panax ginseng ( ginseng ) has been used traditionally in eastern asia over thousands of years .
it has been used orally to treat various diseases including hypertension , diabetes mellitus , liver and kidney dysfunction , mental disorders , and postmenopausal disorders .
in addition , topical applications have also been used to heal wounds and reduce skin inflammation . in the past few decades
, it has been proved that ginseng extracts actually show a wide range of effects against human diseases .
their potential therapeutic effects have been mainly attributed to its immunomodulatory , neuroprotective , antioxidative , antitumor , and hepatoprotective activities .
ginseng contains a number of active ingredients including ginsenosides , polysaccharides , phytosterols , peptides , polyacetylenes , fatty acids , and polyacetylenic alcohols , which have different effects on carbohydrate and lipid metabolism , cognition , angiogenesis , and the neuroendocrine , immune , cardiovascular , and central nervous systems . among the active constituents of ginseng ,
ginsenosides are known to be the major biologically active components of ginseng and the most widely studied .
several studies have shown that ginsenosides play important roles in the pharmacological effects of ginseng .
. however , ginseng contains other constituents , including ginsenoyne , phenolic compounds , polyacetylenes , sesquiterpenes , methoxypyrazine , alkylpyrazine derivatives , sesquiterpene alcohols , panasinsanols , and -carboline .
white ginseng is peeled , dried , ginseng root and red ginseng is produced by steaming fresh ginseng root at 98100c for 23  h , and then drying until the moisture content is < 15% .
red and white ginseng have both been shown to have immunomodulatory , anti - inflammatory , antioxidant , and antiatopic activities . moreover ,
red ginseng has been reported to have more potent pharmacological activities than white ginseng in some respects [ 2022 ] .
the differences in biological activities between red and white ginseng are caused by the chemical changes of ginsenosides after the steaming process .
steaming partially converts the original ginsenosides to deglycoslated derivatives . as a result , the species and amounts of ginsenosides are quite different based on the processing method used .
chu et  al   showed that a total of 53 and 43 compounds were tentatively identified in white ginseng and red ginseng samples , respectively .
the featured compounds are mainly malonyl ginsenosides in white ginseng , and decarboxyl products of mal - ginsenosides and the dehydrated compounds from polar ginsenosides were characteristic in red ginseng .
it is interesting that ginsenosides show a wide variety of biological activities , although the absorption rates from orally administered intact ginsenosides are very low . in the human intestinal tract ,
thus , the pharmacological actions of these ginsenosides have been closely related to their biotransformation by human intestinal bacteria . in this context
several studies showed that the transformation of ginsenosides into deglycosylated ginsenosides is needed to increase ginseng 's effectiveness in  vivo
 .
abnormal changes in skin color induce significant cosmetic problems with a negative effect on quality of life .
there are two groups of pigmentary disorders : disorders of the quantitative and qualitative distribution of normal pigment and the abnormal presence of exogenous or endogenous pigments in the skin .
hyperpigmentation - related diseases include melasma , lentigines , nevus , ephelis , freckles , postinflammatory hyperpigmentation , and age spots .
postinflammatory hyperpigmentation appears in many skin conditions , including acne , eczema , and contact dermatitis .
skin color is determined by various factors including melanin content , oxygenation state of hemoglobin in capillary vessels , carotenoid content , water content , and organization of collagen fibers in the dermis . among these factors , melanin is the major determinant of skin color . in this context ,
melanogenesis is a biochemical pathway responsible for melanin synthesis that is controlled by complex regulatory mechanisms .
melanogenesis occurs in melanocytes confined in separate cytoplasmic organelles called melanosomes , which contain key enzymes of melanogenesis .
differences in skin color are related to the size , number , shape , and distribution of melanosomes , whereas melanocyte density typically remains relatively constant  .
although tyrosinase is the key regulatory enzyme of melanogenesis , tyrosinase - related protein ( trp)-1 , dopachrome tautomerase ( dct / trp2 ) , and melanosomal matrix proteins ( pmel17 , mart-1 ) carry out important roles in regulating melanogenesis .
the genes of tyrosinase , trp-1 , and dct contain common transcription starting sites , the microphthalmia - associated transcription factor ( mitf ) binding sites .
the intracellular signal transduction pathways of protein kinase c , cyclic amp ( camp ) , and nitrogen oxide are involved in the regulation of melanogenesis .
various endogenous and exogenous factors , such as estrogen and ultraviolet ( uv ) radiation , affect melanogenesis via signal transduction pathways .
these endogenous / exogenous factors exert their actions directly on melanocytes or indirectly via surrounding skin cells .
melanocytes , keratinocytes , dermal fibroblasts , and other skin cells communicate with each other by factors that are secreted and cell  cell contacts .
it has been shown that the interactions between keratinocytes and melanocytes are critical in the regulation of melanogenesis .
in addition , dermal factors have been found to be involved in the regulation of melanogenesis . at the same time , stimulated melanocytes secret a number of signal molecules targeting not only keratinocytes but also skin immune cells .
soluble factors released by melanocytes include proinflammatory cytokines and chemokines such as interleukin ( il)-1/1 , il-6 , il-8 il-10 , tumor necrosis factor ( tnf)- , transforming growth factor ( tgf)- , catecholamines , eicosanoids , serotonin , -melanocyte stimulating factor ( -msh ) , and nitric oxide ( no ) .
a variety of hypopigmenting agents including hydroquinone , arbutin , tretinoin , kojic acid , azelaic acid , vitamin c , n - acetylglucosamine , niacinamide , linoleic acid , ellagic acid , methimazole , dioic acid , soy extract , licorice extract , rucinol , and glycolic acid have been used alone or in combination to treat abnormal hyperpigmentation .
these agents can interfere with the pigmentation process at several different steps of skin pigmentation .
however , the treatment of hyperpigmented conditions still remains challenging and the results are often discouraging .
thus there is a need for novel skin - whitening agents that are highly effective and tolerable . in this article
, we review recent reports investigating the skin - whitening effect of ginseng and its components and the underlying mechanisms of action , and then discuss their potential as candidates for novel skin - whitening agents .
p.  ginseng is one of the most widely used medicinal plants in traditional oriental medicine . over thousands of years
, it has been used to improve the overall condition of skin , as well as to treat a wide variety of diseases . however
, genuine scientific approaches to clarify the efficacy of ginseng in skin have only been made in recent years .
several reports have shown that ginseng extract , powder , or some other constituents could inhibit melanogenesis in  vitro and in  vivo . table  1 summarizes the direct effects of ginseng and its components on skin color and key enzymes involved in melanogenesis .
song et  al reported that red ginseng powder improved melasma in a human clinical trial .
they orally administered korean red ginseng powder for 24 weeks to female patients with melasma .
after 24 weeks , the melasma area and severity index score decreased and melasma quality of life scale showed improvement in 91% of patients .
in addition , 74% of the patients showed some improvement on the patient- and investigator - rated global improvement scales .
most of reports investigating the antimelanogenic effect of ginseng were conducted in  vitro used purified tyrosinase or melanocyte cell lines . in melan - a cells treated with ethanol extract of ginseng seeds , melanin content and
in addition to the crude extract or powder , several studies tested the effects of specific constituents of ginseng . the phenol compounds inhibited tyrosinase activity while ginsenoside prevents uvb - induced intracellular increase of reactive oxygen species [ 4648 ] . in some reports , ginsenosides alone exerted antimelanogenic effects .
aglycone of ginsenoside rh4 inhibited melanin synthesis in b16 melanoma cells , possibly by involvement of protein kinase a pathway .
it significantly reduced melanin content and tyrosinase activity in -msh and forskolin - stimulated b16 melanoma cells .
it reduced the camp level and camp response - element binding protein level in b16 melanoma cells , and this might be responsible for the downregulation of mitf and tyrosinase .
in addition , ginsenoside rb1 inhibited melanogenesis through the inhibition of tyrosinase activity in -msh - stimulated b16 cells in a dose - dependent manner .
the crude methanol extract of the fresh leaves of p.  ginseng showed inhibitory activity on mushroom tyrosinase , and p - coumaric acid was characterized as the principal tyrosinase inhibitor in the extract .
p - coumaric acid inhibited melanogenesis in b16f10 melanoma cells stimulated by -msh , and was suggested to interfere with melanogenesis by its structural similarity with tyrosine .
