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   Table of Contents - Current issue
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September-December 2017
Volume 18 | Issue 3
Page Nos. 117-189

Online since Tuesday, October 17, 2017

Accessed 297 times.

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REVIEW ARTICLE  

Ophthalmic complications of targeted therapies: a review Highly accessed article p. 117
Deepti Sharma
DOI:10.4103/DJO.DJO_23_17  
Recently, there has been an increase in the use of targeted therapies for cancer treatments. Nevertheless, the ocular side effects of the commonly used targeted agents are generally under-reported and not well studied in the literature. The aim of this study was to review common targeted therapies leading to ocular side effects and their management. A database search was conducted on Google scholar, PubMed and Medline using phrase words, ‘targeted therapy’, ‘ocular toxicity’, ‘antineoplastic agent’ and ‘management’. Ocular toxicity has been described with numerous approved targeted agents and also seems to be associated with several classes of agents currently being tested in early-phase clinical trials. It is important for oncologists to be aware of the potential for ocular toxicity, with prompt recognition of symptoms that require referral to an ophthalmologist. The ocular side effects of targeted therapy are clinically relevant and can be present in up to 70% of patients depending on the medication used. Because no screening protocol is recommended, ophthalmologists and oncologists should be vigilant; however, a dose reduction or cessation of therapy is only rarely necessary.
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ORIGINAL ARTICLES Top

