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   Table of Contents - Current issue
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May-August 2017
Volume 18 | Issue 2
Page Nos. 51-115

Online since Tuesday, June 20, 2017

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ORIGINAL ARTICLES  

Oral linolenic acid dietary supplementation in posterior blepharitis and meibomian gland dysfunction p. 51
Ahmed T.S. Saif
DOI:10.4103/1110-9173.208534  
Aim The aim of this research is to study the role of oral linolenic acid (omega-3 fatty acids) dietary supplementation in posterior blepharitis and meibomian gland dysfunction (MGD) in patients attending the Outpatient Clinic at Fayoum University Hospital. Patients and methods Fifty patients with moderate to severe chronic blepharitis and simple obstructive MGD were included in the study. Patients received oral omega-3 dietary supplementation consisting of one 1000-mg capsule once daily and were examined every 6 weeks for 3 months. Objective clinical measures included tear production (Schirmer I with anesthesia), tear film stability (fluorescein tear break-up time), ocular surface health (fluorescein surface staining), tear meniscus height, plugged meibomian gland orifices, and eyelid telangiectasia. Results Twenty-four (48%) patients had an age between 45 and 60 years, 20 (40%) patients were more than 60 years old, and six (12%) patients were less than 45 years old. The male to female ratio was 1 : 2. Twelve (24%) male patients were smokers, whereas four (8%) female patients were using oral contraceptive pills. Twenty-two (44%) patients were hypertensive, whereas eight (16%) patients were diabetic. There was a significant improvement of dry-eye symptoms, signs, tear break-up time, Schirmer test, and meibomian gland orifices after 3 months of oral linolenic acid use. Conclusion The results after 3 months of treatment and follow-up were very satisfactory for the efficacy. Oral linolenic acid (omega-3 fatty acids) is effective in the treatment of moderate to severe chronic blepharitis and MGD.
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Ocular involvement and its manifestations in rheumatoid arthritis patients p. 57
Safaa A Aboud, Mohamed O Abd Elkhalek, Nagla H Aly, Enas A Abd Elaleem
DOI:10.4103/DJO.DJO_17_17  
Background Rheumatoid arthritis (RA) is a systemic inflammatory disease associated with a number of extra-articular organ manifestations. Ocular manifestations involved with RA are keratoconjunctivitis sicca (KCS), episcleritis, scleritis, keratitis, and retinal vasculitis. The etiopathogenesis of this autoimmune disorder is still debated. The aim of the current study was to present different ocular manifestations of RA and their frequency. Patients and methods A total of 180 patients with RA participated in this cross-sectional survey. All patients were subjected to general and specific examinations, ophthalmological examinations, and rheumatologic examinations in addition to blood investigations for rheumatoid factor and anti-cyclic citrullinated peptide. Results Of the 180 examined patients, 61 (33.9%) patients had ocular manifestations. There were 52 (85.3%) patients with KCS, three (4.9%) patients with episcleritis, three (4.9%) patients with scleritis, and three (4.9%) patients with keratitis. Patients with longer disease duration were much more likely to have ocular manifestations (odds ratio=7.13, P<0.001). In addition, patients with positive history of steroid intake were more likely to have ocular manifestations (odds ratio=1.88, P<0.001). Conclusion Ocular manifestations involved with RA are significant. The most common manifestation of ocular involvement was KCS. Ocular manifestations were more common among patients with longer disease duration.
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Laser-assisted in-situ keratomileusis with iris registration against manual limbal markings for the correction of myopic astigmatism p. 63
Ali M El-Ghatit, Amr F Abu El-Kheir, Hany A Helaly, Mohamed A Mostafa
DOI:10.4103/DJO.DJO_54_16  
Purpose The aim of this study was to compare the refractive outcomes and visual acuity of laser-assisted in-situ keratomileusis (LASIK) with static preablation iris registration (IR) and LASIK with that of manual limbal markings (LM) in the management of myopic astigmatism. Setting The study was carried out at El-Safwa Laser Vision Center in Alexandria, Egypt. Patients and methods This prospective randomized clinical study was conducted on 40 eyes that were divided into two groups. Group A (IR group) was treated with LASIK procedure with preablation static IR (software of WaveLight EX500 Excimer laser) in conjunction with the Topolyzer Vario to automatically detect and adjust cyclotorsional misalignment. Group B (LM group) was treated with LASIK with the same machine without using the IR software and instead using a corneal marking pen for LM for manual cyclotorsional misalignment adjustments. Refraction and visual acuity data were compared between groups at the first, third, and sixth postoperative months. Vector analysis was performed by the Alpins method using data from the third postoperative month. Results The mean preoperative spherical error was −2.75±1.84 and −3.05±2.67 D in the IR group and the LM group, respectively (P=0.946). The mean preoperative cylindrical error was −2.65±0.81 and −2.31±0.41 D in the IR group and the LM group, respectively (P=0.170). At the sixth postoperative month, the mean spherical error of the IR group was −0.06±0.29 D, whereas that of the LM group was −0.08±0.24 D (P=0.822). The mean cylindrical error of the IR group was −0.43±0.23 D, whereas that of the LM group was −0.38±0.21 D (P=0.353). There was no statistically significant difference between the two groups regarding manifest refraction, best corrected visual acuity, uncorrected visual acuity, and safety index at all postoperative time points. There was no statistically significant difference between the two groups regarding target-induced astigmatism, difference vector, magnitude of error, angle of error, and predictability at 3 months postoperatively. However, the surgically induced astigmatism and efficacy were statistically significantly higher in the IR group at 3 months postoperatively. Conclusion Using the EX500 Excimer laser system, LASIK with IR software is as safe and predictable as LASIK with LM in the treatment of myopic astigmatism.
