Abstract:Thenatural vitreous body has a fine structure and complex functions. The imitation of the natural vitreous body by vitreous substitutes is a challenging work for both researchers and ophthalmologists. Gases, silicone oil, heavy silicone oil and hydrogels, particularly the former two vitreous substitutes are clinically widely used with certain complications. Those, however, are not real artificial vitreous due to lack of structure and function like the natural vitreous body. This article reviews the situations, challenges, and future directions in the development of vitreous substitutes, particularly the experimental and clinical use of a new artificial foldable capsular vitreous body .

Abstract:AIM: To identify whether Aspergillus fumigatus (A. fumigatus) hyphae antigens induced the release of interleukin-8 (IL-8) in anti-fungal innate immunity of cultured human corneal epithelial cells (HCECs) and determine the involvement of intracellular signalling pathways.METHODS: HCECs were treated with A. fumigatus hyphae antigens with different concentrations and time. The cytoplasmic calcium of HCECs were assessed by fluorescence imaging. Western blot was used to detect the expression of Ca²⁺-dependent protein kinase C (PKC). The IL-8 levels were determined by specific human IL-8 enzyme-linked immunosorbent assay (ELISA) and reverse transcriptase polymerase chain reaction (RT-PCR). Using a series of pharmacological inhibitors, we examined the upstream signalling pathway responsible for IL-8 expression in response to A. fumigatus hyphae antigens.RESULTS: Cells exposed to A. fumigatus hyphae antigens showed higher level of IL-8 mRNA expression and protein production. We demonstrated here that stimulation of HCECs with A. fumigatus hyphae triggers an intracellular Ca²⁺ flux and results in the activation of Ca²⁺-dependent PKC (α, βⅠand βⅡ) which can be attenuated by pre-treatment of cells with laminarin, suggesting that Dectin-1 signals pathway induced cytoplasmic calcium and influence the activation of PKC in HCECs. Inhibitors of Ca²⁺-dependent PKC (Ro-31-8220 and Go6976) significantly abolished hyphae-induced expression of IL-8.CONCLUSION: Our findings suggest that A. fumigatus hyphae-induced IL-8 expression was regulated by the activation of Dectin-1-mediated Ca²⁺-dependent PKC in HCECs.

Abstract:AIM:To investigate the expression and role of nuclear factor κB (NF-κB) in diabetic retinopathy (DR) and its relationship with neovascularization and retinal cell apoptosis.METHODS: A total of 80 male Wistar rats were randomly assigned to control (4, 8, 12 and 16wk, n=10 in each group) and diabetes mellitus (DM) groups (4, 8, 12 and 16wk, n=10 in each group). A diabetic rat model was established by intraperitoneal injection of streptozotocin (60 mg/kg). After 4, 8, 12 and 16wk, rats were sacrificed. Retinal layers and retinal neovascularization growth were stained with hematoxylin-eosin and examined under light microscopy. Cell apoptosis in the retina was detected by TdT-mediated dUTP nick end labeling, and NF-κB distribution and expression in the retina was determined using immunohistochemistry.RESULTS: DM model success rate up to 100%. Diabetes model at each time point after the experimental groupcompared with the control group, the blood glucose was significantly increased, decreased body weight, each time point showed significant differences compared with the control group (P<0.01). After 12wk other pathological changes in the retina of diabetic rats were observed; after 16wk, neovascularization were observed. After 1mo, retinal cell apoptosis was observed. Compared with the control group, NF-κB expression in the DM group significantly increased with disease duration.CONCLUSION:With the prolonging of DM progression, the expression NF-κB increases. NF-κB may be related to retinal cell apoptosis and neovascularization.

Abstract:AIM:To prove anthrax lethal toxin (LeTx) blocks the mitogen activated protein kinases (MAPKs) activation by degrading theMAPK/ERK kinases (MEKs) to suppress vascular endothelial growth factor (VEGF) secretion. METHODS:Human adult retinal pigmented epithelium (ARPE) cells were cultured and treated with normal glucose, high glucose or high glucose with LeTx for additional 24, 48 or 72h for viable cell count. Total RNA from the ARPE was isolated for reverse transcription polymerase chain reaction (RT-PCR). The conditioned medium of ARPE cells treated in different group for 48h was filtered and diluted to detect the concentration of VEGF by enzyme-linked immunosorbant assays. Evaluate the role of MEK/MAPK pathway in the secretion of VEGF by immunoblotting. RESULTS:In this study, we proved high glucose induced activation of the MAPK extracellular signal-regulated kinase (ERK1/2) and p38 in the ARPE cell line was blocked by anthrax LeTx. LeTx also inhibited high glucose induced ARPE cell over proliferation. CONCLUSION:LeTx suppressed high glucose induced VEGF over secretion in the ARPE cells, mainly through a post-translational mechanism.

Abstract:AIM:To determine whether the photopic negative response (PhNR) elicited by transient white flash on white background is characterizing for glaucoma model in rabbits.METHODS:Glaucoma was induced in twelve rabbits by subconjunctival injection of 0.05 mL of betamethasone in right eyes (each 1 mL contain betamethasone dipropionate 5 mg and betamethasone sodium phosphate 2 mg).The intraocular pressure (IOP) , electroretinogram (ERG) and visual evoked potential (VEP) were measured successively prior and on the 3, 7d, two weeks and four weeks postglaucoma induction. After four weeks, the animals were sacrificed and the globes were histopathologically examined.RESULTS:The IOP increased significantly after one week (P=0.0001), then it gradually returned to the control level . In ERG examination, the means of a and b wave amplitude and latency were not affected significantly. PhNR amplitude decreased significantly within one week (P=0.0001), but its latency was not affected significantly (P=0.132). The means of VEP latency and amplitude were significantly affected after two weeks and four weeks of glaucoma induction (P=0.0001 and 0.02, respectively). The histopathologic examination of the globes showed reduced number of cells in the retinal ganglion cell layer with multiple vacuoles in the retinal nerve fibre layer.There was significant positive correlation between ganglion cell layer cells and PhNR amplitude (r=0.8, P=0.002).CONCLUSION:The rise in IOP resulted in irreversible changes or incomplete recovery of VEP and PhNR amplitude. Both PhNR and VEP represented good additional tools in early diagnosis of glaucoma.

