Purpose: To evaluate the agreement among Pentacam, Orbscan and ultrasound (US) pachymetry for measurement of central corneal thickness (CCT) in thin corneas with normal topographic pattern. Methods: We included 88 eyes of 44 refractive surgery candidates with thinnest pachymetric readings of 500 micrometers (μm) or less on Orbscan, a normal topographic pattern, no sign of keratoconus, and best corrected visual acuity (BCVA) of 20/20. Pentacam, Orbscan and US were performed in one session by the same examiner. Exclusion criteria were history of ocular surgery, topographic abnormalities suggesting forme fruste keratoconus or keratectasia, and recent contact lens wear. Results: The difference in CCT measurements by US pachymetry and Orbscan II [using an acoustic factor (AF) of 0.92] ranged from −34 to +34 μm. The difference between the thinnest point and central readings measured by US reached 16 μm with Orbscan II (AF: 0.92) and 2 μm with Pentacam. Mean differences between the employed devices were 0.2 μm for Pentacam versus US (P = 0.727), 30.1 μm for uncorrected Orbscan versus US (P < 0.001), 10.4 μm for Orbscan II (AF = 0.92) versus US (P < 0.001), and 0.2 μm for Orbscan II (AF = 0.94) versus US (P = 0.851). Conclusion: In normal thin corneas, Pentacam demonstrated better agreement with US pachymetry as compared to corrected Orbscan readings. Results achieved by Orbscan were better consistent with US pachymetry using an AF of 0.94. We speculate that a dynamically graded AF in reverse proportion to CCT constitutes a better approach for correcting Orbscan measurements.

Purpose: To evaluate the feasibility and efficacy of mini-scleral design (MSD) contact lenses to treat keratoconus patients who were unsatisfied with the results of corneal inlay. Methods: In this prospective interventional case series, 9 eyes of 6 keratoconus patients who were unsatisfied with the results of corneal inlay were fitted with MSD contact lenses. Demographic data, uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), and higher order aberrations (HOAs) were evaluated before contact lens fitting. Corrected visual acuity by placing the MSD contact lens with or without over-refraction, and HOAs were measured one hour after contact lens fitting. One month after contact lens wearing, corrected visual acuity by placing the MSD contact lens with over-refraction and possible contact lens related problems were assessed. Ocular comfort and contact lens handling problems were asked in follow-up visits. The data was analyzed using descriptive statistical tests. Results: Nine eyes of 6 patients were successfully fitted with the mini-scleral lens. Fitting was ideal in 7 eyes and acceptable in 2 eyes. Mean corrected visual acuity by placing the MSD lens without over-refraction was 0.09 (range, 0.00-0.15) LogMAR which was significantly better than the mean BSCVA of 0.38 (range, 0.2-0.6) LogMAR (P = 0.007). The mean root mean square (RMS) of third-order coma and trefoil significantly decreased after MSD contact lens fitting (P = 0.012 and P = 0.015, respectively); however, changes in the fourth-order spherical aberration were not statistically significant (P = 0.336). Conclusion: Mini-scleral contact lenses may be helpful in the management of visually unsatisfied patients after corneal inlay.

Purpose: To evaluate the effects of prophylactic laser peripheral iridotomy on corneal endothelial cell density and cell morphology in subjects with primary angle closure suspect (PACS) within a one-year follow-up period. Methods: In this quasi-experimental prospective study, from June 2012 to November 2013, thirty-five PACS eyes underwent laser peripheral iridotomy at clinics affiliated to Shiraz University of Medical Sciences, Shiraz, Iran. After obtaining informed consent, specular microscopy was performed at baseline and at 3-month, 6-month and 12-month follow-up visits. Central, nasal and temporal endothelial cell counts and cell morphology were evaluated via non-contact specular microscopy. Results: The mean subject age was 53.4 ± 7.9 years, and the majority of subjects were women (88.2%). The mean central corneal endothelial cell count prior to laser peripheral iridotomy was 2528 ± 119.2, and this value changed to 2470 ± 175.9, 2425 ± 150.6, and 2407 ± 69.02 at the 3-month, 6-month, and 12-month follow-up visits, respectively; these differences did not reach statistical significance. Additionally, the changes in the number of cells, the hexagonality of cells, and the coefficient of variation (CV) in the central, nasal, and temporal areas were not significant. Conclusion: In PACS eyes, we did not find a decline in corneal endothelial cell density or a change in cell morphological characteristics, including cell hexagonality and CV, in the central, nasal, and temporal regions of the cornea in any of our subjects over a one-year follow-up period.