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Incidental discovery of retinal pathology on preoperative assessment of implantable contact lens candidate patients: diagnosis and management p. 71
Sherif A Eissa, Mohamed Sabry, Mohamed W Eldeeb
DOI:10.4103/1110-9173.208533  
Purpose The aim of this study was to analyze retinal pathologies incidentally discovered on preoperative preparation of implantable contact lens (ICL) candidate patients. Patients and methods We retrospectively analyzed all data concerning preoperative retinal examination in 304 eyes prepared for posterior chamber phakic intraocular lens surgery. This was a multicenter study conducted between May 2012 and January 2014. This was a retrospective case series. Results The study enrolled 297 of 304 eyes subjected to preoperative screening before the ICL implantation procedure. We encountered 23 (7.56%) eyes with a variety of retinal pathologies on preoperative assessment, which included stage 3 macular hole, myopic choroidal neovascular membrane scar, white without pressure, perforated lattice degeneration, peripheral retinal flat holes that required laser retinopexy, nonproliferative diabetic retinopathy, peripapillary old toxoplasma scar, and active myopic choroidal neovascular membrane. In no case did rhegmatogenous retinal detachment occur following the ICL procedure. Conclusion Preoperative retinal assessment of ICL patients is crucial to detect undiagnosed myopic retinal changes and other latent pathologies not related to myopia.
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Accuracy of intraocular lens power calculation using partial coherence interferometry and OKULIX ray tracing software in high myopic cataract patients p. 77
Karim M Nabil
DOI:10.4103/1110-9173.208536  
Purpose The aim of the study was to evaluate the accuracy of intraocular lens (IOL) power calculation using partial coherence interferometry and OKULIX ray tracing software in high myopic cataract patients. Patients and methods This retrospective study was conducted on 60 consecutive myopic eyes with an axial length of at least 26.5 mm (60 patients, 20 men and 40 women, mean age 62.27±7.74 years). The patients underwent uneventful phacoemulsification and IOL implantation following IOL power calculation using the OA-1000 optical biometer and OKULIX ray tracing software for lens power calculation. All patients were recruited from the Department of Ophthalmology, Faculty of Medicine, Alexandria University (Alexandria, Egypt). All surgeries were performed by the same surgeon (K.M.N.). The accuracy of IOL power calculation was evaluated by subtracting attempted and achieved spherical refraction 1 month postoperatively and was recorded as mean absolute error. Results Fifty-three (88.33%) eyes yielded a postoperative spherical refraction that differed 1.00 D or less from predicted. In 42 (70%) eyes, the postoperative refractive error was within ±0.50 D. The mean absolute error was 0.45±0.40 D. Conclusion Optical biometry combined with OKULIX ray tracing software for calculation of IOL power provides accurate results for highly myopic cataract patients.
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The use of the Ahmed glaucoma valve in postpenetrating keratoplasty glaucoma p. 81
Eman N Elsayed, Ahmed Hossam Abdallah, Alaa Atef Ghaith, Tarek Hussein Ali
DOI:10.4103/1110-9173.208548  
Background and objective Glaucoma drainage devices have shown promise in intraocular pressure (IOP) control in postpenetrating keratoplasty (post-PK) glaucoma and, at the same time, are minimally invasive to the corneal graft. This study aimed to evaluate the effectiveness of the Ahmed glaucoma valve (AGV) in post-PK glaucoma patients. Design The present study was a prospective case series. Patients and methods The study included 20 eyes of 20 patients with refractory post-PK glaucoma who had AGV implanted after variable periods following PK and who were followed up for 6 months postoperatively. Results The mean age of the study population was 40.37±17.02 years. The mean IOP before AGV was 35.71±8.03 (range: 22–58) mmHg. It was reduced postoperatively at the final follow-up to 11.88±2.23 (range: 8–17) mmHg. Complete success was achieved in 35% of the patients and qualified success in 60% with mean IOP-lowering medications of 1.26±1.12 agents. Five cases needed needling with 5-fluorouracil injection. One case experienced early vitreous hemorrhage and failed to be controlled. Graft survival after AGV was 90% at the end of follow-up. Conclusion AGV is an effective treatment for refractory post-PK glaucoma. Although it associated with complications and risk for graft failure, it has to be considered when other treatments fail.