Abstract:AIM: To analyze the CYP4V2 mutations in five unrelated Chinese patients with Bietti crystalline corneoretinal dystrophy (BCD) and to provide clinical features of these patients. BCD is a rare monogenic autosomal recessively inherited disorder characterized by the presence of crystals in the retina and retinal pigment epithelium atrophy. Mutations in the CYP4V2 gene have been found to be causative for BCD.METHODS:Ophthalmic examinations were carried out in the affected individuals. Peripheral blood samples were collected and genomic DNA was extracted. All exons and flanking intronic regions of the CYP4V2 gene were amplified with polymerase chain reaction and screened for mutations by direct DNA sequencing. One hundred control chromosomes were also screened to exclude nonpathogenic polymorphisms.RESULTS: Fundus examination revealed the presence of tiny yellowish-sparkling crystals at the posterior pole of the fundus and atrophy of the retinal pigment epithelium in all patients. Choroid neovascularization was noted in one patient. Five different CYP4V2 mutations were identified, including two missense mutations (p.F73L, p.R400H), two splice site mutations (c.802-8_810del17insGC, c.1091-2A>G), and one single base-pair deletion (p.T479TfsX7 or c.1437delC). The two splice site mutations were identified in three of the patients with BCD. Mutation p.T479TfsX7 was a novel mutation not observed in any of 100 ethnically matched control chromosomes.CONCLUSION: Mutation c.802-8_810del17insGC and c.1091-2A>G are common mutations in Chinese patients with BCD. Our results expand the allelic heterogeneity of BCD.

Abstract:AIM:To evaluate the enrichment of riboflavin in the corneal stroma after intracameral injection to research the barrier ability of the corneal endothelium to riboflavin in vivo.METHODS:The right eyes of 30 New Zealand white rabbits were divided into three groups. Different concentrations riboflavin-balanced salt solutions (BSS) were injected into the anterior chamber (10 with 0.5%, 10 with 1%, and 10 with 2%). Eight corneal buttons of 8.5 mm in diameter from each group were dissected at 30min after injection and the riboflavin concentrations in the corneal stroma were determined using high-performance liquid chromatography (HPLC) after removing the epithelium and endothelium. The other two rabbits in every group were observed for 24h and sacrificed. As a comparison, the riboflavin concentrations from 16 corneal stromal samples were determined using HPLC after instillation of 0.1% riboflavin-BSS solution for 30min on the corneal surface (8 without epithelium and 8 with intact epithelium).RESULTS: The mean riboflavin concentrations were 11.19, 18.97, 25.08, 20.18, and 1.13 μg/g for 0.5%, 1%, 2%, de-epithelialzed samples, and the transepithelial groups, respectively. The color change of the corneal stroma and the HPLC results showed that enrichment with riboflavin similar to classical de-epithelialized corneal collagen crosslinking (CXL) could be achieved by intracameral1% riboflavin-BSS solution after 30min; the effect appeared to be continuous for at least 30min.CONCLUSION:Riboflavin can effectively penetrate the corneal stroma through the endothelium after an intracameral injection in vivo, so it could be an enhancing method that could improve the corneal riboflavin concentration in transepithelial CXL.

Abstract:AIM:To determine whether red blood cell (RBC) membrane and plasma lipids, particularly long-chain polyunsaturated fatty acids such as eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), arachidonic acid (AA) are significantly correlated with severity of normal tension glaucoma (NTG).METHODS:This study included 35 patients with NTG and 12 healthy normal control subjects, matched for age and sex with the study group. The stage of glaucoma was determined according to the Hodapp-Parrish-Anderson classification. Lipids were extracted from RBC membranes and plasma, and fatty acid methyl esters prepared and analyzed by gas chromatography-mass spectrometry (GC-MS).RESULTS:When RBC lipids were analyzed, the levels of EPA, the levels of DHA and the ratio of n3 to n6 were positively associated with the Humphrey Perimetry mean deviation (MD) score (r=0.617, P<0.001; r=0.727, P<0.001 and r=0.720, P<0.001, respectively), while the level of AA was negatively associated with the MD score (r=-0.427, P=0.001). When plasma lipids were analyzed, there was a significant positive relationship between the levels of EPA and the MD score (r=0.648, P<0.001), and the levels of AA were inversely correlated with the MD score (r=-0.638, P<0.001).CONCLUSION:The levels of n3 and n6 polyunsaturated fatty acids in RBC membrane and plasma lipids were associated with severity of NTG.

Abstract:AIM:To describe and evaluate a standardized protocol for measuring the choroidal thickness (ChT) using enhanced depth imaging optical coherence tomography (EDI OCT).METHODS:Single 9 mm EDI OCT line scans across the fovea were used for this study. The protocol used in this study classified the EDI OCT images into four groups based on the appearance of the choroidal-scleral interface and suprachoroidal space. Two evaluation iterations of experiments were performed:first, the protocol was validated in a pilot study of 12 healthy eyes. Afterwards, the applicability of the protocol was tested in 82 eyes of patients with diabetes. Inter-observer and intra-observer agreements on image classifications were performed using Cohen’s kappa coefficient (k). Intraclass correlation coefficient (ICC) and Bland-Altman’s methodology were used for the measurement of the ChT.RESULTS:There was a moderate (k=0.42) and perfect (k=1) inter- and intra-observer agreements on image classifications from healthy eyes images and substantial (k=0.66) and almost perfect (k=0.86) agreements from diabetic eyes images. The proposed protocol showed excellent inter- and intra-observer agreements for the ChT measurements on both, healthy eyes and diabetic eyes (ICC>0.90 in all image categories). The Bland-Altman plot showed a relatively large ChT measurement agreement in the scans that contained less visible choroidal outer boundary.CONCLUSIONS:A protocol to standardize ChT measurements in EDI OCT images has been developed; the results obtained using this protocol show that the technique is accurate and reliable for routine clinical practice and research.

