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   Table of Contents - Current issue
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January-March 2020
Volume 21 | Issue 1
Page Nos. 1-73

Online since Friday, February 28, 2020

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ORIGINAL ARTICLES  

Effect of hyaluronidase addition to retrobulbar local anesthesia for phacoemulsification on intraocular pressure p. 1
Mahmoud Abd El-Radi, Mohamed Anwar, Hassan Lotfy, Ali Natag, Eman Yassin
DOI:10.4103/DJO.DJO_23_19  
Purpose The aim of this study was to evaluate the effect of adding hyaluronidase to local anesthetic agents on intraocular pressure (IOP) following retrobulbar anesthesia for patients scheduled for routine phacoemulsification. Patients and methods This is a prospective comparative study that included patients scheduled for routine phacoemulsification. Patients were classified into two groups: group A patients were planned to have retrobulbar blocks with lidocaine 2% and hyaluronidase 20 IU/ml, and group B patients were planned to have retrobulbar blocks with lidocaine 2% only without hyaluronidase. IOP was measured immediately before and 2, 5, and 10 min after retrobulbar anesthesia administration in both groups using a calibrated Tono-pen. Results The study included 60 eyes of 50 patients. The mean preinjection IOP in group A patients (hyaluronidase group) was 16.38±2.41 mmHg, whereas the mean 10-min postinjection IOP was 18.17±3.54 mmHg (P>0.05). The mean preinjection IOP in group B patients (nonhyaluronidase group) was 15.41±2.63 mmHg, whereas the mean 10-min postinjection IOP was 24.34±5.25 mmHg (P<0.001). The mean change in IOP in group A before and after retrobulbar anesthesia (IOP rise) was 1.79±2.96 mmHg, whereas in group B, the mean IOP rise was 8.93±4.74 mmHg (P<0.001). Conclusion Although the addition of hyaluronidase to lidocaine 2% before cataract surgery had no IOP-lowering effect, it also did not cause any significant rise of postinjection IOP and did keep it within the range of the preinjection IOP.
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Schirmer’s test and tear breakup time in an Egyptian population sample: a hospital-based study p. 6
Ahmed A Youssef, Yomna A Alahmadawy, Hany E Elmekkawy, Ahmed M Abdelrahman
DOI:10.4103/DJO.DJO_37_19  
Background Dry eye is a very common disease in Egypt. Tear film stability and tear secretion are important factors in the assessment of dry eye disease. Schirmer’s test (ST) is used to assess tear secretion, whereas tear breakup time test (TBUT) is used to assess tear film stability. Purpose The aim of this study was to identify the normative data of the ST and TBUT in a sample of Egyptians and to highlight the variables that may significantly affect these values. Patients and methods The study included 150 normal healthy participants. They were divided into different groups according to age, sex, residency, and occupation. History was taken from all participants including ocular surface disease index questionnaire. All participants underwent full ophthalmological examination, ST, and TBUT. Results The mean ST for the population sample was 21.9±9.13 mm, whereas the mean TBUT was 16.04±4.99 s. Studying linear regression for ST with age, sex, occupation, and residency showed that ST was mostly affected by age, where it showed a negative correlation. Studying linear regression for TBUT with age, sex, occupation, and residency showed that TBUT was mostly affected by residency. Conclusion The study allowed us to take an idea about the normative data of ST and TBUT in an Egyptian population and the effect of different variables on both tests.
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Effect of cycloplegic eye drops on pain after photorefractive keratectomy and corneal collagen cross-linking p. 14
Hazem A Elbedewy, Moataz M Sabry
DOI:10.4103/DJO.DJO_40_19  
Purpose The aim of this study was to evaluate the effectiveness of topical cycloplegic eye drops (cyclopentolate) on relieving ocular pain and discomfort after photorefractive keratectomy (PRK) and corneal collagen cross-linking (CXL). Patients and methods This is a randomized controlled double-blind study that included 30 patients eligible for bilateral PRK or CXL. After removal of the corneal epithelium and completion of the procedure, a plano bandage soft contact lens was placed. Postoperative medications were topical prednisolone, moxifloxacin, and tear substitute, each four times/day for both eyes. For each patient, one eye had the cycloplegic drops and the other eye had placebo drops. All the patients were asked to complete three types of pain rating questionnaires: visual analog scale (VAS), verbal rating scale (VRS), and Mac-Gill pain questionnaire (PRI) at each time of postoperative follow-up. Results VAS, VRS, and PRI mean scores at the first postoperative hour did not show any significant difference between cycloplegic and control eyes (P>0.50). However, the cycloplegic eyes had significantly lower mean VAS and PRI scores at 24 and 48 h, postoperatively (P<0.001 and 0.01, respectively). In the first postoperative day, 13.3% of the control eyes had mild pain, 66.7% had moderate pain, and 20% had severe pain, whereas 30.0% of the cycloplegic eyes had mild pain and 70% had moderate pain (0% had severe pain) on the VRS. All cycloplegic eyes had photophobia and blurring of vision during the first three postoperative days, which rapidly improved after cessation of the cycloplegic drops. Conclusion Cycloplegic eye drops (cyclopentolate) were safe and effective in reducing pain and ocular discomfort after removal of the corneal epithelium in PRK and CXL with tolerable side effects, which rapidly improved after cessation of the drops.