interestingly , p - coumaric acid showed weaker inhibition against mushroom tyrosinase but more strongly inhibited human or murine tyrosinase in comparison with kojic acid and arbutin .
enzyme kinetics analysis indicate that p - coumaric acid is a mixed type ( for tyrosine ) or competitive inhibitor ( for dopa ) of human tyrosinase .
in addition , p - coumaric acid potently inhibits melanogenesis in human epidermal melanocytes exposed to uvb .
cinnamic acid , one of the major components of cinnamomum cassia blume , is found in the root and seed of p.  ginseng
 .
cinnamic acid significantly reduced melanin production , tyrosinase activity , and tyrosinase expression in the melan - a cells .
in addition , cinnamic acid showed depigmenting activity on the uvb - tanned skin of brown guinea pigs .
it is already known that the pharmacological actions of these ginsenosides have been closely related to their biotransformation by human intestinal bacteria . although the contents of total ginsenosides in red ginseng and fermented red ginseng using lactobacillus brevis were not significantly different , the ginsenoside metabolite content was higher in fermented red ginseng compared to red ginseng .
the tyrosinase inhibitory activity of fermented red ginseng extract was more potent compared with red ginseng extract in a test using mushroom tyrosinase .
as reviewed above , crude extract or some components of ginseng and its components showed antimelanogenic activities by direct inhibition on key enzymes of melanogenesis , such as tyrosinase .
moreover , ginseng and its components could exert antimelanogenic activity via action on the several factors related in melanocyte physiology . among a large number of soluble factors produced from melanocytes , keratinocytes , fibroblasts , and immune cells in skin , adrenocorticotropic hormone ( acth ) , -msh , endothelin-1 , prostaglandin e2 , prostaglandin f2 , no , and histamine are well - known stimulators of melanogenesis [ 37,5963 ] .
il-1/1 and granulocyte - macrophage colony - stimulating factor ( gm - csf ) stimulate melanogenesis , while il-6 , tgf-1 , and tnf- downregulate melanin production .
gm - csf has been reported to be involved in regulating the proliferation and differentiation of epidermal melanocytes .
treatment of melan - a cells with conditioned media from uv - irradiated sp-1 keratinocytes increased melanocyte proliferation , and the proliferative effect of the conditioned media was blocked by anti - gm - csf antibody treatment . when uv - irradiated sp-1 keratinocytes were treated with red ginseng extract or saponin of red ginseng , the increased melanocyte proliferation by the conditioned media was blocked . in that report ,
red ginseng extract or saponin of red ginseng treatment decreased the expression of gm - csf induced by uv - b irradiation in sp-1 keratinocytes .
as mentioned above , inflammatory cytokines such as il-1 and tnf- take part in the regulation of melanogenesis .
ginseng extracts and ginsenosides have been reported to have anti - inflammatory activities in several different studies .
ginsenosides inhibit different inducer - activated signaling protein kinases and transcription factor nuclear factor ( nf)-b , and then decrease the production of proinflammatory cytokines and mediators of inflammation .
korean red ginseng extracts decreased tnf- and il-8 production in lipopolysaccharide ( lps)-stimulated hacat keratinocytes and show radical scavenging and antioxidant activity in human dermal fibroblasts .
these findings suggest that ginseng extracts and ginsenosides might affect melanogenesis through their anti - inflammatory activities . the effect of ginseng on no production is still questionable .
sun ginseng , a new processed ginseng prepared by steaming at high temperature , reduced uv - b - induced cell damage and decreased no production by inhibition of inducible no synthase mrna synthesis in hacat keratinocytes and human dermal fibroblasts .
red ginseng marc oil inhibited inducible no synthase and cyclooxygenase-2 via nf-b and p38 pathways in lps - stimulated raw264.7 cells .
in addition , ginsenjilinol , a protopanaxatriol - type saponin obtained from the roots of p.  ginseng , shows inhibitory activity on no production in lps - stimulated raw264.7 cells .
by contrast , there are some controversial reports that ginseng extract enhanced no production or no signaling .
hong et  al reported that ginseng extract administration stimulated nongenomic endothelial no synthase activation and enhanced no production in spontaneously hypertensive rats . in another report , water extract of korean red ginseng exerted vasoprotective effects through augmentation of no production by inhibiting arginase .
therefore , the effect of ginseng on melanogenesis via no signaling remains to be clarified by further study .
considerable numbers of immune cells including langerhans cells , macrophages , mast cells , and t cells are working actively in skin tissue . because the immunostimulatory activities of many ginsenosides are known , it is not surprising that ginsenosides could enhance the reactivity of skin immune cells . in a recent paper ,
a cream containing 0.1% ginsenoside f1 ( a metabolite of ginsenoside rg1 ) showed a significant whitening effect on artificially tanned human skin .
however , ginsenoside f1 did not directly inhibit mrna expression of tyrosinase or dct in normal human epidermal melanocytes .
instead , ginsenoside f1 enhanced production of il-13 from human epidermal  t cells , and il-13 significantly reduced the mrna expression and protein amount of both tyrosinase and dct resulting in visible brightening of normal human epidermal melanocyte pellets .
these results suggest that ginsenosides might be able to regulate melanogenesis via their effect on skin immune cells .
recently , several reports have shown that extract , powder , or some constituents of ginseng could inhibit melanogenesis in  vivo or in  vitro
. the underlying mechanisms of the antimelanogenic effect of ginseng or its components included the direct inhibition of key enzymes of melanogenesis ( tyrosinase and dct ) , inhibition of transcription factors ( mitf , nf-b ) or signaling pathways ( protein kinase a pathway and protein kinase c pathway ) involved in melanogenesis , decreasing the production of inducers of melanogenesis ( camp , gm - csf ) , and enhancing production of antimelanogenic factor ( il-13 ) . fig .
although issues surrounding the antimelanogenic activity of ginseng still remain controversial , especially in its effect on the production of proinflammatory cytokines and no , these recent findings suggest that ginseng and its constituents might be potential candidates for novel skin - whitening agents .

 abnormal changes in skin color induce significant cosmetic problems and affect quality of life .
 there are two groups of abnormal change in skin color ; hyperpigmentation and hypopigmentation .
 hyperpigmentation , darkening skin color by excessive pigmentation , is a major concern for asian people with yellow  brown skin .
 a variety of hypopigmenting agents have been used , but treating the hyperpigmented condition is still challenging and the results are often discouraging .
 panax ginseng has been used traditionally in eastern asia to treat various diseases , due to its immunomodulatory , neuroprotective , antioxidative , and antitumor activities . recently
 , several reports have shown that extract , powder , or some constituents of ginseng could inhibit melanogenesis in  vivo or in  vitro .
 the underlying mechanisms of antimelanogenic properties in ginseng or its components include the direct inhibition of key enzymes of melanogenesis , inhibition of transcription factors or signaling pathways involved in melanogenesis , decreasing production of inducers of melanogenesis , and enhancing production of antimelanogenic factor .
 although there still remain some controversial issues surrounding the antimelanogenic activity of ginseng , especially in its effect on production of proinflammatory cytokines and nitric oxide , these recent findings suggest that ginseng and its constituents might be potential candidates for novel skin whitening agents .


aneuploid strains were generated by sporulation of the above polyploid strains , followed by karyotype stability tests and determination as described in fig .
qpcr assays were designed with primers in non - coding regions on each chromosome arm ( supplementary table 1 lists primer sequences ) .
dna samples were prepared by alkaline lysis , and qpcr reactions were performed in 384-well plates using a biomek fx ( beckman coulter ) to assemble 10 l reactions and an abi 7900ht ( applied biosystems ) for cycling .
equal amounts ( od600 ) of aneuploid and euploid control cultures were spotted , using the biomek fx robot , onto omnitrays containing various solid media and grown under conditions listed in supplementary table 2 .
omnitrays representing three biological replicates of each tested condition were scanned on an hp scanjet 4070 desktop scanner .
whole - cell lysates were prepared from 50 ml cycling yeast cultures by bead - beating .
the ms / ms datasets were searched using sequest23 against a database of 11,986 sequences , consisting of 5,816 s. cerevisiae non - redundant proteins ( ncbi ) , 177 contaminants and 5,993 decoy sequences .
all statistical analyses were performed in the r environment25 using standard packages and custom scripts .
aneuploid strains were generated by sporulation of the above polyploid strains , followed by karyotype stability tests and determination as described in fig .
qpcr assays were designed with primers in non - coding regions on each chromosome arm ( supplementary table 1 lists primer sequences ) .
dna samples were prepared by alkaline lysis , and qpcr reactions were performed in 384-well plates using a biomek fx ( beckman coulter ) to assemble 10 l reactions and an abi 7900ht ( applied biosystems ) for cycling .
equal amounts ( od600 ) of aneuploid and euploid control cultures were spotted , using the biomek fx robot , onto omnitrays containing various solid media and grown under conditions listed in supplementary table 2 .
omnitrays representing three biological replicates of each tested condition were scanned on an hp scanjet 4070 desktop scanner .
whole - cell lysates were prepared from 50 ml cycling yeast cultures by bead - beating .
the ms / ms datasets were searched using sequest23 against a database of 11,986 sequences , consisting of 5,816 s. cerevisiae non - redundant proteins ( ncbi ) , 177 contaminants and 5,993 decoy sequences .
all statistical analyses were performed in the r environment25 using standard packages and custom scripts .