Abstract:AIM:To analyze the features of the filtering blebs following implantation of the Ex-PRESS glaucoma device (model P-50) with the aid of the Visante anterior segment optical coherence tomography (AS-OCT)METHODS: Five patients with open angle glaucomas were included in the study. They all underwent implantation of the Ex-PRESS device under a scleral flap. The surgical procedure was augmented with the use of mitomycin C subconjunctivally. The filtering blebs were analyzed with the Visante AS-OCT with the scans taken along the axis of the implantation of the glaucoma device.RESULTS: All filtering blebs were graded as diffuse functioning. The morphological characteristics of the blebs were similar to those of the trabeculectomy. However the use of the Ex-PRESS implant tend to form a characteristic episcleral lake at the site of the plate of the implant.CONCLUSION: The use of the Ex-PRESS implant produces filtering blebs similar to those of the trabeculectomy with the formation of a characteristic episcleral lake at the site of the plate of the implant.

Abstract:AIM: To evaluate the effect of topical dorzolamide-timolol fixed combination prophylaxis on short term intraocular pressure (IOP) changes in patients who had intravitreal bevacizumab injection.METHODS: One hundred and fifty one eyes of 151 patients which were followed up in retina clinic in Ulucanlar Eye Training and Research Hospital were evaluated in this study. Patients were divided into two groups. Group 1 consists of 75 patients who had topical dorzolamid-timolol medication two hours before injection; while Group 2 consists of 76 patients without prophylaxis. Demographic data, IOP measurements prior to the injection and one, thirty and sixty minutes and twenty-four hours after the injection were recorded. The data were analyzed using SPSS software version 15.0 (SPSS Inc., Chicago, IL, USA).RESULTS:There were no significant difference between two groups in age, gender distrubition and indications for injections. The mean IOPs in Groups 1 and 2 prior to the injection (T0) were 17.84±0.43 and 18.15±0.43 mm Hg, one minute after the injection (T1) were 29.75±1.6 and 34.44±1.59 mm Hg, 30min after the injection (T30) were 20.06±0.6 and 21.71±0.59 mm Hg respectively. The mean IOPs were 18.26±0.56 mm Hg in Group 1 and 19.78±0.56 mm Hg in Group 2 sixty minutes after the injection (T60). All IOP values after the injection were compared between two groups, there was a significant difference between two groups only on T1; one minute after the injection (P=0.04). There were a statiscially significant difference between the baseline values and other recorded values; except on T60, in Groups 1 and 2 (P<0.05).CONCLUSION: After intravitreal bevacizumab injection; we observe a transient IOP elevation which normalizes about one hour after intravitreal injection. In patients who had topical dorzolamid-timolol combination prophylaxis before injections, a significant decrease is seen in IOP spikes due to this injection. The appropiate approach will monitor IOP after intravitreal injection and evaluate the using prophylactic antiglaucomatous drugs before the injection in patients with ganglion nerve cell damage.

Abstract:AIM:To evaluate the prediction error in intraocular lens (IOL) power calculation for a rotationally asymmetric refractive multifocal IOL and the impact on this error of the optimization of the keratometric estimation of the corneal power and the prediction of the effective lens position (ELP).METHODS:Retrospective study including a total of 25 eyes of 13 patients (age, 50 to 83y) with previous cataract surgery with implantation of the Lentis Mplus LS-312 IOL (Oculentis GmbH, Germany). In all cases, an adjusted IOL power (PIOLadj) was calculated based on Gaussian optics using a variable keratometric index value (nkadj) for the estimation of the corneal power (Pkadj) and on a new value for ELP (ELPadj) obtained by multiple regression analysis. This PIOLadj was compared with the IOL power implanted (PIOLReal) and the value proposed by three conventional formulas (Haigis, Hoffer Q and Holladay Ⅰ).RESULTS:PIOLReal was not significantly different than PIOLadj and Holladay IOL power (P>0.05). In the Bland and Altman analysis, PIOLadj showed lower mean difference (-0.07 D) and limits of agreement (of 1.47 and -1.61 D) when compared to PIOLReal than the IOL power value obtained with the Holladay formula. Furthermore, ELPadj was significantly lower than ELP calculated with other conventional formulas (P<0.01) and was found to be dependent on axial length, anterior chamber depth and Pkadj.CONCLUSION:Refractive outcomes after cataract surgery with implantation of the multifocal IOL Lentis Mplus LS-312 can be optimized by minimizing the keratometric error and by estimating ELP using a mathematical expression dependent on anatomical factors.

Abstract:AIM: To assess the levels of CD18 on the surface of granulocytes infiltrating the vitreous fluid in patients with diabetic retinopathy (DR).METHODS:Vitreous samples from twelve patients with non-proliferative DR with significant macula edema (group A), 33 patients with proliferative DR (grade 3 as group B, n=14, and, grade 4 as group C, n=19) were obtained during pars plana vitrectomy. Vitreous samples from 12 patients with macular hole as controls (group D) were analyzed together. The infiltrating of granulocytes and its surface level of CD18 were measured by flow cytometry. The level of CD18 was presented as the mean channel fluorescence (MCF) on a logarithmic scale.RESULTS: Granulocytes were detected in 6 of 12 vitreous samples from group A, 9 of 14 from group B, 15 of 19 from group C, and none of 12 from group D. MCF of CD18 on granulocytes from groups A, B, and C were 2.978±1.446, 3.201±0.692, and 4.072±0.837, respectively. The difference was significant (F=4.354, P=0.021). Subjects with more severe DR were more likely to have a higher level of CD18 MCF (trend test, c²=7.351, P=0.007). CD18 MCF was significantly associated with the development of DR (r=0.46, P=0.005 and β=0.147, P=0.035).CONCLUSION:Our results confirm the presence of granulocytes and the elevated levels of CD18 on the surface of them in the vitreous fluid from DR patients. These results may provide indirect evidence shown that granulocytes activation also has occurred in the retinal local compared to non-DR control.