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Corneal higher order aberrations after intrastromal corneal ring segment implantation for keratoconus p. 19
Mohamed Y.S Saif, Mostafa A Saeed, Mohamed A Mekky
DOI:10.4103/DJO.DJO_35_19  
Background Keratoconus is the most common primary corneal ectatic disease. It is a progressive, noninflammatory, and localized paraxial stromal thinning of the cornea, which often results in bilateral and asymmetrical corneal distortion and anterior corneal protrusion. Patients with corneal protrusion often develop high myopia and irregular astigmatism, resulting in significant impairment of visual acuity. Purpose The aim of this study was to assess changes of higher order aberrations (HOAs) induced by the implantation of intrastromal corneal ring segments (ICRS) in keratoconus. Patients and methods In the current study, a prospective analysis of HOAs, measured by using Pentacam, before and after ICRS implantation was done in a nonrandomized consecutive series of 20 eyes having progressive grade II/III keratoconus (Amsler-Krumeich classification). Results At 1 month postoperatively, a statistically highly significant reduction was found in keratometric readings. The flattest keratometric reading (K1) improved from 46.42±3.08 D preoperatively to 43.25±3.45 D postoperatively, which is highly significant (P<0.01). The steepest keratometric reading (K2) improved from 49.96±3.29 D preoperatively to 46.04±3.15 D postoperatively, which is highly significant (P>0.01). The total HOA root mean square improved from 1.55±0.54 preoperatively to 1.26±0.38 postoperatively, with a statistically significant difference (P<0.05). Primary coma improved from 1.27±0.54 preoperatively to 0.87±0.27 postoperatively, which is highly significant (P>0.01). In addition, astigmatism root mean square changed from 2.42±1.52 preoperatively to 1.98±1.31 postoperatively. Trifoil and quadrifoil showed nonsignificant changes (P>0.05). Conclusion ICRS (Keraring) implantation using femtosecond laser is an effective method for improvement and stabilization of optical, keratometric, and aberrometric measures in keratoconic eyes. Most of the improvement in HOAs was achieved after 1 month and nearly locked up or changed insignificantly till the third month.
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The use of iris claw intraocular lens in aphakic eyes with inadequate capsular support and in phakic eyes for correction of high refractive errors p. 25
Abdel-Khalik I El-Saadany, Hany A Khairy, Ghada Z Rajab, Ahmed M.S Fayed
DOI:10.4103/DJO.DJO_11_19  
Background Iris-claw intraocular lens (IOL) implantation is effective for correction of aphakia in the absence of capsular support. Iris claw phakic IOLs lack potential size-related complications that may occur with other phakic IOLs. Objective The aim of this study was to evaluate the technique, efficacy, and safety of iris claw IOL implantation. Patients and methods Patients with inadequate capsular support underwent aphakic iris-claw IOL implantation using two techniques: anterior chamber and retro-pupillary fixation of iris-claw lens. Phakic iris claw IOLs were implanted for myopic patients with high refractive errors or with thin or suspicious corneas. Eyes were evaluated for uncorrected and corrected distance visual acuity, refraction, intraocular pressure, and any postoperative complications. Results The study included 17 eyes. Group I included 12 eyes that underwent aphakic iris-claw lens implantation. Indications for surgery were surgical aphakia (n=8), lens dislocation (n=1), and lens subluxation (n=3). Eight eyes had pre-pupillary lens implantation and four eyes underwent retro-pupillary implantation. Group II included five eyes that underwent phakic iris-claw lens implantation. The final postoperative unaided visual acuity was 0.13±0.067 in group I and 0.22±0.076 in group, II, whereas the corrected visual acuity was 0.28±0.193 in group I and 0.34±0.114 in group II. The visual acuity improved significantly compared with the preoperative values (P=0.003 and 0.003, respectively, in group I and P=0.041 and 0.042, respectively, in group II). Postoperative complications included corneal edema, intraocular pressure elevation, inflammatory reaction, pupil ovalization, vitreous hemorrhage, and lens disenclavation. Conclusion Aphakic iris-claw IOL implantation is an effective option for visual rehabilitation in eyes with inadequate capsular support. Phakic iris-claw lens implantation is useful for correction of high refractive errors with high efficacy and safety.