Purpose: To report the rate of flap-related complications in LASIK surgery performed by in-training ophthalmology residents and to analyze the risk factors for these complications. Methods: We analyzed 273 flap dissections in 145 patients from March 2013 to February 2014. We included all LASIK surgeries performed by 32 ophthalmology residents using a Moria M2 microkeratome. All the flap-related complications were noted. Comparison between both groups with and without complications was performed with an independent Student's t-test and relative risks were calculated. Results: There were 19 flap-related complications out of the 273 flap dissections (6.95%). The most common complication was incomplete flap dissection (n = 10; 3.66%), followed by free-cap (n = 5; 1.83%), and flap-buttonhole (n = 2; 0.73%). There was no significant difference between the complicated and uncomplicated cases in terms of the right versus the left eye, pachymetry results, white-to-white diameter, and spherical equivalent. But this difference was significant for mean keratometry (P = 0.008), K-min (P = 0.01), and K-max (P = 0.03) between these groups. Final visual acuity after rescheduling laser treatment was similar in both groups. Relative risks for flap-related complications were 2.03 for the first LASIK surgery (CI 95% 0.64 to 6.48; P = 0.22) and 1.26 (CI 95% 0.43 to 3.69; P = 0.66) for the surgeon's flap-related complications. Female gender presented an odds ratio of 2.48 (CI 95% 0.68 to 9.00; P = 0.16) for complications. Conclusion: Flap-related complications are common intraoperative event during LASIK surgery performed by in-training ophthalmologists. Keratometries and surgeon's first procedure represent a higher probability for flap related complications than some other biometric parameters of patient's eye.

Purpose: To evaluate the results of intravitreal phacoemulsification with torsional hand piece in eyes with posteriorly dislocated lens fragments. Methods: In this prospective, interventional case series, 15 eyes with retained lens fragments following phacoemulsification were included. All patients underwent standard three-port pars plana vitrectomy and intravitreal phacoemulsification using sleeveless, torsional hand piece (OZiL™, Alcon's Infiniti Vision System). Patients were followed up for a minimum of six months to evaluate the visual outcomes and complications. Results: The preoperative best-corrected visual acuity (BCVA) ranged from light perception to 0.3. No complications such as thermal burns of the scleral wound, retinal damage due to flying lens fragments, or difficult lens aspiration occurred during intravitreal phacoemulsification. Mean post-operative BCVA at the final follow-up was 0.5. Two eyes developed cystoid macular edema, which was managed medically. No retinal detachment was noted. Conclusion: Intravitreal phacoemulsification using torsional hand piece is a safe and effective alternative to conventional longitudinal phacofragmentation.

Purpose: To evaluate the effect of intravitreal bevacizumab (IVB) as a surgical adjunct in prevention of proliferative vitreoretinopathy (PVR) after retinal detachment surgery. Methods: In this controlled, randomized pilot study, 27 patients with primary retinal detachment undergoing pars plana deep vitrectomy were included. Of these, 12 received IVB at the end of procedure. The anatomic success and best corrected visual acuity (BCVA) were compared to the control group at months 3 and 6 postoperatively. Results: At three month follow-up, 3 of 11 eyes (27.3%) had detached retinas in the IVB group versus 6 of 12 (50.0%) in the control group (P = 0.40). At six-month follow-up, 3 of 10 eyes (30%) had detached retinas in the IVB group versus 3 in 8 (37.5%) in the control group (P > 0.99). Mean logMAR BCVA improved significantly in both groups relative to baseline, but did not show a significant difference at three-and six-month follow-ups between the two groups. Conclusion: Our preliminary results show neither a benefit nor any harm from intervention in both anatomic and visual outcomes. Our results support conducting additional studies to evaluate the effect of intravitreal bevacizumab on postoperative PVR.

Purpose: To compare three different methods for determining addition in presbyopes. Methods: The study included 81 subjects with presbyopia who aged 40-70 years. Reading addition values were measured using 3 approaches including the amplitude of accommodation (AA), dynamic retinoscopy (DR), and increasing plus lens (IPL). Results: IPL overestimated reading addition relative to other methods. Mean near addition obtained by AA, DR and IPL were 1.31, 1.68 and 1.77, respectively. Our results showed that IPL method could provide 20/20 vision at near in the majority of presbyopic subjects (63.4%). Conclusion: The results were approximately the same for 3 methods and provided comparable final addition; however, mean near additions were higher with increasing plus lens compared with the other two methods. In presbyopic individuals, increasing plus lens is recommended as the least time-consuming method with the range of ±0.50 diopter at the 40 cm working distance.