Abstract:AIM:To describe the clinical and imaging characteristics associated with focal choroidal excavation (FCE), analyze the possible complication, and interpret its probable etiopathogenesis.METHODS:Retrospective descriptive case series of 37 eyes of 32 patients with FCE. Findings of spectral-domain optical coherence tomography (SD-OCT), fluorescein angiography, indocyanine green angiography, and clinical features were analyzed.RESULTS: All patients were Chinese. Five patients (15.6%) were bilaterally involved. Patients’ ages ranged from 7 to 66y. Refractive error ranged between +2.0 D and ?11.0 D. Mean best-corrected visual acuity was 0.6 (range, 0.1 to 1.2). Fundus examinations exhibited mild-moderate localized pigmentary disturbances in the corresponding area of 17 eyes. Fluorescein angiography performed in 18 patients showed varying degrees of hyperfluorescence and hypofluorescence related to a range of retinal pigment epithelium (RPE) alterations. Indocyanine green angiography performed in 7 patients showed hypofluorescence at the excavation. SD-OCT demonstrated choroidal excavation in all 37 eyes. Twenty-nine eyes showed a single lesion of FCE, and three eyes showed 2-3 separated lesions. Fifteen eyes showed separation between the photoreceptor tips and RPE consistent with nonconforming FCE. Central serous chorioretinopathy (CSC, n=1) and choroidal neovascularization (CNV, n=1) developed during follow-up.CONCLUSION:FCE could be interpreted as congenital focal choroidal dysplasia involving the RPE, choriocapillaris, and photoreceptor associated with the faulty anatomy. The abnormal anatomy of FCE was similar to anatomy at risk of CSC and CNV.

Abstract:AIM:To find the risk factors related to the reproliferation of the pterygial tissue after excision and graft surgery.METHODS:Charts of 130 eyes of 130 patients who had pterygial excision from March 2006 to April 2011 were reviewed. Preoperative pterygium morphology, surgical methods, and adjunctive treatments were statistically analyzed for their relationship with recurrence.RESULTS: During the follow-up period, recurrence was observed in 20 eyes (15.4%). None of the preoperative morphologic features were affected the rate of the recurrence. However, an age < 40y [P =0.085, odds ratio (OR) 3.609, 95% confidence interval (CI) 0.838-15.540] and amniotic membrane graft instead of conjunctival autograft (P =0.002, OR 9.093, 95% CI 2.316-35.698) were statistically significant risk factors for recurrence. Multivariate analysis revealed that intraoperative mitomycin C (MMC) (P=0.072, OR 0.298, 95% CI 0.080-1.115) decreased the rate of recurrence.CONCLUSION:Younger age is a risk factor for reproliferation of pterygial tissue after excision and amniotic membrane transplantation (AMT) are less effective in preventing recurrence of pterygium after excision based on the comparison between conjunctival autograft and AMT. Intraoperative MMC application and conjunctival autograft reduce recurrence.

Abstract:AIM: To determine the difference of surgical induced astigmatism between conventional 20-gauge sutured vitrectomy and 23-gauge transconjunctival sutureless vitrectomy, and the influence of corneal pachymetry and intraocular pressure (IOP) on surgical induced astigmatism in diabetic patients.METHODS:This retrospective, consecutive case series consisted of 40 eyes of 38 diabetic subjects who underwent either 20-gauge or 23-gauge vitrectomy. The corneal curvature and thickness were measured with Scheimpflug imaging before surgery and 1wk; 1, 3mo after surgery. We compared the surgical induced astigmatism (SIA) on the true net power in 23-gauge group with that in 20-gauge group. We determined the correlation between corneal thickness change ratio, IOP and SIA measured by Pentacam.RESULTS: The mean SIAs were 1.082±0.085 D (mean±SEM), 0.689±0.070 D and 0.459±0.063 D at postoperative 1wk; 1, 3mo respectively in diabetic subjects. The vitrectomy induced astigmatisms were declined significantly with time (F2,36=33.629, P=0.000) postoperatively. The 23-gauge surgery group induced significantly less astigmatism than 20-gauge surgery group (F1,37=11.046, P=0.020). Corneal thickness in diabetes elevated after surgery (F3,78=10.532, P=0.000). The linear regression analysis at postoperatively 1wk went as:SIA=-4.519+4.931 change ratio (Port3) +0.026 IOP (R²=0.46, P=0.000), whereas the rate of corneal thickness change and IOP showed no correlation with the change of astigmatism at postoperatively 1 and 3mo.CONCLUSION: There are significant serial changes in both 20-gauge and 23-gauge group in diabetic subjects. 23-gauge induce less astigmatism than 20-gauge and become stable more rapidly than 20-gauge. The elevation of corneal thickness and IOP was associated with increased astigmatim at the early postoperative stage both in 23-gauge and 20-gauge surgery group.

Abstract:AIM:To quantify corneal ultrastructure using laser scanning in vivo confocal microscopy (IVCM) in patients with keratoconus and control subjects.METHODS: Unscarred corneas of 78 keratoconic subjects without a history of contact lens use and 36 age-matched control subjects were evaluated with slit-lamp examination (SLE), corneal topography and laser scanning IVCM. One eye was randomly chosen for analysis. Anterior and posterior stromal keratocyte, endothelial cell and basal epithelial cell densities and sub-basal nerve structure were evaluated.RESULTS: IVCM qualitatively demonstrated enlarged basal epithelial cells, structural changes in sub-basal and stromal nerve fibers, abnormal stromal keratocytes and keratocyte nuclei, and pleomorphism and enlargement of endothelial cells. Compared with control subjects, significant reductions in basal epithelial cell density (5817±306 cells/mm² vs 4802±508 cells/mm², P<0.001), anterior stromal keratocyte density (800±111 cells/mm² vs 555±115 cells/mm², P<0.001), posterior stromal keratocyte density (333±34 cells/mm² vs 270±47 cells/mm², P<0.001), endothelial cell density (2875±223 cells/mm² vs 2686±265 cells/mm², P<0.001), sub-basal nerve fiber density (31.2±8.4 nerves/mm² vs 18.1±9.2 nerves/mm², P<0.001), sub-basal nerve fiber length (21.4±3.4 mm/mm² vs 16.1±5.1 mm/mm², P<0.001), and sub-basal nerve branch density (median 50.0 (first quartile 31.2 - third quartile 68.7) nerve branches/mm² vs median 25.0 (first quartile 6.2 - third quartile 45.3) nerve branches/mm², P<0.001) were observed in patients with keratoconus.CONCLUSION: Significant microstructural abnormalities were identified in all corneal layers in the eyes of subjects with keratoconus using IVCM. This non-invasive in vivo technique provides an important means to define and follow progress of microstructural changes in patients with keratoconus.