 aneuploidy , referring here to genome contents characterized by abnormal numbers of chromosomes , has been associated with developmental defects , cancer , and adaptive evolution in experimental organisms19 .
 however , it remains unresolved how aneuploidy impacts gene expression and whether aneuploidy could directly bring phenotypic variation and improved fitness over that of euploid counterparts . in this work
 , we designed a novel scheme to generate , through random meiotic segregation , 38 stable and fully isogenic aneuploid yeast strains with distinct karyotypes and genome contents between 1n and 3n without involving any genetic selection . through phenotypic
 profiling under various growth conditions or in the presence of a panel of chemotherapeutic or antifungal drugs , we found that aneuploid strains exhibited diverse growth phenotypes , and some aneuploid strains grew better than euploid control strains under conditions suboptimal for the latter . using quantitative mass spectrometry - based proteomics ,
 we show that the levels of protein expression largely scale with chromosome copy numbers , following the same trend observed for the transcriptome .
 these results provide strong evidence that aneuploidy directly impacts gene expression at both the transcriptome and proteome levels and can generate significant phenotypic variation that could bring about fitness gains under diverse conditions .
 our findings suggest that the fitness ranking between euploid and aneuploid cells is context- and karyotype - dependent , providing the basis for the notion that aneuploidy can directly underlie phenotypic evolution and cellular adaptation .


in order to assess sexual well - being and provide treatment or education for iranian women 's sexuality , it is necessary to understand their sexuality and the meanings they give to sexual behaviors .
sexual behavior is a complex concept that is difficult to measure . according to webster 's online dictionary ,
the manner of conducting oneself and  sexual simply means whatever relates to  sex ,  the sexes or
sexual reproduction. thus , sexual behavior would be an act by someone that expresses their sexuality . in the archive for sexology , erwin j. haeberle introduces
sexual as a word with double meaning , referring to  human anatomy as well as to human behavior  . he defines  sexual behavior as erotic behavior .
therefore , in contrast with webster , the critical dictionary in the archive for sexology defines human reproduction as  asexual behavior  because it concentrates on  the biological facts without reference to the erotic feelings of the man and the woman involved  .
the functional analysis of sexual behaviors has led researchers to develop instruments to gather observable data . in order to change subjective meanings to observable data ,
the researchers need to extract meanings from the contexts and populations they seek to measure .
many sexually related measures and instruments have been published ; they measure perceptions , attitudes , beliefs and so on . however , the contexts from which the concepts and meanings were extracted to develop these instruments vary .
doubtless , their reliability in measuring sexual behaviors as socially constructed , complex and dynamic phenomena can be questioned . in order to determine a research approach for the context of iranian women 's sexuality , review and assessment of existing instruments was essential . after a brief overview of the existing instruments measuring
non - risky  sexual behaviors among heterosexual women , we look at their cultural appropriateness to measure sexual behaviors within an iranian context .
finally , because we find these instruments insufficient , we suggest criteria for cultural - specific sexually related measures in the iranian settings .
for the purpose of this paper , we searched literature using medline , pub - med , psychinfo and cinahl from june 2006 to june 2011 .
the mesh terms used to search title and abstract included  sexuality  ,  sexual behavior  ,  questionnaire  and  sexual behavior and questionnaire  or
sexually related measure  ,  sexually related tools  limited to  human , female , english and reproductive age  . focused exclusively on the concept of sexual behavior , we screened titles and abstracts . considering that not all abstracts highlighted the specified population and name of the applied tools ,
these articles were found in full , and methods sections were reviewed to identify populations and the tools used .
retrieved articles were included if they used a structured instrument(s ) to measure sexual behaviors of the female population .
we excluded those studies whose outcome of interest included risky sexual behaviors or sexual behaviors measured among same sex relationships .
we excluded same sex relationships because this form of relationships is illegal and deniable in iran .
if the original paper was unavailable , we selected the article that used the given tool to measure the study outcomes . in this stage , tools in languages other than english , those employed just for menopausal women and those not related to sexual behaviors were excluded . using gagnon and simon sexual script theory as the theoretical framework ,
cultural appropriateness ( i.e. understanding and language of sexuality , ethics , and morality ) was our selection criteria for the instruments .
evaluation of the 143 articles revealed that a majority of them ( 65% ) had utilized the female sexual function index ( fsfi ) in their research .
the second most used scale was the pelvic organ prolapsed / urinary incontinence sexual function questionnaire ( pisq-12 ) , utilized in 10.4% of the final articles .
the golombok - rust inventory of sexual satisfaction ( griss ) and the arizona sexual experience scale ( asex ) were the next most used instruments by 6.9% and 5.6% of articles , respectively .
we reviewed all instruments and determined the subscales as well as measurement types [ table 1 ] .
we categorized these instruments into three groups based on their working definitions of  sexual behavior and theoretical frameworks .
these instruments were reviewed by the authors , who are iranian experts in sexology , reproductive health , and epidemiology .
of 50 instruments , we found 19 tools applicable in the iranian culture [ table 2 ] .
the third group included those which were focused on a specific sexual problem rather than looking at sexual behaviors overall [ table 4 ] .
the multidimensional derogatis sexual functioning inventory ( dsfi ) did not fit into any of those three categories . with this overview
, it appears that there are significant challenges to using these instruments in iranian contexts .
instruments features including the subscales compatible scales for iranian culture instruments incompatible with iranian culture problem - focused instruments
inspiring gagnon and simon 's description of sexual behaviors defined with  social scripts , understanding and language of sexuality , ethics , and morality are the main cultural determinants of sexual norms in the iranian society . in her linguistic analysis of sexuality expression of iranian women ,
merghati - khoei has revealed the ways of developing terminology and cultural explanations , which are juxtaposed with the exploration of the development of women 's sexuality .
iranian women expressed their sexuality differently from western women even though they understood and talked about the same issues .
there is , however , a hesitation when it comes to discussing or reporting the emotional aspects of sexual encounters .
the power of culture in dictating daily language for females has been highlighted in morocco as an arab - islamic context .
similarly , culturally meaningful ambiguity in language guides iranian people 's behavior . even though persian vocabulary ,
concepts and expressions about sexual matters exist in art , poetry and the beauty of nature , these linguistic resources are not applied in daily life to express sexuality .
for example , the sexual attitude scale ( sas ) , certainly a well - designed tool for use within many cultures measures a person 's awareness toward her / his sexual interests and needs as well as sexual - self judgment .
communication of sexual needs or interests with others is another feature of this tool . as a neglected subject matter in the iranian culture , questioning people about their sexual needs and interests or sexual - self concept seems impractical .
sexuality is an unspoken issue , and individuals might not be linguistically skilled to communicate their sexuality with an interviewer . in sum , the art of using a rich vocabulary of metaphors and euphemisms is a characteristic of iranian speech , used to communicate and encapsulate matters not normally spoken explicitly .
for example , for fluent english speakers phrase  marital life may indicate all kinds of relationships within a marital framework , while in farsi zendegi - e - zanashoyi ( literally marital life ) has sexual connotations and is usually understood to mean the sexual relationship between husband and wife .
another difficulty in asking about sexuality during a study is the struggle between conscious embarrassment and sexual talk . by conscious embarrassment , we mean the shame , prohibition and modesty about sex .