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Multifocal electroretinogram changes in patients with retinal vein occlusion p. 35
Heba M Shafik, Amin E Nawar
DOI:10.4103/DJO.DJO_22_19  
Background Retinal vein occlusion (RVO) is one of the most common vascular retinal disorders that lead to macular edema. There is often discrepancy between visual prognosis and optical coherence tomography (OCT) changes. Multifocal electroretinogram (mfERG) provides useful information about retinal function in affected parts of the retina in patients with RVO. Purpose The aim of this study was to assess the functional changes in patients with RVO by mfERG and to correlate these changes with OCT findings in those patients. Patients and methods This is a prospective study of 30 eyes of patients with RVO, with their fellow eyes being taken as control. Thirteen eyes with central RVO, 12 eyes with branch RVO, and five eyes with hemi-RVO were included in the study. OCT to measure the central macular thickness was done in all patients. mfERG was also done in all patients. P wave amplitude and p wave implicit times were measured in the central area and all quadrants. Results mfERG responses were markedly affected in all quadrants in central RVO, in the affected quadrants in branch RVO, and in the affected hemiretina in hemi-RVO. The differences between the p amplitude and p implicit time between the affected eyes and the fellow eyes were statistically significant in all patients. There was a significant correlation between the central macular thickness and p amplitude in the affected half of the retina in hemi-RVO. Conclusion mfERG is a sensitive tool for assessment of retinal function in patients with RVO. mfERG can assess local retinal dysfunction in patients with RVO, which is sensitive to morphological changes detected by OCT.
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Foveal evaluation in diabetic patients with macular edema using optical coherence tomography angiography p. 43
Manal I Gadallah, Hossam M Moharram, Khaled M Mourad, Mohamed Attia Ali Ahmed
DOI:10.4103/DJO.DJO_50_19  
Purpose The aim of this study was to evaluate the foveal avascular zone (FAZ) in patients with diabetic macular edema (DME) by documenting the morphological and quantitative changes by optical coherence tomography angiography (OCTA). Patients and methods The study included 47 eyes of 47 participants. They were allocated into two groups: 27 eyes of 27 patients having DME and 20 eyes of 20 age-matched healthy controls. All study participants were imaged using OCTA machine to assess the FAZ area and to compare the changes between patients and controls. Results The FAZ area was significantly enlarged in patients with DME than in controls (P<0.001), together with the presence of other morphological changes (microaneurysms, capillary loops, and widened intercapillary spaces). Retinal vessel densities were also reduced in patients than in controls at both the superficial and deep retinal capillary complexes. Conclusion Qualitative and quantitative changes do occur in patients with DME, which could be documented using the OCTA. This helps better disease staging and monitoring as well as treatment decisions.
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Choroidal thickness measured by swept source optical coherence tomography in diabetic macular edema p. 49
Haitham Y Al-Nashar, Sahar Hemeda
DOI:10.4103/DJO.DJO_32_19  
Purpose The aim of this study was to evaluate the choroidal thickness in eyes with diabetic macular edema (DME) with the use of swept source optical coherence tomography (SS-OCT). Patients and methods A total of 240 eyes were included in this prospective nonrandomized study. They were divided into three groups, each including 80 eyes. Group I included patients with DME, group II included diabetic patients without retinopathy, and group III were normal persons. Fluorescein angiography was done for all diabetic patients. Macular and choroidal thicknesses were measured by SS-OCT in all eyes. Forty-five eyes from group I received two intravitreal injections of 0.5 mg/0.05 ml ranibizumab with 1-month interval. Correlation between choroidal and macular thickness was evaluated in eyes with DME. Results The mean choroidal thickness in the central subfield area was 129.7±12.5 μm in group I (eyes with DME), 200.4±2.8 μm in group II (diabetic patients without DME), and 208.3±9.7 μm in group III (normal eyes). There was a statistically significant difference in choroidal thickness between eyes with DME (group I) and both groups II and III (P<0.001), whereas there was no statistically significant difference between diabetic patients without macular edema (group II) and normal participants (group III) (P=0.2). There was no statistically significant difference among the three groups regarding age, refractive errors, and intraocular pressure. The mean best-corrected visual acuity was 0.31±0.09, 0.78±1.1, and 0.84±1.2 in groups I, II, and III, respectively (P=0.001). Negative correlation between macular and choroidal thickness was observed in eyes with DME (r=−0.7, P<0.001). There was no significant difference between choroidal thickness before and after intravitreal injection of ranibizumab (P=0.4). Conclusion Choroidal thickness measured with SS-OCT was decreased in eyes with DME in comparison with normal participants. A negative correlation was observed between choroidal and macular thickness in eyes having DME.