Abstract:AIM: To evaluate the intraocular pressure (IOP) measurements by Icare rebound tonometer over a contact lens in comparison with Goldmann applanation tonometry (GAT).METHODS: Fifty patients using contact lens were included in this study. One of the eyes of the patients was selected randomly and their IOP were measured by rebound tonometer with and without contact lens (RTCL, RT respectively) and by GAT, as well as their central corneal thickness (CCT) by optical pachymeter. The results of both methods were compared by correlation analysis, general linear method repeated measure and Bland-Altman analysis.RESULTS: Mean IOP values measured by RTCL, RT and GAT were 15.68±3.7, 14.50±3.4 and 14.16±2.8 (P<0.001), respectively. Mean IOP by RTCL was significantly higher than the measurements implemented by RT and GAT (P<0.001), while there was no difference between the measurements by GAT and RT (P=0.629). There was a good level of positive correlation between GAT and RTCL as well as RT (r=0.786 P<0.001, r=0.833 P<0.001, respectively). We have observed that CCT increase did not show any correlation with the differences of the measurements between RTCL and RT (P=0.329), RTCL and GAT (P=0.07) as well as RT and GAT (P=0.189) in linear regression model.CONCLUSION: The average of the measurements over contact lens by rebound tonometer was found to be higher than what was measured by GAT. Although this difference is statistically significant, it may be clinically negligible in the normal population.

Abstract:AIM:To compare the effectiveness of topical cyclosporine A emulsion with that of oral doxycycline for rosacea associated ocular changes and dry eye complaints.METHODS:One hundred and ten patients with rosacea were screened. Thirty-eight patients having rosacea associated eyelid and ocular surface changes and dry eye complaints were included in the study. Patients were randomly divided into two groups:nineteen patients were given topical cyclosporine twice daily and nineteen patients were given oral doxycycline 100 mg twice daily for the first month and once daily for the following two months. Symptom and sign scores, ocular surface disease index questionnarie and tear function tests were evaluated at baseline and monthly for 3mo. Three months after results were compared with that of baseline.RESULTS:Mean values of symptom, eyelid sign and corneal/conjunctival sign scores of each treatment group at baseline and 3mo after treatments were compared and both drugs were found to be effective on rosacea associated ocular changes (P<0.001). Cyclosporine was more effective in symptomatic relief and in the treatment of eyelid signs (P=0.01). There was statistically significant increase in the mean Schirmer score with anesthesia and tear break up time scores in the cyclosporine treatment group compared to the doxycycline treatment group (P<0.05).CONCLUSION:Cyclosporine as a topical drug can be used in the treatment of rosacea associated ocular complications because it is more effective than doxycycline. In addition ocular rosacea as a chronic disease requires long term treatment and doxycycline has various side effects limiting its long term usage.

Abstract:AIM:To compare therapeutic effects of intravitreal triamcinolone acetonide (IVTA) versus intravitreal bevacizumab (IVB) injections for bilateral diffuse diabetic macular edema (DDME).METHODS: Forty eyes of 20 patients with bilateral DDME participated in this study. For each patient, 4 mg/0.1 mL IVTA was injected to one eye and 2.5 mg/0.1 mL IVB was injected to the other eye. The effects of injection for diabetic macular edema (DME) were evaluated using best-corrected visual acuity (BCVA), central macular thickness (CMT) by optical coherence tomography (OCT) and intraocular pressure (IOP) by applanation tonometer. Patients underwent eye examinations, including BCVA, CMT, and IOP at pre-injection, 1, 4, 8, 12 and 24wk after injection. During the follow-up, second injections were performed to eyes which have CMT greater than 400 μm at 12wk for salvage therapy.RESULTS: BCVA (logarithm of the minimum angle of resolution) at pre-injection, 1, 4, 8, 12 and 24wk after injection was 0.71±0.19, 0.62±0.23, 0.63±0.12, 0.63±0.13, 0.63±0.14 and 0.61±0.24 in the IVTA group and 0.68±0.25, 0.61±0.22, 0.60±0.24, 0.62±0.25, 0.65±0.26 and 0.59±0.25 in the IVB group, respectively. CMT (μm) at pre-injection, 1, 4, 8, 12 and 24wk after injection was 544±125, 383±96, 335±87, 323±87, 333±92, 335±61 in the IVTA group and 514±100, 431±86, 428±107, 442±106, 478±112, 430±88 in the IVB group respectively. Reduction ratios of mean CMT were 29% at 1wk, 38% at 4wk, 40% at 8wk, 38% at 12wk, and 38% at 24wk in the IVTA group. Second IVTA injections were performed to the 6 eyes (30%) at 12wk. Reduction ratios of mean CMT were 16% at 1wk, 17% at 4wk, 14% at 8wk, 7% at 12wk, and 16% at 24wk in the IVB group. Second IVB injections were performed to the 15 eyes (75%) at 12wk.CONCLUSION:This study showed earlier and more frequent macular edema recurrences in the eyes treated with bevacizumab compared with the ones treated with triamcinolone acetonide. Triamcinolone acetonide was found to provide more efficient and long-standing effect in terms of reducing CMT compared with the bevacizumab.

Abstract:AIM:To evaluate the high sensitivity C-reactive protein (hsCRP), Fetuin-A and matrix γ-carboxyglutamate protein (MGP) as the main factors for vascular calcification and inflammation in serum of patients with advanced age-related macular degeneration (ARMD) in comparison to healthy controls.METHODS: The subjects were 40 patients with choroidal neovascularization (CNV) having a mean age of 70.9±9.1y and a matched group of 49 apparently healthy control subjects. The ARMD was diagnosed using a slit-lamp with superfield lens, fundus photography and fluorescein angiography. Measurement of hsCRP was done by nephelometry method. Levels of Fetuin-A and MGP were measured by enzyme-linked immunosorbent assay (ELISA) technique.RESULTS:hsCRP [0.45(0.07-2.63) mg/L vs 0.25(0.03-1.2) mg/L, P=0.02)] and Fetuin-A levels (50.27±5.04 vs 44.99±10.28 ng/mL, P=0.009) were higher in the patients than in the control groups. We could not find significant difference in MGP level between two groups (P=0.08). There was not a significant correlation between MGP with Fetuin-A and hsCRP among the patients (P=0.7, P=0.9 respectively). A significant negative correlation of hsCRP with Fetuin-A was observed in both case and control groups (P=0.004, r=-0.33 and P=0.001, r=-0.54, respectively).CONCLUSION: Although our study shows that serum hsCRP and Fetuin-A is increased in CNV patients as well as negatively correlated with both study groups, their direct role on pathogenesis of ARMD required future studies.