the majority of the women who participated in merghati - khoei 's qualitative study pointed out that they were not culturally expected to be straightforward or frank in expressing sexual matters .
for example , the sexual desire inventory tends to measure sexual desire as a biologic factor . out of 14 items ,
4 focus on masturbation and 2 items ask about having interest in casual sex . in iranian contexts ,
none of these 6 items would be posed by researchers or responded to by the participants .
why human have sex ? ( ysex ) is another example , which measures number of variables .
for instance , some of the items focus on motivations leading people to out - of - wedlock or casual sex .
although casual or extra marital sex happens in every society , questioning iranians about these behaviors is not ethically and religiously possible or feasible .
this assertion is based on the common assumptions . in iran , people strongly hold onto the traditional culture of sexuality based on  purity ( paki ) ,
 chastity ( nejabat ) ,  honour ( aberoo ) and  honesty ( sedagat ) underlying the family structure .
there is also the belief commonly permeating iranian society that people are fairly innocent in terms of sexuality compared with non - muslim or western societies .
however , with these assumptions we can not minimize the impact of factors such as modernization , worldwide communication and cultural transformations in younger generations and the way they learn about sex , practice and develop their sexual understandings . undoubtedly , these factors change behaviors and attitudes .
social conduct and religiosity define the ethical aspect of sexuality in the iranian culture . in iran
the teachings of islamic principles tie strongly to shia interpretations , which form the basis for iranians understandings of sexuality  .
the expression of sexuality is considered legitimate only within the framework of islamic marriage ( nikah ) . moreover , as shown in merghati et al .
study , sexual obedience was seen as the primary goals of the committed muslim woman .
the concept of nejabat ( modesty ) is the most important ethical code applied to an iranian woman who is not sexually expressive .
in contrast , islamic scholar morteza motahari pointed out the islamic clear guidelines toward sexuality ,  leading neither to any sense of sexual deprivation and frustration , nor to any repressed or inhibited sexual desire  .
however , in the islamic doctrine  freeing sexual desire and lifting of traditional moral restraints is not accepted . as a criterion ,
religiosity has significant effects on iranian women 's sexual understandings ; and that experts working in the fields of gender and sexuality need to be sensitive to the notion that some muslim women may not speak out their sexuality as an indicator of submission to religious codes , of modesty and of being an idealized muslim wife .
in her linguistic analysis of sexuality expression of iranian women , merghati - khoei has revealed the ways of developing terminology and cultural explanations , which are juxtaposed with the exploration of the development of women 's sexuality .
iranian women expressed their sexuality differently from western women even though they understood and talked about the same issues .
. there is , however , a hesitation when it comes to discussing or reporting the emotional aspects of sexual encounters .
the power of culture in dictating daily language for females has been highlighted in morocco as an arab - islamic context .
even though persian vocabulary , concepts and expressions about sexual matters exist in art , poetry and the beauty of nature , these linguistic resources are not applied in daily life to express sexuality .
for example , the sexual attitude scale ( sas ) , certainly a well - designed tool for use within many cultures measures a person 's awareness toward her / his sexual interests and needs as well as sexual - self judgment .
communication of sexual needs or interests with others is another feature of this tool . as a neglected subject matter in the iranian culture , questioning people about their sexual needs and interests or sexual - self concept seems impractical .
sexuality is an unspoken issue , and individuals might not be linguistically skilled to communicate their sexuality with an interviewer . in sum , the art of using a rich vocabulary of metaphors and euphemisms is a characteristic of iranian speech , used to communicate and encapsulate matters not normally spoken explicitly .
for example , for fluent english speakers phrase  marital life may indicate all kinds of relationships within a marital framework , while in farsi zendegi - e - zanashoyi ( literally marital life ) has sexual connotations and is usually understood to mean the sexual relationship between husband and wife .
another difficulty in asking about sexuality during a study is the struggle between conscious embarrassment and sexual talk . by conscious embarrassment , we mean the shame , prohibition and modesty about sex .
the majority of the women who participated in merghati - khoei 's qualitative study pointed out that they were not culturally expected to be straightforward or frank in expressing sexual matters .
for example , the sexual desire inventory tends to measure sexual desire as a biologic factor . out of 14 items ,
4 focus on masturbation and 2 items ask about having interest in casual sex . in iranian contexts ,
none of these 6 items would be posed by researchers or responded to by the participants .
for instance , some of the items focus on motivations leading people to out - of - wedlock or casual sex .
although casual or extra marital sex happens in every society , questioning iranians about these behaviors is not ethically and religiously possible or feasible .
this assertion is based on the common assumptions . in iran , people strongly hold onto the traditional culture of sexuality based on  purity ( paki ) ,  chastity ( nejabat ) ,  honour ( aberoo ) and  honesty ( sedagat ) underlying the family structure .
there is also the belief commonly permeating iranian society that people are fairly innocent in terms of sexuality compared with non - muslim or western societies .
however , with these assumptions we can not minimize the impact of factors such as modernization , worldwide communication and cultural transformations in younger generations and the way they learn about sex , practice and develop their sexual understandings .
undoubtedly , these factors change behaviors and attitudes . social conduct and religiosity define the ethical aspect of sexuality in the iranian culture .
in iran the teachings of islamic principles tie strongly to shia interpretations , which form the basis for iranians understandings of sexuality  .
the expression of sexuality is considered legitimate only within the framework of islamic marriage ( nikah ) . moreover , as shown in merghati et al .
study , sexual obedience was seen as the primary goals of the committed muslim woman .
the concept of nejabat ( modesty ) is the most important ethical code applied to an iranian woman who is not sexually expressive .
in contrast , islamic scholar morteza motahari pointed out the islamic clear guidelines toward sexuality ,  leading neither to any sense of sexual deprivation and frustration , nor to any repressed or inhibited sexual desire  .
however , in the islamic doctrine  freeing sexual desire and lifting of traditional moral restraints is not accepted . as a criterion ,
religiosity has significant effects on iranian women 's sexual understandings ; and that experts working in the fields of gender and sexuality need to be sensitive to the notion that some muslim women may not speak out their sexuality as an indicator of submission to religious codes , of modesty and of being an idealized muslim wife .
to investigate sexual behaviors in an iranian context , we recognize the importance of identifying or developing an instrument to assess sexual behavior domains among women in the particular context of iranian culture .
we thought that such an instrument would be essential tool for achieving a more systematic and in - depth understanding of iranian women 's sexuality , may be useful in applied settings , and would advance sexuality research as a whole . no matter the context or use
, however , measuring a construct such as sexual behavior is subjective and therefore entirely dependent on self - report .
it has been argued that iranian women may not report properly if they believe sexuality has nothing to do with health .
for example , a woman 's inability to gain sexual pleasure due to painful intercourse might not be defined as a sexual health problem to be reported , whereas other people would consider it as a sexual health problem for the woman .
this suggests the idea that the culture of sexuality affects people 's interpretations of sexually related problems .
developing a contextualized instrument to measure the domains of sexual behavior would allow sexuality and gender researchers to better answer questions related to the influence of culture in those domains , sexual scripts across diverse cultures , and other factors influencing sexual health outcomes . in the 1970s , gagnon and simon 's sexual conduct represented the first truly sociological analysis of sexual behavior .
gagnon and simon defined  sexual behavior within a new theoretical framework of  social scripts. they produced a critique that moved us beyond the objective definition of sexual behavior : our concern here is to understand sexual activities of all kinds  as the outcome of a complex psychological process of development , and it is only because they are embedded in social scripts that the physical acts themselves become possible  it is neither fixed by nature or by the organs themselves .
the very experience of sexual excitement that seems to originate from hidden internal sources is in fact a learned process and it is only our insistence on the myth of naturalness that hides these social components from us . the
character through a  cultural scenario in which they take up , internalize and enact culturally prescribed normative roles ;  interpersonal scripts in which they make a suitable identity based on desired expectations and  intrapsychic scripting in which they make  the self in relation to social life .
thus , sexual practice is separated from the biology of the body and one 's sexuality is strongly formed by the very complex social world .
having investigated the history of human sexuality , we believe sexuality is influenced by the society , culture and era in which people live . within an iranian context , we therefore recognized existing instruments targeting
non - risky  sexual behaviors among heterosexual women are insufficient to measure sexual behaviors .
