Hamed Esfandiari

Anwar versus Melles Deep Anterior Lamellar Keratoplasty for Keratoconus: A Prospective Randomized Clinical Trial

PURPOSE To compare the outcomes of 2 techniques (Anwar vs. Melles) of deep anterior lamellar keratoplasty (DALK) in patients with keratoconus. DESIGN Randomized, double-blind clinical trial. PARTICIPANTS Fifty-seven eyes of 57 patients 20 to 35 years of age were enrolled. METHODS Patients with clinical diagnosis of keratoconus who were contact lens intolerant and whose corrected distance visual acuity (CDVA) was less than 20/80 were enrolled. Eligible eyes were allocated randomly into 2 groups: the Anwar technique (23 eyes) or the Melles technique (25 eyes). MAIN OUTCOME MEASURES The primary outcome measure was CDVA. Secondary outcomes were spherical equivalent, contrast sensitivity, corneal aberrations, corneal biomechanical properties, endothelial cell count, and central corneal thickness. All outcomes were compared 15 months after surgery. RESULTS The CDVA was 0.17 ± 0.09 logarithm of the minimum angle of resolution (logMAR) units and 0.18 ± 0.11 logMAR units in the Anwar and Melles groups, respectively (P = 0.803). Spherical equivalent was -1.82 ± 2.7 diopters (D) and -2.69 ± 3.94 D in the Anwar and Melles groups, respectively (P = 0.155). Overall, the difference in photopic and mesopic contrast sensitivity function between the 2 groups was statistically significant (P<0.05). There was no significant difference between 2 groups in total and higher-order aberrations up to the fifth order (P>0.05 for all parameters). Corneal hysteresis was not significantly different between the 2 groups (9.9 ± 0.8 vs. 9.9 ± 0.6; P = 0.606). The corneal resistance factor was 10.02 ± 0.8 and 10.13 ± 0.76 (P = 0.509). There was no significant difference in percentage of endothelial cell loss between the 2 groups (1 ± 2% vs. 1 ± 3% in the Anwar and Melles groups, respectively; P = 0.869). Mean central corneal thickness was 525.56 ± 47.87 μm versus 504.64 ± 54.20 μm in the Anwar and Melles groups, respectively (P = 0.155). CONCLUSIONS The Anwar and Melles techniques of DALK have comparable visual acuity and refractive outcomes, aberrometric profiles, biomechanical properties, corneal thicknesses, and endothelial cell densities. However, patients who underwent the Anwar technique showed better contrast sensitivity.

Eyelid masses: A 10-year survey from a tertiary eye hospital in Tehran

Purpose: The purpose of this study was to evaluate the demographics and clinical features of eyelid masses in a tertiary eye hospital over a 10-year period. Materials and Methods: A retrospective chart review was performed for patients admitted with eyelid tumors from 2000 to 2010. Data were collected and analyzed on the demographic features, location of the tumor, types of treatment, and pathologic findings. Results: A total number of 182 patients were evaluated of which, 82 cases were benign and 100 cases were malignant neoplasms. The most common benign tumors included melanocytic nevi (35%), papilloma (19.5%), and cysts (11%). The most frequent malignant tumors included basal cell carcinoma (BCC) (83%), squamous cell carcinoma (8%) and sebaceous gland carcinoma (6%). The most common site for malignancy was the lower lid followed by the upper lid. BCC recurred in 16 cases that were most frequent in the lower lid. Conclusion: Melanocytic nevus, papilloma and cysts are the most common benign lesions and BCC is the most common malignant lesion in the eyelids. Recurrence is a feature of BCC especially in the lower lid.

Effect of Photorefractive Keratectomy with Mitomycin-C on Corneal Biomechanical Features

Purpose: To evaluate corneal biomechanical properties and intraocular pressure (IOP) after photorefractive keratectomy (PRK) with or without mitomycin-C (MMC) 0.02% in myopic eyes. Methods: In this prospective, comparative interventional case series, 33 right eyes of 33 patients were included. Corneal hysteresis (CH), corneal resistance factor (CRF), Goldmann-correlated IOP (IOPg), and cornea-compensated IOP (IOPcc) were measured using ocular response analyzer (ORA) before and 3 months after PRK. IOP was determined using Goldmann applanation tonometry (GAT). The pre- and post-operative values were compared. Effects of ablation depth, optical zone (OZ) and duration of MMC application on corneal biomechanics were examined. Results: Mean ablation depth was 56.6 ± 20.8 μm. Postoperatively, there was a significant reduction in corneal biomechanics and IOP readings by the GAT and ORA. Ablation depth was significantly associated with percentage change in CH (P = 0.021), CRF (P = 0.001), and IOP GAT (P < 0.001). However, the size of OZ and duration of MMC application did not have any correlation with these parameters. The percentage change in IOP GAT and IOPg but not IOPcc was significantly associated with percentage change in CH and CRF. Conclusions: The corneal biomechanical strength significantly reduced after PRK which is associated to the amount of ablation. However, the OZ and the duration of MMC application did not affect these parameters. IOPcc appeared to be less dependent on altered corneal properties compared to IOPg and IOP GAT.