Abstract:AIM:To evaluate the outcomes of Ahmed glaucoma valve (AGV) implantation surgery for refractory glaucoma.METHODS:This one-armed historical cohort study was conducted in 2011. Refractory glaucoma was defined as eyes with an intraocular pressure (IOP) greater than 21 mm Hg with maximally tolerated glaucoma medications, failed surgeries, or both. For all eyes with refractory glaucoma that underwent AGV implantation, data were collected on IOP, the best corrected visual acuity (BCVA) and glaucoma medications preoperatively and 4, 6, 12, 24 and 56wk postoperatively. Logarithm values of IOP were calculated and compared.RESULTS: The study group was comprised of 30 patients (30 eyes, 16 males and 14 females) with refractory glaucoma. Mean preoperative IOP was 39.3±13.8 mm Hg. Postoperative mean IOP was 15.7±7.1 mm Hg, 19.6±12.8 mm Hg and 13.9±14.2 mm Hg at 12, 24 and 56wk respectively. BCVA was ≥ 6/60 in 11 eyes preoperatively, and five eyes had BCVA≥6/60 at 56wk postoperatively. Preoperatively, more than four medications were used to treat glaucoma in 21 eyes. At 12wk postoperatively, no medications were required to control IOP in 20 eyes. At 56wk postoperatively, at least one medication was required to control IOP in 10 eyes. Over the entire follow up period, four eyes were treated with yttrium aluminium garnet (YAG) laser and 14 eyes required a second surgery. The AGV was removed in four eyes.CONCLUSION: AGV implantation reduced IOP and the number of medications required to control refractory glaucoma. However, there was a higher risk of decreased vision. Long-term follow up and prompt intervention are recommended.

Abstract:AIM: To compare higher order aberrations in two aspherical intraocular lenses (IOLs):Akreos advanced optics (AO) and Dr. Schmidt Microcrystalline 6125 aspheric anterior surface (MC6125AS) with each other.METHODS: Forty eyes of 39 patients underwent phacoemulsification and Akreos AO and MC6125AS were implanted in their eyes in a random manner. Three months post-operatively, higher order aberrations including spherical aberration, coma aberration, and total aberrations were measured and compared.RESULTS: The total aberration was 0.24±0.17 in eyes with Dr. Schmidt and 0.20±0.01 in eyes with Akreos AO (P=0.361). The mean of coma aberration was 0.17±0.21 and 0.09±0.86 in Dr. Schmidt and Akreos lenses, respectively (P=0.825). Total spherical aberration was almost the same in both groups (Mean:0.05, P=0.933). Best corrected visual acuity in Akreos AO (0.10±0.68) and Dr. Schmidt (0.09±0.67) did not differ significantly (P=0.700).CONCLUSION: There is no statistically significant difference in the higher order aberrations between these two aspherical lenses.

Abstract:AIM:To investigate changes in fundus excyclotorsion after inferior oblique myectomy or myotomy.METHODS:The records of 21 patients undergoing strabismus surgery by a single surgeon between 2009 and 2012 were examined. Only patients who had undergone an inferior oblique myectomy or myotomy, with or without horizontal rectus muscle surgery, were evaluated. Digital fundus photographs were obtained, and the angle formed by a horizontal line passing through the optic disc center and a reference line connecting the foveola and optic disc center was measured. Associated clinical factors examined include age at the time of surgery, presence or absence of a head tilt, degree of preoperative vertical deviation, torsional angle, inferior oblique muscle overaction/superior oblique muscle underaction, and surgery laterality. Whether the procedure was performed alone or in combination with a horizontal rectus muscle surgery was also examined.RESULTS:Mean preoperative torsional angle was 12.0±6.4°, which decreased to 6.9±5.7° after surgery (P<0.001, paired t-test). Torsional angle also decreased from 15.1±7.0° to 6.2±4.3° in the myectomy group (P<0.001, paired t-test) but there were no significant changes in the myotomy group (P=0.093, Wilcoxon signed rank test). Multivariable linear regression analysis showed that preoperative torsional angle, degree of inferior oblique overaction, and age at surgery independently and significantly affected postoperative torsional angle.CONCLUSION:Mean torsional angle decreased after inferior oblique myectomy. Degree of preoperative torsional angle, inferior oblique overaction, and age at surgery influence postoperative torsional angle.

Abstract:RESULTS: Twenty-one eyes and 22 eyes completed follow-up of 60mo in LASEK and PRK group respectively. Manifest refraction at 60mo follow-up was -0.01 and 0.26 in LASEK and PRK group respectively. In the LASEK group mean UDVA and mean CDVA after 60mo were 20/22 and 20/20 respectively (P>0.01). In the PRK group mean UDVA and mean CDVA at 60mo follow-up were 20/20 and 20/20 after 60mo (P>0.01). The efficacy indexes were 0.87 and 0.95, and the safety indexes were 1.25 and 1.4 respectively for LASEK group and PRK group.CONCLUSION:Both standard PRK and no-alcohol LASEK offer safe and effective correction of low-moderate myopia in the long term without any statistically significant difference between the two groups.

Abstract:AIM: To investigate the efficacy and safety of krypton laser peripheral iridoplasty (LPIP) for Chinese patients with primary angle closure (PAC) or primary angle-closure glaucoma (PACG) status post laser iridotomy in reversing the positive results of the dark room provocative test (DRPT).METHODS:This study was prospective, noncomparative, interventional case series. Thirty-three patients (thirty-eight eyes) with PAC or PACG status post patent laser iridotomy and maintained normal intraocular pressure (IOP) but with positive DRPT results were enrolled. All the subjects were treated with krypton LPIP. DRPT was repeated after krypton LPIP. Results of DRPT were recorded. The visual acuity, IOP and gonioscopy were analyzed before and after krypton LPIP. A minimum time limit for follow-up was 6mo.RESULTS:Thirty-three patients (thirty-eight eyes) were followed for 17.7±8.37mo (range 7-41mo) after LPIP. Positive results of DRPT decreased from 38 eyes to 9 eyes (23.7%) after LPIP. Peripheral anterior synechiae of angle in 34 of 38 eyes (89.5%) remained unchanged at dynamic gonioscopy throughout the follow-up period after LPIP.CONCLUSION:LPIP decreased positive rates of the DRPT significantly. The mechanism may be that LPIP minimized contact between the peripheral iris and trabecular meshwork, which is a key factor for developing peripheral anterior synechiae.

