate obvious publication bias. The pooled analysis reveals that the accuracy rates were 93.8% for C2 pedicle screw free-hand, 93.7% for pars screw free-hand, 92.2% for navigated C2 pedicle screw, and 86.2% for navigated C2 pars screw (all, P value < 0.001). No statistically significant differences were observed between the accuracy of placement C2 pedicle versus C2 pars screws with the free-hand technique and the free-hand C2 pedicle group versus the navigated C2 pedicle group (all, P value > 0.05). CONCLUSION: Overall, there was no difference in the safety and accuracy between the free-hand and navigated techniques. Further well-conducted studies with detailed stratification are needed to complement our findings.

Functional Outcome of Surgical versus Conservative Therapy in Patients with Traumatic Thoracolumbar Fractures and Thoracolumbar Injury Classification and Severity Score of 4; A Non-randomized Clinical Trial.

OBJECTIVE: To compare the effectiveness of surgical intervention to conservative treatment in patients with thoracolumbar fracture and thoracolumbar injury classification and severity score (TLICS) of 4. METHODS: Twenty-five patients with TLICS 4 were enrolled in this non-randomized clinical trial. Based on clinical symptoms and radiologic findings, patients were considered under surgical or conservative treatments. The JOA Back Pain Evaluation Questionnaire (JOABPEQ) was assessed at baseline and at 3, 6, 12 months after treatment. A 20-point improvement from the baseline JOABPEQ scores was considered as clinical success in both the conservative and surgery groups. Additionally, residual canal, angulations and height loss were determined in all patients. RESULTS: Eight patients received conservative and 17 surgical treatment. Both study groups were comparable regarding the baseline characteristics. Both study demonstrated treatment success, regarding functional recovery when compared to baseline (p<0.001). However, those undergoing surgical intervention had significantly better JOABPEQ score (p<0.001) and higher residual canal (p=0.042) when compared to those receiving conservative therapy. The success rate of treatment was comparable between the two study groups in 6- (p=0.998) and 12-month (p=0.852) intervals; however, surgical therapy had significantly higher success arte in 3-month interval (p=0.031). CONCLUSION: Our findings revealed that surgical treatment was preferred more in comparison to conservative treatment in patients with TLICS 4. Additionally, residual canal might be a modifying factor to decide the ideal therapeutic approach.

Corneal endothelial assessment in xeroderma pigmentosum: a case-control study.

PURPOSE: To analyze and compare corneal endothelial mosaic in terms of endothelial cell population, morphology and irregularity in patients with xeroderma pigmentosum (XP) with clear corneas with normal age and sex matched subjects using specular microscopy. METHODS: Nine patients with XP without corneal involvement were evaluated in the study. An age and sex matched group of nine healthy subjects participated as control group. Evaluation of corneal endothelial layer was performed using specular microscopy. RESULTS: Each study group consisted of five males and four females with total mean age of 28 ± 11.3 years (12-46 years). Endothelial cell density was significantly lower in patients with XP in comparison with controls (P < 0.002). Maximum and minimum cell areas were significantly higher in XP group (P < 0.016 and P < 0.029, respectively). Although central corneal thickness was higher in controls, the difference was not statistically significant (P = 0.106). Furthermore, our study showed that the patients with XP had no difference with controls in terms of coefficient of variation of cell areas. CONCLUSIONS: This study showed that endothelial cell population can decrease in patients with XP, although other specular microscopic variables such as coefficient of variation and central corneal thickness may remain within normal values.

A Review on the Use of Artificial Intelligence in Spinal Diseases.

Artificial neural networks (ANNs) have been used in a wide variety of real-world applications and it emerges as a promising field across various branches of medicine. This review aims to identify the role of ANNs in spinal diseases. Literature were searched from electronic databases of Scopus and Medline from 1993 to 2020 with English publications reported on the application of ANNs in spinal diseases. The search strategy was set as the combinations of the following keywords: "artificial neural networks," "spine," "back pain," "prognosis," "grading," "classification," "prediction," "segmentation," "biomechanics," "deep learning," and "imaging." The main findings of the included studies were summarized, with an emphasis on the recent advances in spinal diseases and its application in the diagnostic and prognostic procedures. According to the search strategy, a set of 3,653 articles were retrieved from Medline and Scopus databases. After careful evaluation of the abstracts, the full texts of 89 eligible papers were further examined, of which 79 articles satisfied the inclusion criteria of this review. Our review indicates several applications of ANNs in the management of spinal diseases including (1) diagnosis and assessment of spinal disease progression in the patients with low back pain, perioperative complications, and readmission rate following spine surgery; (2) enhancement of the clinically relevant information extracted from radiographic images to predict Pfirrmann grades, Modic changes, and spinal stenosis grades on magnetic resonance images automatically; (3) prediction of outcomes in lumbar spinal stenosis, lumbar disc herniation and patient-reported outcomes in lumbar fusion surgery, and preoperative planning and intraoperative assistance; and (4) its application in the biomechanical assessment of spinal diseases. The evidence suggests that ANNs can be successfully used for optimizing the diagnosis, prognosis and outcome prediction in spinal diseases. Therefore, incorporation of ANNs into spine clinical practice may improve clinical decision making.

Postoperative Blepharoptosis After Modern Phacoemulsification Procedure.