Purpose: The purpose of this study was to evaluate the results of a teamwork revision endoscopic dacryocystorhinostomy (DCR) in eyes with previously failed external DCR. Methods: This retrospective study was performed on 50 failed external DCR subjects who underwent a teamwork revision endoscopic DCR by an ophthalmologist and an otolaryngologist. Paranasal sinus CT scanning was performed for each patient before the revision surgery. During surgery, any abnormal tissue noticed before silicone intubation was sent for pathological evaluation. Results: Endoscopic revision DCR was performed on 50 failed external DCR subjects with one-year follow-up. Of these, 31 were female (62%). The age range of the subjects was 18-88 years (mean: 59.98 years). Sinus CT showed at least one abnormality in 94% of cases. Revision endoscopy showed septal deviation (66%), scar formation (32%), ostium problems (28%), and sump syndrome (6%). Pathologic and clinical findings showed that chronic inflammation had a significant association with scar tissue and septal synechia (P = 0.001 and 0.008, respectively). At the final follow-up, anatomical and functional success was achieved in 45 out of 50 (90%) of subjects. Conclusion: Endoscopic revision DCR when performed as cooperation of otolaryngologists and ophthalmologists may help resolve the endonasal problems and increase the success rate.

Purpose: To evaluate the role of fine needle aspiration (FNAC) as a diagnostic tool in cases of orbital and ocular adnexal masses. Cytological findings were correlated with histopathological diagnosis wherever possible. Methods: FNAC was performed in 29 patients of different age groups presenting with orbital and ocular adnexal masses. Patients were evaluated clinically and investigated by non-invasive techniques before fine needle aspiration of the masses. Smears were analyzed by a cytologist in all cases. Further, results of cytology were compared with the histopathological diagnosis. Results: The age of patients ranged from 1 to 68 years (mean: 29.79±19.29). There were 14 males and 15 females with a male to female ratio of 0.93:1. Out of 29 cases, 26 aspirates were cellular. Cellularity was insufficient in three (10.34%) aspirates. Out of 26 cellular aspirates, 11 were non-neoplastic while 15 were neoplastic on cytology. Subsequent histopathologic examination was done in 21/26 cases. Concordance rate of FNAC in orbital and ocular adnexal mass lesions with respect to the precise histologic diagnosis was 90%. Conclusion: When properly used in well-indicated patients (in cases where a diagnosis cannot be made by clinical and imaging findings alone), FNAC of orbital and periorbital lesions is an invaluable and suitable adjunct diagnostic technique that necessitates close cooperation between the ophthalmologist and cytologist. However, nondiagnostic aspirates may sometimes be obtained, and an inconclusive FNAC should not always be ignored.

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.

Scleral buckling is a highly successful technique for the repair of rhegmatogenous retinal detachment that requires intra-operative examination of the retina and treatment of retinal breaks via indirect ophthalmoscopy. Data suggest that scleral buckling likely results in improved outcomes for many patients but is declining in popularity, perhaps because of significant advances in vitrectomy instrumentation and visualization systems. Emerging data suggest that chandelier-assisted scleral buckling is safe and has many potential advantages over traditional buckling techniques. By combining traditional scleral buckling with contemporary vitreoretinal visualization techniques, chandelier-assistance may increase the popularity of scleral buckling to treat primary rhegmatogenous retinal detachment for surgeons of the next generation, maintaining buckling as an option for appropriate patients in the future.

Congenital cataract is a leading cause of visual deprivation which can damage the developing visual system of a child; therefore early diagnosis, management and long-term follow-up are essential. It is recommended that all neonates be screened by red reflex examination at birth and suspected cases be referred to ophthalmic centers. Early surgery (<6 weeks of age, based on general neonatal health) is important for achieving the best visual outcome particularly in unilateral cases. In bilateral cases, surgery is highly recommended before appearance of strabismus or nystagmus (<10 weeks of age) with no longer than a one-week interval between the fellow eyes. Parents should be informed that surgery is a starting point and not the endpoint of treatment. Appropriate postoperative management including immediate optical correction in the form of aphakic glasses or contact lenses, or intraocular lens (IOL) implantation at the appropriate age (>1 year) is highly recommended. After surgery, amblyopia treatment and periodic follow-up examinations should be started as soon as possible to achieve a satisfactory visual outcome. Practitioners should consider the possibility of posterior capsular opacity, elevated intraocular pressure and amblyopia during follow-up, especially in eyes with microphthalmia and/or associated congenital anomalies. All strabismic children should undergo slit lamp examination prior to strabismus surgery to rule out congenital lens opacities. From a social point of view, equal and fair medical care should be provided to all children regardless of gender.