Abstract:AIM: To determine whether retinal circulatory changes play a role in the pathogenesis of macular disorders in patients who are otherwise healthy.METHODS:Patients with macular disorders that required angiographic imaging were included in this prospective case series. After a complete ocular exam, fluorescein angiography was performed using a standardized technique on the HRA-II (Heidelberg Engineering, Heidelberg, Germany) with special focus on the posterior pole. Only patients with good quality images were included in the analysis. Circulatory parameters recorded included the arm-choroid time, choroid-retinal artery, and finally the retinal artery-vein time. Zonal asymmetry (between the upper and lower zones divided by a line passing through the centre of the fovea) in transit times, if any was also noted. Appropriate statistical analysis was done. Circulation times were compared with age matched historical controls. Changes in retinal dye transit times relative to historical age matched controls, if any, were noted and compared between various disorders.RESULTS:A total of 156 eyes of 156 patients (120 males) were included in the study. Mean age:49.14±14.93y. Macular disorders studied were age related degeneration, polypoidal vasculopathy, central serous chorioretinopathy (CSCR) and parafoveal telangiectasia. Delayed circulation time was noted in CSCR patients only.CONCLUSION:CSCR patients appear to have delayed arterial filling, retinal circulatory disturbances do not seem to contribute to the pathogenesis of other macular disorders.

Abstract:AIM:To compare surgical peeling and aspiration and neodymium yttrium garnet laser capsulotomy for pearl form of posterior capsule opacification (PCO).METHODS:A prospective, randomized, double blind, study was done at Rotary Eye Hospital, Maranda, Palampur, India, Santosh Medical College Hospital, Ghaziabad, India and Laser Eye Clinic, Noida India. Consecutive patients with pearl form of PCO following surgery, phacoemulsification, manual small incision cataract surgery and conventional extracapsular cataract extraction (ECCE) for age related cataract, were randomized to have peeling and aspiration or neodymium yttrium garnet laser capsulotomy. Corrected distance visual acuity (CDVA), intra-operative and post-operative complications were compared.RESULTS:A total of 634 patients participated in the study, and 314 (49.5%) patients were randomized to surgical peeling and aspiration group and 320 (50.5%) to the Nd:YAG laser group. The mean pre-procedural logMAR CDVA in peeling and neodymium:yttrium-aluminium-garnet (Nd:YAG) laser group was 0.80±0.25 and 0.86±0.22, respectively. The mean final CDVA in peeling group (0.22±0.23) was comparable to Nd:YAG group (0.24±0.28; t test, P=0.240). There was a significant improvement in vision after both the procedures (P<0.001). A slightly higher percentage of patients in Nd:YAG laser group (283/88.3%) than in peeling group (262/83.4%) had a CDVA of 0.5 (20/63) or better at 9mo (P<0.001). On the contrary, patients having CDVA worse than 1.00 (20/200) was also significantly higher in Nd:YAG laser group as compared to peeling group (25/7.7% vs 15/4.7%, respectively). On application of ANCOVA, there was less than 0.001% risk that PCO thickness and total laser energy had no effect on rate of complications in Nd:YAG laser group and less than 0.001 % risk that PCO thickness had no effect on complications in peeling group respectively. Sum of square analysis suggests that in the Nd:YAG laser group, thick PCO had a stronger impact on complications (Fischer test probability, Pr<0.0001) than thin PCO and total laser energy (Fischer test probability, Pr<0.002), respectively; similarly, in peeling group, thick PCO and preoperative vision had a stronger effect on complications than thin PCO, respectively (Fischer test probability, Pr<0.001).The rate of complications like uveitis (P=0.527) and cystoid macular edema (P=0.068), did not differ significantly between both the groups. However, intraocular pressure spikes (P=0.046) and retinal detachment (P<0.001) were significantly higher in Nd:YAG laser group as compared to peeling group. Retinal detachment was more common in patients having degenerative myopia (7/87.5%, P<0.001). Recurrence of pearls was the most common cause of reduction of vision in the peeling group (24/7.6%, P<0.001).CONCLUSION:There is no alternative to Nd:YAG laser capsulotomy for fibrous subtype of PCO. For pearl form of PCO, both techniques are comparable with regard to visual outcomes. Nd:YAG laser capsulotomy has a higher incidence of IOP spikes and retinal detachment whereas recurrence of pearls may occur after successful peeling and aspiration. When posterior capsulotomy is needed in patients with retinal degenerations, retinopathies and pre-existing retinal breaks, the clinician should be cautious about increased risks of possible complications of Nd:YAG laser capsulotomy.

Abstract:AIM: To review published clinical studies examining the effect of natamycin in the treatment of fungal keratitis.METHODS:We selected the publications in CENTRAL, MEDLINE, EMBASE, CNKI, and CBM. This study systematically reviewed published randomized controlled trials (RCTs) that compared natamycin to other antifungal agents, and conducted feasible Meta-analysis of efficacy results using Revman 5.2 software.RESULTS: We included seven trials which were mainly carried out in developing countries of Asia, with five trials conducted in India, one each in China and Bangladesh. A total of 804 participants were randomized to following comparisons:2% econazole versus 5% natamycin showed little difference in the effects of treatment of fungal keratitis [RR=0.99, 95% confidence interval (CI), 0.8 to 1.21]; chlorhexidine gluconate versus 5% natamycin indicated that the results on healing of the ulcer at 21d was less conclusive (RR=0.77, 95% CI, 0.55 to 1.08; I²=0%); 1% voriconazole versus 5% natamycin suggested that natamycin treatment appeared to be significantly better outcomes than voriconazole (regression coefficient =-0.18 logMAR; 95% CI, -0.30 to -0.05; P=0.006), especially in Fusarium cases (regression coefficient=-0.41 logMAR; 95% CI, -0.61 to -0.20; P<0.001); natamycin versus fluconazole showed a significant difference in cure rate (χ² =5.048, P<0.05) and natamycin group was more effective than fluconazole in average period of therapy (t=7.94, P<0.01).CONCLUSION: Natamycin was a preferable choice in the treatment of fungal keratitis, especially in the early period of Fusarium cases.