PURPOSE: To investigate the frequency of transient (1 month) and persistent (at least 6 months) postoperative ptosis following clear corneal sutureless phacoemulsification and to analyze the factors affecting them. DESIGN: Cohort study. METHODS: Patients who underwent phacoemulsification cataract surgery from October 2016 to June 2018 in a tertiary center were enrolled. Margin reflex distance 1 (MRD1), MRD2, and levator function were measured and facial photography was taken before, 1 month, and at least 6 months after the surgery. Clinical ptosis was defined as any postoperative drop of MRD1 and clinically significant ptosis as MRD1 drop of ≥2 mm. Photo-based ptosis was assessed by a masked oculofacial plastic surgeon at the end of the study. RESULTS: A total of 234 patients (313 eyelids) were included. The majority of surgeries were performed by senior residents (65.5%, 205/313) and under topical anesthesia (78.0%, 244/313). Persistent clinical, clinically significant, and photo-based ptosis were 25.4% (71/279), 3.2% (9/279), and 3.3% (9/276). Eyelids with persistent postoperative ptosis showed a significantly (P = .03) lower preoperative levator function (13.9 vs 15.8 mm). No other factor was significantly different between the eyelids with and without postoperative ptosis. CONCLUSION: Persistent clinically significant ptosis was observed in more than 3% of patients undergoing clear corneal sutureless phacoemulsification cataract surgery. It should be counseled preoperatively. Lower preoperative levator function was significantly associated with a higher frequency of postoperative ptosis. Duration of surgery, level of surgeons, and other variables did not have any significant effect on the frequency of postoperative ptosis.

Effects of intranasal administration of violet oil in dry eye disease.

BACKGROUND: Dry eye disease is a disorder of the tear film. In this study, the effect of Viola odorata L. oily extract was examined for the treatment of patients suffering from dry eye disease. METHODS: A randomised, double-blind, placebo-controlled study was designed. During the trial, Schirmer's test, tear breakup time, Oxford staining and the Ocular Surface Disease Index were assessed. Overall, 105 patients with dry eye symptoms between the ages of 18 and 60 years were allocated to the violet-almond oil, almond oil and placebo (1% w/v hydroxypropyl methylcellulose solution) groups. The treatment and placebo were administered intranasally, two drops three times a day for one month. The patients were followed up for four weeks. A total of 91 patients (32, 29 and 30 in the violet-almond oil, almond oil and placebo groups, respectively) completed the study. RESULTS: At baseline, there was no difference between the three groups in terms of demographic data and the measurement parameters. After the intervention, the results revealed that the Schirmer's score without local anaesthesia and the tear breakup time results significantly improved in the violet-almond oil group. One-way ANOVA indicated a significant improvement in the Schirmer's score, tear breakup time and Ocular Surface Disease Index of the treatment group, as compared with the other groups (p < 0.05). However, the obtained results did not present any significant mean difference between and within the groups of the Oxford staining grade (p > 0.05). CONCLUSIONS: This trial showed that the intranasally administered V. odorata L. oily extract enhances tear production and improves tear film stability.

Comparison of toluidine blue 1% staining patterns in cytopathologically confirmed ocular surface squamous neoplasias and in non-neoplastic lesions.

PURPOSE: To evaluate the role of toluidine blue (TB) staining patterns in diagnosis of ocular surface squamous neoplasia (OSSN) in comparison to that of impression cytology. METHODS: TB 1% dye was applied to different ocular surface lesions, followed by impression cytology (IC). Dye distribution, intensity, and pattern of uptake by the lesion were scored and total score ≥5 was considered "positive TB staining". The TB results were then compared with those using IC to determine the presence of cellular atypia. RESULTS: The study enrolled 88 eyes of 82 patients. IC demonstrated cellular atypia in 50 (56.8%) cases. Forty-three of 45 "TB-positive" eyes (95.51%) had cellular atypia on IC (p < 0.001). Sensitivity and specificity of TB in identifying OSSN were 86% and 94.74%, respectively, with positive and negative predictive values of 95.56% and 83.72%. TB staining intensity of dark blue and/or mixed types and stippled pattern of TB staining were strongly correlated with dysplastic changes in IC (P ˂ 0.001). TB staining distribution whether in form of diffuse, patchy or scattered eyes with atypia did not significantly differ from those without atypia in IC (P = 0.172). CONCLUSION: The sensitivity and specificity of TB vital dye in diagnosing OSSN can be increased by focusing on color intensity and a stippled pattern.

Subclinical Inflammatory Response: Accelerated versus Standard Corneal Cross-Linking.

Purpose: To compare the subclinical inflammatory response (as measured by anterior chamber flare) induced after standard (3 mW/cm2, 30 min) and accelerated (18 mW/cm2, 5 min) corneal cross-linking (CXL). Methods: In this comparative, non-randomized study, patients with progressive keratoconus who underwent standard or accelerated CXL were studied. Laser flare photometery (FM-600; Kowa, Tokyo, Japan) was used to measure anterior chamber flare preoperatively and at 1 week, 1 month, 3 months, and 6 months after the procedure. Results: Sixty eyes of 60 patients were studied; 30 eyes in each group. Mean baseline flare values were 4.15 ± 1.19 and 4.57 ± 2.17 ph/ms in standard and accelerated groups, respectively (p = 0.228).and after surgery increased in all follow-up measurements in the both groups similarly (P > 0.05). Conclusion: Both standard and accelerated CXL results in induction of a subclinical inflammatory response that persists up to 6 month. The response was similar between the two groups.