Loss of light perception (LP) after open globe injury (OGI) does not necessarily mean the patient will have permanent complete visual loss. Findings that seem to be associated reliably with permanent profound vision loss after OGI include optic nerve avulsion, optic nerve transection, and profound loss of intraocular contents, which can be identified with CT/MRI imaging albeit with varying degrees of confidence. Eyes with NLP after OGI that undergo successful primary repair with intact optic nerves may be considered for additional surgery, particularly if there is: (1) recovery of LP on the first day after primary repair; (2) treatable pathology underlying NLP status (e.g., extensive choroidal hemorrhage, dense vitreous and subretinal hemorrhage); (3) NLP in the fellow eye. We counsel patients that the chance of recovering ambulatory vision under these circumstances is very low (~5%).

Purpose: To report a case of unilateral post trabeculectomy globe massage-induced keratoconus (KCN). Case Report: A 52-year-old lady with a history of trabeculectomy due to iridocorneal endothelial syndrome in her right eye was instructed to massage her globe to control gradual rise of intraocular pressure 1.5 years after surgery. The patient experienced high astigmatism and marked inferior corneal steepening after 3 years of globe massage. The left eye was normal in all aspects. Findings in different visual examinations were compatible with the diagnosis of unilateral KCN in the right eye of our patient. Conclusion: Chronic forceful frequent eye rubbing particularly with fingertips can be assumed to be the most important causative factor for KCN formation in this patient.

Purpose: To present a case of total Descemet's membrane detachment (DMD) after trabeculectomy and its surgical management. Case Report: A 68-year-old woman presented with large DMD and corneal edema one day after trabeculectomy. Intracameral air injection on day 3 was not effective. Choroidal effusion complicated the clinical picture with Descemet's membrane (DM) touching the lens. Choroidal tap with air injection on day 6 resulted in DM attachment and totally clear cornea on the next day. However, on day 12 the same scenario was repeated with choroidal effusion, shallow anterior chamber (AC), and DM touching the lens. The third surgery included transconjunctival closure of the scleral flap with 10/0 nylon sutures, choroidal tap, and intracameral injection of 20% sulfur hexafluoride. After the third surgery, DM remained attached with clear cornea. Suture removal and needling bleb revision preserved bleb function. Lens opacity progressed, and the patient underwent uneventful cataract surgery 4 months later. Conclusion: Scleral flap closure using transconjunctival sutures can be used for DMD after trabeculectomy to make the eye a closed system. Surgical drainage of choroidal effusions should be considered to increase the AC depth.

Purpose: To report a case of post laser in situ keratomileusis (LASIK), nebulomacular corneal opacity following a trauma induced flap dehiscence and was managed with superficial anterior lamellar keratoplasty (SALK). Case Report: A 32-year-old female underwent LASIK 2.5 years back, with a postoperative unaided visual acuity (VA) of 6/6 in both eyes. She was involved in a road traffic accident and sustained blunt trauma to the right eye 5 months before. At the time of presentation, the VA was 1/60 in the right eye. Slit lamp examination revealed flap dehiscence, stromal scar and descemet folds in that eye. There was a small macular scar in the parafoveal area due to a resolved Berlin's edema. SALK was performed in the affected eye. Unaided VA of 6/36 was noted on post- operative day 1. After 4 weeks of SALK surgery, best corrected VA was 6/24. Conclusion: This case highlights that flap adhesions are not very strong even years after LASIK and SALK may be an effective treatment option for post refractive surgery corneal opacities.

Purpose: To describe a patient with Schwartz Jampel vel Aberfeld syndrome (SJS) who underwent orbicularis oculi myectomy as a treatment for blepharospasm. Case Report: A 4-year-old child with SJS did not respond to an injection of a single dose of botulinum toxin after one month, so orbicularis myectomy was then performed under general anesthesia. During the procedure, orbicularis vermiform movements were a useful guide for the extent of myectomy that the patient needed. He responded very well to this procedure and experienced significant relief of blepharospasm documented in follow-up visits for up to 6 months. Conclusion: Blepharospasm in patients with SJS can be treated with orbicularis oculi myectomy as a good functional method with faster and durable response in comparison to botulinum toxin injection.