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Assessment of visual acuity of commercial long-distance drivers in Benin City, Edo State, Nigeria p. 57
Kingsley C Okafor, Nyemike S Awunor, Osayem Otabor-Olubor, Obehi H Okojie
DOI:10.4103/DJO.DJO_19_19  
Objective To assess the visual acuity of commercial long-distance drivers in Benin City, Nigeria. Patients and methods A descriptive cross-sectional study design was used, and data were collected for 315 commercial long-distance drivers and their vehicles from January to October, 2013. Respondents were recruited using systematic random sampling technique. The study instruments included structured interviewer-administered questionnaires. Data were analyzed using SPSS, version 20. Results The results showed that 114 (36.2%) drivers were within the age group of 31–40 years. Most of the respondents [272 (86.3%)] were married; almost all the respondents [311 (98.7%)] were males, whereas four (1.3%) were surprisingly females. More than half of the respondents [172 (54.6%)] had a secondary level of education, whereas 12 (3.8%) had no formal education. Less than a tenth [30 (9.5%)] were visually impaired, with two (0.6%) having severe visual impairment, whereas majority of respondents had normal visual acuity [285 (90.5%)]. There were statistically significant associations between the respondents’ level of education (P<0.001) driving experience (P<0.001), blood pressure (P<0.007), and visual acuity. Regression analysis [odds ratio (95% confidence interval)] showed that respondents with secondary level of education and above were 2.762 (1.162–6.563) times more likely to have normal vision compared with their counterparts with primary level of education or none. Conclusion Approximately a tenth of the commercial drivers were visually impaired. This emphasizes the need for regular health checks, especially for visual screening and blood pressure measurement among this occupational group.
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Evaluation of efficacy and safety of Botulinum toxin injection in treatment of epiphora p. 64
Nashwa A Elshaieb, Sameh S Mandour, Fahad R Almarshed, Hatem M Marey, Hassan G Farahat
DOI:10.4103/DJO.DJO_44_19  
Purpose The aim of this study was to evaluate the efficacy and safety of Botulinum toxin injection in the palpebral lobe of the lacrimal gland for treatment of epiphora. Patients and methods A total of 20 patients with epiphora (crocodile tears syndrome, lower lid laxity, malposition of the lower lid, and obstruction of lacrimal drainage system in which lacrimal surgery was impossible) received intralacrimal gland injection of Botulinum toxin (2.5 IU/0.1 ml). Follow-up was performed on the first day, first week, first month, third month, and sixth month after injection to evaluate the efficacy, safety, and occurrence of any complications and to record the rate of recurrence. Results Cure was successfully achieved in 60% of the patients after the first injection and in 90% of patients after the second injection. There were 15% of recurrent cases after the first injection, and there were no recurrent cases after the second injection. Temporary ptosis occurred in 10% of this study group after the first injection and in 5% after the second injection. There was a highly significant decrease in Schirmers test and tear meniscus height among the study group regarding the pre-injection and follow-up values (P<0.01). In addition, there was a highly significant decrease in Munk scale and time of dye disappearance test among the study group regarding the pre-injection and follow-up values (P<0.01). Conclusion The injection of Botulinum toxin in the palpebral lobe of the lacrimal gland was effective and safe as a temporary measure to reduce excessive tearing until a more permanent measure can be taken.
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Comparative study of bilateral rectus hang-back recession versus unilateral recession-resection for management of large-angle basic intermittent exotropia in Egyptian children p. 69
Nermeen M Badawi
DOI:10.4103/DJO.DJO_56_19  
Purpose The aim of this study was to compare the efficacy of lateral rectus recession-medial rectus resection (R-R) and bilateral rectus recession (BLR) for the management of large-angle basic intermittent exotropia (IXT) in Egyptian children. Patients and methods One-hundred patients with basic IXT were included in the study. They were divided into two groups: group A underwent R-R, and group B underwent BLR. All patients were subjected to a complete ophthalmological examination, including measuring the angles of deviation at distant and near. They were followed up at 1 day, 1 week, 1 month, 3 months, and 6 months postoperatively. Results At the end of the follow-up period, the R-R group showed a success rate of 62%, whereas the BLR group showed a success rate of 64%. The effect of both techniques was similar on the distant angle of deviation, which was 6.4±4.3 for group A and 4.0±6.9 for group B postoperatively. In addition, the postoperative near angle of deviation was 5.4±2.3 for group A and 3.0±8.2 for group B, with no statistically significant difference between the two groups (P>0.05). Conclusion The two surgical procedures were comparable in the management of large-angle basic IXT.
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