we categorized instruments as culturally compatible or incompatible based on the sexuality domains they tend to measure .
the instruments , by which the biological aspects of sexual behaviors are measured were found applicable for any given community or population , the iranian context included .
alternatively , those measuring outcomes related to subjects attitudes , understanding or sexual scripts were identified as culturally incompatible .
most of the tools seem reasonable candidates for use in the iranian culture and society with minor revisions [ table 1 ] .
review of these instruments shows that most of them are functional based , such as the most used scale in literature , ( fsfi ) .
other well known tools , such as the arizona sexual experience scale ( asex ) and the golombok - rust inventory of sexual satisfaction ( griss ) , are also functional based .
some other tools are problem - focused [ table 3 ] and specific to measure only disorder - based outcomes .
we argue that the medically oriented instruments employed in the field are drawn from concepts and meanings based on investigations conducted in western societies .
yet as researchers , we sometimes found ourselves disappointed by the level of difficulty , which we professionals encountered in fitting our participants into those biomedical frameworks .
the culture - bound nature of sexuality limits the research - based information in iran . in our society
, the lack of information in the sexual domain will be most productively addressed first through research attention to subjective concepts .
lack of sufficient knowledge in the field of sexuality in iranian contexts , makes it important to identify normative sexual behaviors qualitatively before applying problem - oriented tools in research .
there are social and cultural challenges arising from the recognition that iranians use culturally specific sexual expressions .
these expressions may construct different ways of perceiving sexuality that are not easily translatable or even understandable by outsiders .
this means that sexuality is a complex phenomenon embedded in various meanings and understandings , not merely objective and measurable behavior . explaining those meanings and perceptions makes sexuality a  dynamic phenomenon through one 's life time .  how we know what we know changes periodically and therefore , creating an epistemological crisis in knowledge as well as the research process .
however , scholars in science and human behavior such as skinner have powerfully questioned the reliability of subjective measures of private events such as sexual behaviors .
we concluded that the published instruments are well - designed and used worldwide ; however , we must also acknowledge that the sexual scripts of iranian women define  sexual behaviors differently , limiting their communication in the research setting and compromising the compatibility of these instruments .
therefore , exploring and analyzing the lexicon and expressions used by the iranian women creates a ground for developing a culturally comprehensive measure , which can adequately examine how these women explain their sexual behaviors .

 the cultural compatibility of sexually related instruments is problematic because the contexts from which the concepts and meanings were extracted may be significantly different from related contexts in a different society .
 this paper describes the instruments that have been used to assess sexual behaviors , primarily in western contexts .
 then , based on the instruments working definition of  sexual behavior and their theoretical frameworks , we will ( 1 ) discuss the applicability or cultural compatibility of existing instruments targeting women 's sexual behaviors within an iranian context , and ( 2 ) suggest criteria for sexually related tools applicable in iranian settings .
 iranian women 's sexual scripts may compromise the existing instruments compatibility .
 suggested criteria are as follows : understanding , language of sexuality , ethics and morality .
 therefore , developing a culturally comprehensive measure that can adequately examine iranian women 's sexual behaviors is needed .


a level of pain that completely incapacitates one individual may cause only a minor annoyance in another .
characterizing the genetic factors affecting susceptibility to chronic pain could lead to novel treatment or prevention strategies , which are desperately needed . a recent paper by costigan et al .
the authors performed a multi - dimensional analysis using rat gene expression and human genetic association that identified a new genetic factor affecting susceptibility to chronic pain .
this study   was initiated by analysis of gene expression changes within rat dorsal root ganglia obtained after nerve damage was induced in three different models of chronic pain .
the mrna for a potassium channel alpha subunit ( kcns1 ) was constitutively expressed in sensory neurons , but was downregulated after three types of nerve injury in these models .
other studies have successfully identified a human genetic susceptibility factor on the basis of a candidate gene emerging from analysis of a rodent model .
costigan and colleagues   therefore examined snp alleles within the human homolog ( kcns1 ) in five independent cohorts ( two with chronic low back pain , two after limb amputation and one after mastectomy ) that have a high incidence of chronic pain . in four of
the five cohorts studied , there was a significant association of the val allele at a nonsynonymous snp ( rs734784 , val / ile ) with increased risk for chronic pain .
for example , homozygous val / val individuals had a 2.4-fold increased relative risk of failing to achieve pain improvement 1 year after back surgery .
the proportion of individuals without phantom limb pain after leg amputation was 45% in those without the val allele , but fell to 22% in val / val homozygotes . among healthy volunteers that were subjected to multiple experimental pain stimuli ,
although experimental studies demonstrating an allelic effect were not presented , which is a substantial limitation of this study , these results   make it likely that kcns1 alleles contribute to susceptibility to chronic pain .
although kcns1 by itself does not have potassium channel function when tested in heterologous expression systems , its expression has been shown to modulate the currents formed by other channels [ 3 - 5 ] .
voltage - gated potassium channels have important effects on neuronal function , including altering the resting membrane potential and the shape and frequency of the action potential
. similarly , gain - of - function mutations in the nav1.7 sodium channel cause syndromes associated with increased pain sensitivity .
chronic pain has a huge impact on our society , and its treatment is a major driver for the increasing cost of health care . an estimated 76 million people in the us have chronic pain , which costs the us public over $ 100 billion per year .
approximately 25% of chronic pain is neuropathic ( caused by nerve damage ) , which is characterized by spontaneous pain that is burning or stabbing in nature .
this can develop after limb amputation , mastectomy or lower back injury , or in individuals with a long history of diabetes .
although multiple kinds of treatment can be used , they often have limited efficacy , and chronic pain is often managed by administration of opioids ( morphine and related synthetic compounds , including hydrocodone ) .
the increased focus on pain management resulted in a six - fold increase in the per capita sales of prescription opioid medications in the us between 1997 and 2006 .
hydrocodone - acetaminophen is prescribed over 100 million times per year in the us , which is far more than any other medication , including lipid - lowering and blood - pressure - lowering agents .
this has led to a dramatic increase in the incidence of opioid misuse , emergency room visits due to opioid analgesic poisoning , and fatal opioid overdose .
prescription opioids have now surpassed marijuana as the drug that is most commonly abused among the newly initiated .
because of the enormity of this public health problem , we desperately need new approaches for the prevention or treatment of chronic pain conditions .
it is likely that genetic discoveries can lead to new approaches for chronic pain , because genetic discoveries have catalyzed new approaches for related clinical conditions .
for example , haplotype - based computational genetic analysis has identified causative genetic factors affecting analgesic medication   and inflammatory pain responses , and it has identified four genes affecting narcotic drug responses [ 11,14 - 16 ] in mice .
the latter genetic discovery generated a new treatment strategy for preventing narcotic drug withdrawal symptoms , which was shown to be effective in humans .
moreover , the variable response to multiple classes of analgesic medications among inbred mouse strains was shown to be due to genetic variation within a genetic locus ( kcnj9 ) that also encodes a potassium channel ( girk3 ) .
hopefully , characterizing the functional role of kcns1 in neuronal responses and pain perception , and the impact of the allelic differences , could lead to new approaches for treatment of chronic pain .
although the tractability of kcns1 ( or other potassium channels ) as a therapeutic target remains to be determined , small molecules targeting potassium channels have been produced ( reviewed in ) , and one has attenuated neuropathic pain in animal models . although the kcns1 val allele explains only a small percentage of the total variance ( 4.6 to 7.8% ) in the chronic pain endpoints in the cohorts studied , the identification of an initial genetic factor for chronic pain is an important achievement for two reasons .
first , it shows that genetic factors can be identified for this condition , and this study provides a template for subsequent studies .
second , it is likely that a greater percentage of the genetic susceptibility to chronic pain can be explained by combining this genetic factor with other subsequently identified factors .
moreover , pain is a subjective sensory symptom ; it is difficult to measure ; and there are substantial psychological and emotional components that contribute to the perception of pain .
it has recently been found that there are different subtypes of chronic pain , which are distinct from the causative disease ( diabetic neuropathy , radicular back pain and so on ) .
it is likely that genetic factors determine whether a chronic pain syndrome will develop and the specific subtype that emerges after exposure to a triggering cause .
thus , the impact of a single genetic factor could be much larger if a specific pain subtype is examined relative to that measured in a large cohort of individuals with different types of chronic pain .