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Choroidal detachment after trabeculectomy versus deep sclerectomy in myopic patients p. 87
Abdelhamed S Elhofi, Mohamed M Lolah
DOI:10.4103/DJO.DJO_49_16  
Purpose The aim of this study was to compare the prevalence of choroidal detachment after penetrating trabeculectomy (PT) versus nonpenetrating trabeculectomy (NPT) in glaucomatous myopic eyes. Patients and methods This is an interventional controlled randomized clinical study. The present study included 60 eyes with open-angle glaucoma, 30 of which underwent traditional PT with mitomycin C (MMC), whereas the other 30 eyes underwent NPT (deep sclerectomy collagen implant) with MMC. Results The mean postoperative intraocular pressure (IOP) in the PT group was significantly lower than that in the NPT group (P<0.0001). The occurrence of choroidal detachment was correlated with lower levels of IOP assessed 1 week after surgery (r=−0.664, P<0.0001) and consequently positively correlated with drop in IOP (%) after 1 week of surgery (r=0.67, P<0.0001). There was no significant difference between preoperative and postoperative best-corrected visual acuity in the PT group (P=0.278), whereas there was a significant difference between preoperative and postoperative best-corrected visual acuity in the NPT group (P=0.032). Postoperative shallowing of the anterior chamber was not observed in the NPT group, in contrast to the PT group, with a statistically significant difference (P=0.001). The prevalence of postoperative choroidal detachment in the NPT group was significantly lower than that in the PT group (P=0.008). Conclusion PT was found to be more effective compared with deep sclerectomy in lowering the IOP, especially with the use of MMC. The nonpenetrating technique with MMC is safer in avoiding hypotony complications and reducing the incidence of choroidal detachment, which occur significantly more frequently in myopic eyes.
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‘Wipe-out’ after subscleral trabeculectomy in advanced glaucoma patients p. 94
Ahmed M Abdelrahman, Heba M.A. ElSaied, Riham S.H.M. Allam, Moataz H Osman
DOI:10.4103/DJO.DJO_44_16  
Purpose The aim of this study was to evaluate the safety of trabeculectomy in advanced glaucoma patients in the Egyptian population, and to detect postoperative wipe-out syndrome in high-risk patients. Patients and methods Thirty-six eyes of 33 patients with advanced glaucoma were included in the study. All patients underwent subscleral trabeculectomy. The patients were followed up for 3 months during which intraocular pressure (IOP), best-corrected visual acuity (BCVA), slit lamp biomicroscopy, fundus examination, and perimetry were done. Results The mean age of the study group was 51.17±2.64 years. The study included 24 males and nine females. The mean preoperative BCVA was 0.36±0.33. the mean IOP was 31±8.75 mmHg and the mean number of medications was 3.08±0.1. In all cases, complete success was achieved except for two cases with qualified success. The BCVA at day 90 showed no change in 21 eyes, visual decline in three eyes and visual gain in 12 eyes. A negative linear correlation was noticed between the percent reduction in IOP and the reduction in BCVA in the first postoperative day (r=−0.239) which was not statistically significant (P=0.162). The color of the neuroretinal rim was not a significant determinant for the final BCVA (P=0.48). Visual field changes showed no statistically significant differences. Conclusion Wipe-out phenomenon is not an ultimate postoperative outcome for filtering surgery in patients with advanced glaucoma. Pale neuroretinal rim and postoperative hypotony are risk factors for postoperative visual deterioration.
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Evaluation of the outcome of ab-interno revision in high-risk failing trabeculectomy bleb p. 99
Abdelhamed S Elhofi, Mohamed M Lolah
DOI:10.4103/DJO.DJO_50_16  
Purpose The purpose of this study was to evaluate the outcome of ab-interno revision as a method to re-establish filtration in a failing trabeculectomy bleb. Patients and methods This is a retrospective clinical study that included 56 patients who underwent one or more revisions of a failing trabeculectomy bleb through the years 2014–2015. Once recognized, a failing bleb was treated aggressively using anti-inflammatory agent, antifibrotic agent, digital massage, and/or argon laser suture lysis. If those measures failed, the revision technique of the bleb was applied. A failing bleb is defined as intraocular pressure (IOP) greater than 21 mmHg combined with flat vascularized bleb. Results The mean age of the included cases was 56.18±10.88 years. Out of the 56 cases operated, 16 (28.57%) cases failed, 12 (21.42%) of whom had clinical failure and four (7.14%) had technical failure. Regarding the drop in IOP, for the complete success group, there was a marked significant drop of IOP shortly postoperatively and after 6 months. Conclusion Patients with failing filtration bleb because of different types of glaucoma benefit from 5-fluorouracil-augmented ab-interno revision to re-establish the full pathway from the anterior chamber to the subconjunctival space. However, the least response was noticed in the neovascular type of glaucoma.