Abstract:AIM:To collectively evaluate the association of intercellular adhesion molecule-1 (ICAM-1) gene K469E polymorphism (rs5498) with diabetic retinopathy (DR) in patients with type 2 diabetic mellitus (T2DM).METHODS:Overall review of available literatures relating K469E polymorphism to the risk of DR was conducted on 4 electronic databases. Meta-analysis was performed by Stata 12.0 to calculate pooled odds ratios (ORs). Potential sources of heterogeneity and bias were explored.RESULTS:Seven studies with genotype frequency data including 1120 cases with DR and 956 diabetic controls free of DR were included. Meta-analysis did not show significant association of K469E polymorphism with DR (P>0.05). A statistically significant association was detected between the K469E polymorphism and proliferative diabetic retinopathy (PDR) in Asians only in dominant model (GG+AG vs AA) with pooled OR of 0.729 (95%CI:0.564-0.942, P=0.016, Pheterogeneity=0.143), however, this association was not detected in recessive model (GA+AA vs GG; OR=1.178, 95%CI:0.898-1.545, P=0.236, Pheterogeneity=0.248) or allelic model (G vs A; OR=0.769, 95% CI:0.576-1.026, P=0.074, Pheterogeneity=0.094). No publication bias was found by Funnel plot, Begg''s and Egger''s test.CONCLUSION:This research found no statistically significant association between ICAM-1 gene K469E polymorphism and DR in patients with T2DM, but showed significant association of the K469E polymorphism with PDR in Asian diabetic patients only in dominant model. Further investigation would be required to consolidate the conclusion.

Abstract:AIM:To investigate the corneal endothelial cell density and morphology and central corneal thickness in the Guangxi Maonan and Han adolescent students of China.METHODS:Noncontact specular microscope (Topcon SP3000P, Tokyo, Japan) was performed in 133 adolescent students of Maonan nationality (M:F 54:79) and 105 adolescent students of Han nationality (M:F 50:55), 5 to 20y of age, who were randomly selected from 3 schools in Huanjiang Maonan Autonomous County of Guangxi Zhuang Autonomous Region of China. Parameters studied included endothelial cell density, mean cell area, coefficient of variation in cell size, percentage hexagonality and central corneal thickness.RESULTS:Endothelial cell density, mean cell area, coefficient of variation in cell size, percentage hexagonality and central corneal thickness in the study population were (2969.50±253.93) cells/mm², (339.23±29.44) μm², (29.96±4.07) %, (64.58±9.41) % and (523.71±32.82) μm in Maonan and (2998.26±262.65) cells/mm², (336.11±30.07) μm², (29.89±5.03) %, (64.91±11.64) % and (524.39±33.15) μm in Han, respectively. No significant differences were observed in endothelial cell density, mean cell area, coefficient of variation in cell size, percentage hexagonality and central corneal thickness between Maonan and Han (P=0.615, 0.659, 0.528, 0.551, 0.999). In Maonan and Han, we found age was negatively correlated with endothelial cell density and percentage hexagonality and positively correlated with mean cell area and coefficient of variation in cell size. Negative correlation was also found between central corneal thickness and age in Han, whereas no correlation was found in Maonan.CONCLUSION:There were no differences between Maonan and Han in corneal endothelial cell density and morphology and central corneal thickness. In these two nationalities, there were statistically significant decrease in endothelial cell density and percentage hexagonality with increasing age and statistically significant increase in cell area and coefficient of variation in cell size with increasing age. Central corneal thinned with increasing age in Han, whereas difference did not attain statistical significance in Maonan.

Abstract:AIM: To investigate the number of hypertensive patients, the optometrist is able to identify by routinely taking blood pressure (BP) measurements for patients in “at-risk” groups, and to sample patients’ opinions regarding in-office BP measurement. Many of the optometrists in Saudi Arabia practice in optical stores. These stores are wide spread, easily accessible and seldom need appointments. The expanding role of the optometrist as a primary health care provider (PHCP) and the increasing global prevalence of hypertension, highlight the need for an integrated approach towards detecting and monitoring hypertension.METHODS:Automated BP measurements were made twice (during the same session) at five selected optometry practices using a validated BP monitor (Omron M6) to assess the number of patients with high BP (HBP) -in at-risk groups-visiting the eye clinic routinely. Prior to data collection, practitioners underwent a two-day training workshop by a cardiologist on hypertension and how to obtain accurate BP readings. A protocol for BP measurement was distributed and retained in all participating clinics. The general attitude towards cardiovascular health of 480 patients aged 37.2 (±12.4)y and their opinion towards in-office BP measurement was assessed using a self-administered questionnaire.RESULTS: A response rate of 83.6% was obtained for the survey. Ninety-three of the 443 patients (21.0%) tested for BP in this study had HBP. Of these, (62 subjects) 66.7% were unaware of their HBP status. Thirty of the 105 subjects (28.6%) who had previously been diagnosed with HBP, still had HBP at the time of this study, and only 22 (73.3%) of these patients were on medication. Also, only 25% of the diagnosed hypertensive patients owned a BP monitor.CONCLUSION: Taking BP measurements in optometry practices, we were able to identify one previously undiagnosed patient with HBP for every 8 adults tested. We also identified 30 of 105 previously diagnosed patients whose BP was poorly controlled, twenty-two of whom were on medication. The patients who participated in this study were positively disposed toward the routine measurement of BP by optometrists.

Abstract:Retinal degenerative diseases pose a serious threat to eye health, but there is currently no effective treatment available. Recent years have witnessed rapid development of several cutting-edge technologies, such as gene therapy, stem cell therapy, and tissue engineering. Due to the special features of ocular structure, some of these technologies have been translated into ophthalmological clinic practice with fruitful achievements, setting a good example for other fields. This paper reviews the development of the gene and stem cell therapies in ophthalmology.

Abstract:Phacoemulsification is the main gold standard for cataract operation in the developed world together with foldable intraocular lens (IOL) implantation by injection, allowing for stable wound construction and less postoperative astigmatism. It is a safe procedure with high success rate with the advancement in machines, improvement of IOL injection systems and further maturation of surgeons’ techniques. Despite the large number of operations performed every day, foldable IOL injection leading to an intra-stromal corneal track is a very rare complication. We report a case of this unusual finding in a 70-year-old gentleman who has undergone cataract operation in November 2011 in our hospital and will review on the complications related to foldable IOL injection.

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