beyond finding new drug targets , identification of genetic factors affecting susceptibility to chronic pain syndromes could be the lever that drives advances in this difficult clinical area .
a genetic risk factor could have a substantial impact on clinical practice because individuals at increased risk for developing a chronic pain syndrome could be identified before a surgical procedure or immediately after a traumatic incident . the genetic information could be used to develop proactive methods for prevention of chronic pain syndromes , enabling interventions to be targeted to the high - risk subset . because of the great inter - individual variation in the response to painful stimuli and to analgesic drugs , knowledge of genetic risk factors could enable better stratification of chronic pain patients or aid in the selection of the appropriate therapy . rather than focusing on the disease that is etiologically associated with the chronic pain ,
study   is hopefully one of the first of many subsequent genetic studies that could lead to entirely new ways to approach chronic pain syndromes .
clearly , the clinical and research communities have a long way to go before genetically targeted therapies for chronic pain become a reality .
however , kcns1 ( or other channels ) could perhaps become the next target for a new class of analgesics that are selectively used in the 20% of the population that are homozygous for the val alleles of kcns1 .
the day might soon come when we no longer think of ' chronic pain ' as a single clinical entity , but have the tools to characterize the specific ' channelopathy ' that underlies the clinical presentation and targeted treatments for each subgroup .
gp is a professor and mz is the director of statistical research in the department of anesthesia at stanford university medical school .

 a recent publication that combined rat gene expression data and a human genetic association study has identified the first genetic risk factor for chronic pain in humans . in four of
 the five cohorts studied , there was a significant association of an allele within a gene ( kcns1 ) encoding a potassium channel ( kv9.1 ) with an increased risk for chronic pain .
 identification of genetic risk factors for chronic pain could catalyze new advances in this difficult clinical area that has become a major public health problem .
 genomic - medicine - based advances for chronic pain could include the development of a mechanism - based classification system for chronic pain , new treatment options , improved methods for treatment selection and targeted prevention strategies for high - risk individuals .


optical coherence tomography ( oct ) is a noninvasive method that evaluates biological tissues by in vivo imaging.1 since its introduction , oct has undergone several improvements and revolutionized the diagnostic , monitoring , and therapeutic approaches to many retinal diseases and glaucoma .
computerized algorithms can be used on the high - resolution images obtained by modern oct devices in order to identify and measure the thicknesses of discrete retinal layers , including the retinal nerve fiber layer ( rnfl ) , macular ganglion cell complex ( gcc ) , and choroid.2,3 the choroid is the most vascular tissue in the eye and is known to have an important role in ocular nutrition , volume regulation , and temperature control.4 choroidal abnormalities are critical to the onset and progression of many chorioretinal disorders such as age - related macular degeneration ( amd ) , polypoidal choroidal vasculopathy , vogt - kayanagi - harada disease , and central serous chorioretinopathy.5 with the recent development of enhanced depth imaging ( edi ) , in vivo assessment of the choroid has become an area of interest .
edi allows better visualization and quantitative evaluation of the choroid , which was not possible before .
information about the choroidal thickness ( ct ) is useful in many clinical situations for decision making regarding the management and monitoring of disease progression.6 neurodegenerative diseases such as glaucoma preferentially affect the gcc , which is the sum of the three innermost layers : the rnfl , the retinal ganglion cell layer , and the inner plexiform layer .
these contain the axons , cell bodies , and the dendrites of the retinal ganglion cells , respectively.7,8 recent studies have shown that measurement of macular gcc thickness has the same diagnostic potential for glaucoma as rnfl thickness.911 moreover , it has been reported that measurements of average gcc thickness had better sensitivity in detecting changes in retinal thickness in multiple sclerosis neurodegeneration than rnfl thickness measured by oct.12 both ct and gcc thickness measurements can be affected by several factors such as pupil size , scan quality , and cataract . in this study
, we aimed to evaluate the effect of uneventful cataract surgery on subfoveal ct and gcc thickness measured by edi - oct .
this prospective study included consecutive patients who had undergone uneventful phacoemulsification surgery for senile cataract at sakarya university medical education and research hospital between november 2013 and june 2015 .
the present study was approved by the institutional review board of sakarya university medical education and research hospital and adhered to the tenets of the declaration of helsinki and all patients signed informed consent after they received an explanation of the nature and possible consequences of the procedure .
exclusion criteria included a history of prior ocular surgery and systemic / ocular diseases such as diabetes mellitus , hypertension , glaucoma , amd , diabetic retinopathy , retinal vein occlusion , uveitis , or other inflammatory and vascular pathologies .
patients with unstable fixation or dense cataracts leading to a poor scan quality of oct images and eyes with increase in postoperative intraocular pressure ( iop ) or cystoid macular edema were also excluded .
all patients had a full ophthalmic examination , including best - corrected visual acuity ( bcva ) assessment , as well as slit - lamp biomicroscopy and dilated fundoscopy evaluation , and iop measurement by goldmann applanation tonometry .
axial length ( al ) was measured by immersion echography ( axis ii ; quantel medical inc . , cedex , france ) and central corneal thickness ( cct ) was measured by ultrasonographic pachymetry ( pacline ; optikon 2000 spa , rome , italy ) .
prior to the operation , tropicamide 1% and phenylephrine hydrochloride 2.5% were applied to patients eyes for pupil dilation .
phacoemulsification was performed by one experienced surgeon ( ec ) using infiniti vision system ( alcon laboratories , inc . ) . a clear corneal incision of 2.8 mm , 600 mmhg vacuum , an aspiration flow rate of 30 ml / min , bottle height of 75 cm , and quick - chop technique were used in all surgeries .
two different dispersive viscoelastics ( viscoat and bivisc ) and two different cohesive viscoelastics ( healon and bio - hyalur ) were used during cataract surgery .
one - piece hydrophobic acrylic intraocular lens ( sensar model : aab00 ; abbott medical optics inc . , santa ana , ca , usa ) was used in all surgeries .
viscoelastics were cleaned out with marked attention , even behind the intraocular lenses . the procedure ended with intracameral cefuroxime axetil 1 mg/0.1 ml for prophylaxis for endophthalmitis .
the operative times ( ots ) and effective phaco times ( epts ) were recorded in each case .
postoperatively , all patients were treated with topical antibiotics ( ofloxacin 0.3% ) for 1 week and topical steroid drops ( prednisolone acetate 1% ) for 4 weeks .
cirrus edi - oct ( carl zeiss meditec ag , jena , germany ; software version 6.5.0.772 ) was used to obtain subfoveal ct and gcc thickness measurements using high - definition one - line raster and ganglion cell analysis ( macular cube 512128 ) scan protocols , respectively .
scans with misalignment , segmentation failure , decentration of the measurement circle , and poor illumination , or those out of focus , were also excluded .
the one - line raster is a 6 mm line consisting of 4,096 a - scans .
scan 3 of the five scans taken , which passes through the fovea , was used for all measurements .
ct was defined as the vertical distance from the outer portion of the hyperreflective line corresponding to bruch s membrane beneath the retinal pigment epithelium to the outermost hyperreflective line of the inner scleral border . to avoid the effects of mydriatic agents or diurnal changes ,
the ct was measured from the subfoveal region by using the cirrus linear measurement tool .
when there was a discrepancy of > 10% of the mean of the two values between the observers in two eyes in the study , observers discussed and repeated the measurements , and the average results from the two observers were determined as the final ct readings .
the cirrus oct device allows a quantitative assessment of the ganglion cell and inner plexiform layers ( gcipl ) in six circular sectors centered in the fovea .
it also gives information on the mean and minimum gcipl thickness for each eye and compares these figures with a normative database .
macular cube 512128 acquisition protocol generates a cube through a 6 mm square grid of 128 b - scans , each composed of 512 a - scans .
a built - in gcipl analysis algorithm detects and measures the thickness of the macular gcipl within a 662 mm elliptical annulus area centered on the fovea .
the annulus has an inner vertical diameter of 1 mm , which was chosen to exclude the portions of the fovea where the layers are very thin and difficult to detect accurately , and an outer vertical diameter of 4 mm , which was chosen according to where the ganglion cell layer again becomes thin and difficult to detect .
the ganglion cell analysis algorithm identifies the outer boundaries of the rnfl and the inner plexiform layer .