Three intravitreal bevacizumab versus two intravitreal triamcinolone injections in recent onset central retinal vein occlusion

To evaluate the effects of repeated intravitreal injections of bevacizumab (IVB) versus triamcinolone acetonide (IVT) in the treatment of acute central retinal vein occlusion (CRVO).

Intravitreal Injection of a Rho‐Kinase Inhibitor (Fasudil) for Recent‐Onset Nonarteritic Anterior Ischemic Optic Neuropathy

This study evaluated the effects of intravitreal injection of fasudil (IVF), a Rho‐kinase inhibitor, in cases of recent‐onset nonarteritic anterior ischemic optic neuropathy (NAION). In this interventional case series, 13 eyes of 13 patients diagnosed with NAION within 14 days of onset were included. The affected eyes received a 0.025 mg/0.05 mL IVF. Functional and structural outcomes were assessed 1 and 3 months following treatment. Best corrected visual acuity (BCVA) was the main outcome measured, with mean deviation (MD) index of the VF test and peripapillary retinal nerve fiber layer thickness as secondary measures. There was a statistically significant improvement in the patients’ BCVA 1 and 3 months following IVF; BCVA improved from 1.69 ± 0.55 logMAR at baseline to 0.98 ± 0.47 and 0.93 ± 0.51 logMAR at 1 and 3 months, respectively (P = .004). The change in BCVA was not significant between month 1 and month 3 (P = .22). Peripapillary retinal nerve fiber layer thickness decreased from 173.5 ± 29.28 µm in the baseline evaluation to 85.8 ± 8.8 µm at 1 month, and 62.9 ± 5.97 µm at 3 months (P = .003). MD values changed from 24.60 ± 3.80 to 21.0 ± 6.10 and 20.5 ± 6.50 at 1 and 3 months, respectively (P = .007 and .005, respectively). This pilot study suggests that IVF may be an effective treatment for patients with recent‐onset NAION. Larger studies are required to establish the therapeutic role of fasudil for NAION.

The Ocular Hypotensive Efficacy of Topical Fasudil, a Rho-associated Protein Kinase Inhibitor, in Patients With End-stage Glaucoma

To investigate the effects of topical administration of a selective Rho-associated kinase (ROCK) inhibitor, fasudil 0.5% and 1.2% in glaucomatous patients. In this interventional case series study, 4 eyes of 4 patients with unilateral end-stage primary open-angle glaucoma and no light perception vision were assigned to receive topical fasudil 0.5% (in 3 eyes) or 1.2% (in 1 eye) ophthalmic solution twice daily for 8 weeks. At weeks 1, 2, 3, 4, and 8, intraocular pressure (IOP) and adverse events were evaluated. Baseline mean IOP was 53.5 ± 3.4 mm Hg and mean IOP reductions of the last visit were −8.25 ± 1.2 mm Hg at 2 hours and −8.75 ± 2.2 mm Hg at 4 hours. Mean IOP reductions were clinically and statistically significant with 0.5% and 1.2% fasudil and peak effects occurred 2–4 hours after application (P = 0.0002). The largest IOP reductions were produced by 1.2% fasudil (up to −12 mm Hg). Conjunctival hyperemia was found in 1 patient with 1.2% fasudil. Topical administration of fasudil in end-stage primary open-angle glaucoma patients, caused reduction in IOP and was well tolerated. ROCK inhibitors could be considered as a candidate for glaucoma therapy in future.

Risk factors for pterygium in Ilam Province, Iran

Purpose: To evaluate the risk factors for pterygium in the dry, high altitude province of Ilam, Iran. Methods: The study included patients who presented to ophthalmology clinic. The patients were divided into two groups: 210 diagnosed with pterygium or pinguecula (unilateral or bilateral), and 210 healthy controls. Demographic variables, living environment, disease type, disease laterality, family history of pterygium as well as history of smoking, working outdoors, baking, welding, ocular conditions (trachoma keratopathy, glaucoma, refractive error, and dry eye), use of glasses, ultraviolet light exposure, and systemic conditions were collected from both groups and compared for risk assessment. Results: Univariate analysis revealed that age (P = 0.001), sex (P = 0.001), family history of pterygium (P = 0.001), positive history of smoking (P < 0.001), history of baking (P = 0.045), welding experience (P < 0.001), severe blepharitis (P < 0.001), hyperopia (P < 0.001), dry eye (P < 0.001), hypertension (P < 0.001), ischemic heart disease (P < 0.001), obesity (P = 0.038), and primary residential area (P = 0.025) had significant associations with increased incidence of pterygium. However, in multivariate analysis, only family history of pterygium, cigarette smoking, history of baking, age, and severe blepharitis were significantly associated with the incidence of pterygium (P< 0.001, P< 0.001, P = 0.002, P = 0.023 and P = 0.002, respectively). Conclusion: This study tested more risk factors related to the prevalence of pterygium compared to previous studies. It also confirmed previously established risk factors. Family history of pterygium and blepharitis were risk factors that have not been reported in previous studies and were found to be significantly associated with the development of pterygium in this study.