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Comparison between choroidal thickness in normal and glaucomatous eyes using spectral-domain optical coherence tomography p. 104
Mohsen A Abou Shousha, Karim M Nabil
DOI:10.4103/DJO.DJO_46_16  
Purpose The aim of this study was to compare choroidal thickness in healthy and glaucomatous eyes using spectral-domain optical coherence tomography. Patients and methods This prospective study was carried out on patients recruited from the Department of Ophthalmology, Faculty of Medicine, University of Alexandria, Alexandria, Egypt, from April 2015 to April 2016. Informed consent was obtained from all participants. The studied participants were divided into two groups: group 1, which included 100 healthy eyes with normal intraocular pressure, and group 2, which included 100 juvenile and adult-onset primary open-angle glaucomatous eyes. All participants had undergone high-definition raster scanning using spectral-domain optical coherence tomography (Cirrus HD-OCT Model 4000) (software, version 6.0) with frame enhancement software. Choroidal thickness was measured from the posterior edge of the retinal pigment epithelium to the choroid/sclera junction in 11 points. The centre of the fovea (F0) plus five temporal points separated by 500 μm (T0.5, T1.0, T1.5, T2.0 and T2.5) and five nasal points separated by 500 μm (N0.5, N1.0, N1.5, N2.0 and N 2.5) was studied. Statistical analysis of the results was performed using the unpaired t-test. Results Choroidal thickness in group 2 was significantly less than that in group 1 in all studied points with the exception of T0.5 and subfoveal (F0) choroidal thickness. Conclusion The findings of the present study confirmed that choroidal thickness, except for the subfoveal choroidal thickness and 500 μm temporal to the fovea, is significantly less in juvenile and adult-onset primary open-angle glaucoma eyes compared with age-matched normal eyes. Whether this finding represents a risk factor or a consequence of the disease requires further investigations.
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Retinal nerve fiber layer thickness in normal Egyptian population p. 108
Mohammad A.M. El-Hifnawy, Amir A Abo-Samra, Mohsen A Abou Shousha, Ehab M Kassem
DOI:10.4103/1110-9173.208538  
Purpose The aim of this study was to collect normative retinal nerve fiber layer thickness (RNFLT) data in the Egyptian population using the Spectralis SD-OCT and to assess its correlations with demographic data and ocular parameters. Participants and methods A total of 100 healthy eyes of 100 Egyptian individuals were enrolled in this study. BMI was calculated for each participant. Uncorrected visual acuity (UCVA) and best-corrected visual acuity were measured and converted to the logarithm of the minimum angle of resolution (logMAR). Autorefraction, keratometric (K) readings, and axial length were obtained. Patients underwent a comprehensive ophthalmic examination, including cup disc (CD) ratio and intraocular pressure (IOP) measurement. RNFLT measurement by Spectralis SD-OCT scanning was carried out using circular scans of the retinal nerve fiber layer of a diameter of 3.4 mm centered on the optic nerve head. Results The mean global (G) RNFLT was 101.74±10.05 μm (range: 79.0–123.0 μm). The mean RNFLT was the least at the temporal (T) sector, followed by nasal (N), nasal superior (NS), nasal inferior (NI), temporal superior (TS), and temporal inferior (TI) sectors. Using Pearson’s correlation, age showed a significant negative correlation with T and TI sectors. BMI showed a significant positive correlation with the G RNFLT and NS and TI sectors. Square root of logMAR of UCVA showed a significant negative correlation with the G RNFLT and NI and TI sectors. Spherical equivalent showed a significant positive correlation with the G RNFLT and the N sector. K-readings showed a significant positive correlation with the G RNFLT and N, NS, TS, NI, and TI sectors. IOP showed a significant negative correlation with the NS sector only. CD ratio showed a significant negative correlation with the G RNFLT and NS, TS, and TI sectors. Axial length showed a significant negative correlation with the G RNFLT and N, NS, and TI sectors. Using regression analysis, RNFLT was directly related to better UCVA, hyperopic refractive error, and steeper cornea, and inversely related to age, IOP, and CD ratio. Conclusion The mean RNFLT was the least at the T sector, followed by N, NS, NI, TS, and TI sectors, respectively. RNFLT was directly related to better UCVA, hyperopic refractive error, and steeper cornea, and inversely related to age, IOP, and CD ratio.
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