the difference between the rnfl and the inner plexiform layer outer boundary segmentations yields the combined thickness of the retinal gcipl .
similar to other cirrus printouts , it provides gcipl measurements in six wedge - shaped sectors with a pseudocolor scheme .
those that are abnormal at the < 5% and at the < 1% level are represented by yellow and red backgrounds , respectively .
the primary objective of this study was to evaluate the subfoveal ct and average gcc thickness changes ; however , central macular thickness ( cmt ) and peripapillary rnfl thickness were also obtained by the macular cube 512128 and optic disc cube 200200 protocols , respectively , using the cirrus oct device .
statistical analysis was performed using spss statistics for windows , version 20.0 ( ibm corporation 2011 , armonk , ny , usa ) .
paired - samples t - test was used for equality of means , and analysis of variance regression and pearson correlation analysis were used for correlations between parameters .
this prospective study included consecutive patients who had undergone uneventful phacoemulsification surgery for senile cataract at sakarya university medical education and research hospital between november 2013 and june 2015 .
the present study was approved by the institutional review board of sakarya university medical education and research hospital and adhered to the tenets of the declaration of helsinki and all patients signed informed consent after they received an explanation of the nature and possible consequences of the procedure .
exclusion criteria included a history of prior ocular surgery and systemic / ocular diseases such as diabetes mellitus , hypertension , glaucoma , amd , diabetic retinopathy , retinal vein occlusion , uveitis , or other inflammatory and vascular pathologies .
patients with unstable fixation or dense cataracts leading to a poor scan quality of oct images and eyes with increase in postoperative intraocular pressure ( iop ) or cystoid macular edema were also excluded .
all patients had a full ophthalmic examination , including best - corrected visual acuity ( bcva ) assessment , as well as slit - lamp biomicroscopy and dilated fundoscopy evaluation , and iop measurement by goldmann applanation tonometry .
axial length ( al ) was measured by immersion echography ( axis ii ; quantel medical inc . , cedex , france ) and central corneal thickness ( cct ) was measured by ultrasonographic pachymetry ( pacline ; optikon 2000 spa , rome , italy ) .
prior to the operation , tropicamide 1% and phenylephrine hydrochloride 2.5% were applied to patients eyes for pupil dilation .
phacoemulsification was performed by one experienced surgeon ( ec ) using infiniti vision system ( alcon laboratories , inc . ) . a clear corneal incision of 2.8 mm , 600 mmhg vacuum , an aspiration flow rate of 30 ml / min , bottle height of 75 cm , and quick - chop technique were used in all surgeries .
two different dispersive viscoelastics ( viscoat and bivisc ) and two different cohesive viscoelastics ( healon and bio - hyalur ) were used during cataract surgery .
one - piece hydrophobic acrylic intraocular lens ( sensar model : aab00 ; abbott medical optics inc . , santa ana , ca , usa ) was used in all surgeries .
viscoelastics were cleaned out with marked attention , even behind the intraocular lenses . the procedure ended with intracameral cefuroxime axetil 1 mg/0.1 ml for prophylaxis for endophthalmitis .
the operative times ( ots ) and effective phaco times ( epts ) were recorded in each case .
postoperatively , all patients were treated with topical antibiotics ( ofloxacin 0.3% ) for 1 week and topical steroid drops ( prednisolone acetate 1% ) for 4 weeks .
cirrus edi - oct ( carl zeiss meditec ag , jena , germany ; software version 6.5.0.772 ) was used to obtain subfoveal ct and gcc thickness measurements using high - definition one - line raster and ganglion cell analysis ( macular cube 512128 ) scan protocols , respectively .
scans with misalignment , segmentation failure , decentration of the measurement circle , and poor illumination , or those out of focus , were also excluded .
the one - line raster is a 6 mm line consisting of 4,096 a - scans .
scan 3 of the five scans taken , which passes through the fovea , was used for all measurements .
ct was defined as the vertical distance from the outer portion of the hyperreflective line corresponding to bruch s membrane beneath the retinal pigment epithelium to the outermost hyperreflective line of the inner scleral border . to avoid the effects of mydriatic agents or diurnal changes ,
the ct was measured from the subfoveal region by using the cirrus linear measurement tool . when there was a discrepancy of > 10% of the mean of the two values between the observers in two eyes in the study , observers discussed and repeated the measurements , and the average results from the two observers
the cirrus oct device allows a quantitative assessment of the ganglion cell and inner plexiform layers ( gcipl ) in six circular sectors centered in the fovea
. it also gives information on the mean and minimum gcipl thickness for each eye and compares these figures with a normative database .
macular cube 512128 acquisition protocol generates a cube through a 6 mm square grid of 128 b - scans , each composed of 512 a - scans .
a built - in gcipl analysis algorithm detects and measures the thickness of the macular gcipl within a 662 mm elliptical annulus area centered on the fovea .
the annulus has an inner vertical diameter of 1 mm , which was chosen to exclude the portions of the fovea where the layers are very thin and difficult to detect accurately , and an outer vertical diameter of 4 mm , which was chosen according to where the ganglion cell layer again becomes thin and difficult to detect .
the ganglion cell analysis algorithm identifies the outer boundaries of the rnfl and the inner plexiform layer .
the difference between the rnfl and the inner plexiform layer outer boundary segmentations yields the combined thickness of the retinal gcipl .
similar to other cirrus printouts , it provides gcipl measurements in six wedge - shaped sectors with a pseudocolor scheme .
those that are abnormal at the < 5% and at the < 1% level are represented by yellow and red backgrounds , respectively .
the primary objective of this study was to evaluate the subfoveal ct and average gcc thickness changes ; however , central macular thickness ( cmt ) and peripapillary rnfl thickness were also obtained by the macular cube 512128 and optic disc cube 200200 protocols , respectively , using the cirrus oct device .
statistical analysis was performed using spss statistics for windows , version 20.0 ( ibm corporation 2011 , armonk , ny , usa ) .
paired - samples t - test was used for equality of means , and analysis of variance regression and pearson correlation analysis were used for correlations between parameters .
a total of 30 eyes of 30 patients ( 16 male and 14 female ) , with a mean age of 60.24.2 years were included in this study .
mean bcva improved in all eyes , and this improvement was statistically significant ( 0.460.15 logarithm of minimum angle of resolution [ logmar ] units preoperatively and 0.060.49 logmar units postoperatively ; p<0.001 ) .
mean preoperative al was 22.80.6 mm ( range : 21.524.1 mm ) and mean cct was 551.522.1 m .
mean ot was 8.62.7 minutes and mean ept was 6.92.5 seconds ( table 1 ) .
the mean subfoveal ct was 294.439.2 m ( range : 201356 m ) preoperatively and 301.439.9 m ( range : 231367 m ) postoperatively .
the mean gcc thickness was 85.04.4 m ( range : 7894 m ) preoperatively and 89.25.3 m ( range : 8199 m ) postoperatively .
the mean cmt was 247.917.6 m preoperatively ( range : 211280 m ) and 249.017.8 m ( range : 213278 m ) postoperatively .
the mean rnfl thickness was 97.45.4 m preoperatively ( range : 87110 m ) and 101.75.6 m ( range : 91113 m ) postoperatively .
regression analysis showed that age , sex , al , cct , ot , and ept were not associated with ct changes ( p=0.834 , p=0.129 , p=0.203 , p=0.343 , p=0.547 , and p=0.147 , respectively ) and gcc thickness changes ( p=0.645 , p=0.542 , p=0.152 , p=0.664 , p=0.448 , p=0.268 , respectively ) after cataract surgery .
in this study , we investigated the effect of cataract surgery on subfoveal ct and gcc thickness , as measured by edi - oct , and we found that both subfoveal ct and gcc thickness increased slightly after cataract surgery .
cmt and peripapillary rnfl thicknesses were also evaluated as a secondary objective , and we observed statistically significant increases in cmt and rnfl thickness .
our results indicate that cmt , subfoveal ct , as well as rnfl and gcc thicknesses are slightly affected after phacoemulsification surgery .
although our study included a small group ( only 30 eyes ) , we assume that our data reliability is high because of the homogeneous nature of the patients ( similarities of age , cataract type and severity , cct , al , ot , ept and so on ) and the careful / detailed oct examinations performed by two observers , avoiding the effects of diurnal changes and mydriatic agents .