Mitomycin C-augmented trabeculectomy: subtenon injection versus soaked sponges: a randomised clinical trial

Background/aims To compare the efficacy and safety of subtenon injection of mitomycin C (MMC) with that of conventional application of MMC-soaked sponges in trabeculectomy. Methods In this multicentre randomised clinical trial, 80 consecutive open-angle glaucoma cases were randomised into two groups; group 1 received a subtenon injection of 0.1 mL of 0.01% MMC, while group 2 received 0.02% MMC-soaked sponges. Primary outcome measure was intraocular pressure (IOP), and secondary outcome measures were endothelial cell count (ECC) changes and bleb morphology according to the Indiana Bleb Appearance Grading Scale. Outcome measures were compared at 1, 3 and 6 months postoperatively. Complete and qualified success was defined as IOP within 6–15 mm Hg without and with medications at month 6, respectively. Results Mean preoperative IOP was 21.8±5.1 in group 1, which reduced to 10.3±3.7 mm Hg at final visit (p<0.001). Corresponding values for group 2 were 21.8±5 and 10.8±3.5 mm Hg respectively (p<0.001). Complete success was 82.5% in both groups, and qualified success was 0 and 2.5% in groups 1 and 2, respectively. (p=0.316) The blebs tended to be more diffuse, less vascularised and shallower in group 1, at month 6 (p=0.45,<0.001 and <0.007 respectively). ECCs did not change significantly at final visit (p=0.813). Conclusions Subtenon injection of MMC is a safe and effective alternative to the conventional soaked sponge method. This method produces more favourable bleb morphology after trabeculectomy. Trial registration number NCT02385370, Post-results.

Intraocular lens power changes after mitomycin trabeculectomy.

Purpose To evaluate biometric changes after mitomycin C augmented trabeculectomy and their effect on intraocular lens (IOL) power calculation using different formulas. Methods In this prospective, interventional case series study, 34 eyes of 31 phakic glaucoma patients who were scheduled for primary trabeculectomy were enrolled. Using a noncontact biometry device (Lenstar, Haag-Streit AG, Koeniz, Switzerland), axial length (AL), mean corneal power, and IOL power were calculated with the Hoffer Q, Holladay, and SRK/T formulas 1 day before surgery and compared to those obtained 3 and 6 months after the operation. Bland-Altman plot was used to determine agreement between preoperative and postoperative IOL power values. Results The AL was significantly decreased at month 3 (-0.14 ± 0.13 mm) and month 6 (-0.14 ± 0.15 mm) as compared to baseline values (both p values <0.001). Mean corneal power increased significantly at month 3 (0.41 ± 0.46 D; p<0.001) and month 6 (0.27 ± 0.47 D; p = 0.008). Using different formulas, IOL power did not change significantly after the operation (all ps≥0.17). The IOL power changes using the Hoffer Q formula were −0.09 ± 0.76 (p = 0.505) and 0.14 ± 0.9 D (p = 0.442) at 3 and 6 months, respectively; corresponding values were −0.1 ± 0.75 (p = 0.427) and 0.16 ± 0.79 D (p = 0.319) for Holladay and 0.01 ± 0.64 (p = 0.895) and 0.2 ± 0.71 D (p = 0.17) employing the SRK/T formula. Conclusions Despite significant changes in AL and corneal power after trabeculectomy, IOL power calculation remains unchanged; therefore adjustment of IOL power calculation after trabeculectomy seems unnecessary.

Ocular biometric changes after trabeculectomy

This review article aimed to evaluate ocular biometric changes after trabeculectomy. The PubMed database was searched using the keywords “axial length” (AL), “anterior chamber depth” (ACD), “corneal astigmatism,” “corneal topography” and “trabeculectomy.” The extracted studies were categorized based on the evaluated parameters and the biometry method (contact and non-contact). Comparable studies with respect to their sample size were combined for statistical analysis. Twenty-five studies including 690 individuals which met the inclusion criteria were selected. After trabeculectomy, a significant and persistent AL reduction, with a range of 0.1-0.19 and 0.1-0.9 mm measured with contact and non-contact methods, respectively, was observed. With respect to topographic changes, 0.38-1.4 diopters (D) with-the-rule (WTR) astigmatism was induced postoperatively. All studies revealed ACD reduction immediately after surgery, which gradually deepened and approximated its preoperative levels on day 14. ACD reduction was not significant after that period in the majority of cases. In conclusion, changes in ACD is of small amount and of short period, thus it can be ignored; however, reported changes in AL and keratometry are of sufficient magnitude and can affect the refractive prediction of combined cataract surgery and trabeculectomy.