zhao et al13 revealed significant diurnal variations of the ct at the macular region in young healthy female individuals .
cataract surgery by phacoemulsification is one of the most common intraocular surgeries that improve the quality of vision .
however , it is an invasive procedure leading to an inflammatory response  mostly induced by the release of prostaglandins  in the retina and choroid and , in many patients , can lead to worsening of preexisting retinal diseases such as diabetic macular edema.15,16 recent studies have shown subclinical increase of cmt and peripapillary rnfl thickness after uneventful cataract surgery.1719 however , the morphologic changes that this inflammatory insult produces in the choroid have not been studied well because of the lack of detailed imaging techniques for the choroid .
after the introduction of edi , changes in ct in several pathologic ( central serous chorioretinopathy , choroidal neovascularization , and high myopia ) and physiologic ( age , sex , and al ) conditions can be easily assessed.2022 therefore , ct is being measured increasingly often and is becoming an accepted procedure for clinical and research applications .
falco et al23 evaluated the effect of uneventful phacoemulsification on the subfoveal ct and cmt , and they reported that phacoemulsification induced nonpathologic increases in cmt ; however , these changes were not accompanied by significant changes in ct .
they claimed that the inflammatory insult due to phacoemulsification mainly affects at the retinal level and seems to be independent of ct changes.23 by contrast ; our results support the recent studies by ohsugi et al24 and noda et al,25 which report significant increases in ct after uneventful phacoemulsification .
ohsugi et al24 evaluated 100 eyes and emphasized that the al and changes in iop were critical for evaluating the changes in ct after cataract surgery .
noda et al25 evaluated 29 eyes and observed that the increase in subfoveal ct did not subside to baseline even at 6 months postoperatively .
they also found that male sex and thicker baseline ct predicted a larger magnitude of increase in ct after cataract surgery.25 in our study , interestingly , the parameters of age , sex , al , baseline ct , and cct did not influence the postoperative ct statistically in regression analysis .
we also analyzed the effect of ot and ept on postoperative ct and we did not find any relationship .
this may be explained by the short / similar results in terms of ots and epts , as well as the experience of the surgeon conducting a quick surgery with less anterior segment manipulation , thus reducing the inflammatory response after cataract surgery .
a speculation is that it may be related to postoperative inflammation because proinflammatory prostaglandins and cytokines are considered to explain macular edema after cataract surgery , and inflammatory disorders are also known to increase the ct.26,27 another speculation is that cataract surgery introduces more light into the eyes , leading to greater metabolic activation in the retinal pigment epithelium , causing angiogenesis and inflammation.28,29 in the beaver dam and blue mountains eye studies,3032 it has been suggested that cataract surgery is associated with the onset of amd , resulting in visual impairment due to neovascularization originating from the choroid .
noda et al25 report that cataract surgery influences the ct and this influence persists for as long as 6 months postoperatively and may affect the process of amd .
choroidal abnormalities are central to chorioretinal disorders such as amd , polypoidal choroidal vasculopathy , and central serous chorioretinopathy .
furthermore , it has been claimed that pathologic choroidal blood supply is an important factor in open - angle glaucoma leading to optic nerve damage.33,34 cts of glaucomatous eyes have been reported to be thinner in postmortem histologic studies .
in addition , significant increases in choroidal extravascular volume have been confirmed in many primary angle - closure glaucoma eyes and abnormal ct has been hypothesized to be a contributing feature in these eyes.35,36 however , it is unclear whether these findings represent a risk factor or a consequence of these diseases .
the hallmark of glaucoma is the loss of the retinal ganglion cell axons , which leads to a typical optic neuropathy .
qualitative and quantitative evaluations of the optic nerve head and rnfl have been used to detect evidence of glaucomatous damage.911 in a recent study,8 it has been suggested that the gcc thickness may be the most relevant parameter to measure in glaucoma .
nouri - mahdavi et al37 also reported that regional gcc measurements derived from cirrus hd - oct performed as well as regional rnfl outcomes for the detection of early glaucoma .
moreover , macular gcc thickness has been found to have better structure  function correlations than rnfl thickness with both visual function and central nervous system findings in multiple sclerosis neurodegeneration.12 as oct uses near - infrared light and is based on interferometry , its image quality is influenced by opacities in the optical path .
loss of oct image quality is caused by attenuation of the light in the oct scanning spot on the retina.17,18 several studies have shown that lens opacity decreased image quality and postoperative rnfl thickness measurements increased significantly.3840 the more advanced the cataract , the less is the signal quality and the thinner are the recorded rnfl and gcc thicknesses .
the coexistence of neurodegenerative diseases such as glaucoma and cataract among elderly patients is not unusual , and cataract may decrease the quality of fundus images , leading to an incorrect evaluation in the diagnosis and follow - up of these patients .
nakatani et al7 examined the effect of cataract on the measurements of gcc and rnfl thicknesses , and they reported that all thickness parameters in gcc and rnfl increased slightly after phacoemulsification surgery .
therefore , we decided that the presence of cataract may lead to an underestimation of the thicknesses of gcc and rnfl , and this should be taken into account when analyzing progression in glaucoma and/or neurodegenerative diseases such as multiple sclerosis .
after cataract surgery , the examiners should consider obtaining new baseline measurements , as suggested in previous studies .
this study has many limitations such as short follow - up time , relatively small sample size , and lack of eyes with glaucoma and neurodegenerative diseases .
in addition , we analyzed just mean subfoveal ct and mean thickness of gcc and rnfl , leading to lack of segmentation of these parameters .
scleral interface and measured ct with cirrus linear measurement tool . although we used scans with signal strength 6 for analysis and excluded poor images , the effect of signal strength index on measurements was not investigated .
furthermore , we used postoperative topical steroids after cataract surgery ; thus , the true effect of phacoemulsification on oct parameters could not be evaluated and we could not determine whether and when the increased ct can return to baseline measurements .
phacoemulsification surgery increased ct and it should be kept in mind that the small changes in ct may affect the onset of amd , which is a serious disease that results in central visual impairment .
although the mechanism is unclear , it has been postulated that ct changes may also play a role in glaucoma .
we suggest establishment of new baseline measurements after cataract surgery for monitoring patients with glaucoma and neurodegenerative diseases .
further studies with a greater number of patients and longer duration of follow - up and conducted using new computerized oct algorithms are needed .

 purposewe aimed to evaluate the effect of cataract surgery on subfoveal choroidal thickness ( ct ) and ganglion cell complex ( gcc ) thickness , as measured by enhanced depth imaging - optical coherence tomography ( oct).methodsthis prospective study included 30 eyes of 30 patients who had undergone uneventful phacoemulsification surgery for senile cataract but had no previous ocular surgery or other ocular abnormality .
 best - corrected visual acuity , slit - lamp biomicroscopy , intraocular pressure , axial length , and central corneal thickness were measured preoperatively .
 the operative times ( ots ) and effective phaco times were also recorded in each case .
 oct measurements were performed at the preoperative visit and 1 month after cataract surgery .
 study of ct and gcc thickness changes was the primary objective , but central macular thickness ( cmt ) and peripapillary retinal nerve fiber layer ( rnfl ) thicknesses were also obtained by oct.resultsthe mean subfoveal ct was 294.439.2 m preoperatively and 301.439.9 m postoperatively ( p<0.001 ) .
 the mean gcc thickness was 85.04.4 m preoperatively and 89.25.3 m postoperatively ( p<0.001 ) .
 the mean cmt was 247.917.6 m preoperatively and 249.017.8 m postoperatively ( p=0.029 ) .
 the mean rnfl thickness was 97.45.4 m preoperatively and 101.75.6 m postoperatively ( p<0.001 ) .
 regression analysis showed that age , sex , axial length , central corneal thickness , operative time , and effective phaco time were not associated with ct changes ( p=0.834 , p=0.129 , p=0.203 , p=0.343 , p=0.547 , and p=0.147 , respectively ) and gcc thickness changes ( p=0.645 , p=0.542 , p=0.152 , p=0.664 , p=0.448 , and p=0.268 , respectively ) after cataract surgery.conclusionour results indicate that all subfoveal ct , cmt , as well as rnfl and gcc thicknesses are slightly affected after uneventful phacoemulsification surgery .
 after cataract surgery , the examiners should consider obtaining new baseline measurements .