Correlation of tear film-specific immunoglobulin E assay with the skin prick test in allergic conjunctivitis p. 123
Basem M Ibrahim, Randa S Abdel-Latif
DOI:10.4103/DJO.DJO_30_17  
Purpose The aim of this study was to investigate the correlation and validity of tear film allergen-specific immunoglobulin E (IgE) in relation to the skin prick test in diagnosing different types of allergic conjunctivitis. Design The study design was a prospective randomized case series. Patients and methods One hundred and twenty patients with allergic conjunctivitis were included in this study and were classified into four groups according to the type of allergy. Group 1 included 48 patients with perennial allergic conjunctivitis. Group 2 included 35 patients with seasonal allergic conjunctivitis. Group 3 included 30 patients with vernal keratoconjunctivitis (VKC), and group 4 included seven patients with atopic keratoconjunctivitis. All patients were subjected to the skin prick test, which was performed with aeroallergen panel using kits containing different inhalant allergens, positive control (histamine 1 mg/ml), and negative control (saline 0.9%). Tear samples were collected using the microcapillary method for the quantitative determination of specific IgE using immune blot assay. Data were evaluated and statistically analyzed. Results In this study, the skin prick test and specific IgE were performed to 11 different allergens and the results revealed that the most common mixed allergens were mixed pollen, mixed mould, and mixed mite. Validity of tear film-specific IgE in the detection of allergens was assessed against the skin prick test (gold standard). There was IgE specificity of 100%, whereas the sensitivity ranged from 50 to 100% to the three common allergens in the four groups. There was a statistically significant correlation between specific IgE and the skin prick test for the most common allergens in patients with perennial allergic conjunctivitis, seasonal allergic conjunctivitis, and VKC (except for mould allergens in the VKC group). There was only a statistically significant correlation between specific IgE and the skin prick test for mite allergen in patients with atopic keratoconjunctivitis. Conclusion Tear film-specific IgE has a statistically significant correlation and validity when compared with the skin prick test in diagnosing the causative allergen in different types of allergic conjunctivitis. It could be a good alternative to the skin prick test in the diagnosis of allergic conjunctivitis with high sensitivity and specificity and fewer complications and limitations.
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Comparison of fibrin glue and autologous serum for conjunctival autograft fixation in pterygium p. 133
Saurabh Shrivastava, Priyanka Patkar, Reshma Ramakrishnan, Minal Kanhere, Zahna Riaz
DOI:10.4103/DJO.DJO_18_17  
Aim The aim of the study was to compare the outcome of conjunctival autograft (CAG) surgery for pterygium using autologous serum versus fibrin glue. Materials and methods A prospective, randomized, controlled trial was carried out on 40 patients over a period of 2 years. Twenty eyes underwent CAG with fibrin glue and another 20 eyes underwent CAG with autologous serum. Postoperatively, the parameters noted in both groups were the time taken for surgery in both groups, postoperative outcome like redness and discomfort during blinking, outcome of the graft (graft edema, graft retraction, graft rejection, graft displacement, and graft loss) and pterygium recurrence. Results In the CAG group with autologous serum, the mean surgical time was 34.8 min (SD=3.66), whereas in the group of CAG with fibrin glue the mean surgical time was 22.95 min (SD=3.09), a statistically significant difference (P=0.0000). The intensity of postoperative discomfort was greater in the group with autologous serum than the group with fibrin glue; however, the difference was not statistically significant. Graft rejection was observed in one patient belonging to the fibrin glue group, after 1 month postoperatively, which eventually by the end of the third month, led to graft loss. Conclusion The operating time in the fibrin glue group was significantly less as compared with the autologous serum group. The cost of surgery was more with fibrin glue. Graft edema, graft loss, graft retraction, and displacement of the graft were more with the use of fibrin glue. However, the difference was not statistically significant.
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Combined sutureless gluefree conjunctival autograft with subconjunctival bevacizumab for treatment of primary pterygium p. 138
Mona M Aly, Doaa A Mahmoud, Heba M Abd Al Rahman
DOI:10.4103/DJO.DJO_29_17  
Purpose The aim of this study was to assess the efficacy of subconjunctival bevacizumab injection as adjuvant therapy in the prevention of recurrence following excision of pterygium and application of sutureless gluefree conjunctival autograft (SL/GF CAG). Patients and methods A prospective randomized comparative study was performed on 20 eyes of 20 patients with primary pterygium. They were divided into two groups: group A (10 eyes) had pterygium excision with SL/GF CAG and received subconjunctival 2.5 mg/0.1 ml of bevacizumab at the end of the surgery and group B (10 eyes) had pterygium excision with SL/GF CAG only followed by eye pressure patching for 24 h in both groups. Results SL/GF CAG was successful in all cases except in one (10%) eye in group B that developed conjunctival graft retraction on the first postoperative day necessitating resurgery. Adjuvant subconjunctival bevacizumab injection used in group A was well tolerated with no systemic or local side effects but in the term of recurrence, no statistically significant difference was reported between the two groups in the postoperative 6 months follow-up period. Conclusion SL/GF CAG is a novel technique for the treatment of primary pterygium. Augmentation of this technique with a single injection of bevacizumab by the end of surgery aiming at reducing the recurrence rate did not seem to provide any statistically significant difference than SL/GF CAG alone, although bevacizumab injection was well tolerated as an adjuvant therapy.
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Results of pupil dilatation using Oasis ring in eyes with narrow pupil during phacoemulsification p. 143
Ahmed M Ghoneim, Tamer E Wasfy
DOI:10.4103/DJO.DJO_15_17  
Purpose To compare the results using Oasis ring for mechanical dilatation of the pupil during phacoemulsification in cases of narrow pupil with nonmechanical dilatation. Patients and methods This study included 80 eyes of 67 patients with cataract with narrow pupil. They were divided into two groups, each including 40 eyes. In one group, Oasis ring was used to achieve adequate pupillary dilatation, whereas in the other group, nonmechanical device methods such as bimanual stretching with partial sphincterotomies were used. Both groups were compared regarding achieved pupil size, additional time for dilatation, intraoperative difficulties, and postoperative pupil characters at 1-month follow-up. Results The mean pupil size was 6.00±0.00 mm in the Oasis ring group, whereas it was 4.26±0.48 mm in the nonmechanical device dilatation group, with statistically significant difference. Additional intraoperative time needed for pupil dilatation was significantly longer in Oasis ring group where it ranged from 83 to 117 s, whereas in the nonmechanical device dilatation group, it ranged from 48 to 76 s. There was more liability for intraoperative difficulties as iris prolapse, minimal bleeding, and iris trauma in the nonmechanical device dilatation group. Postoperative pupil characters after 1 month were rounded, central, and reactive in the Oasis ring group with oval-shaped pupil found only in one (2.5%) eye and minute tears in two (5%) eyes, whereas oval pupil was found in seven (17.5%) eyes and minute tears in five (12.5%) eyes in the nonmechanical device dilatation group. Statistically significant differences were found between the two studied groups. Conclusion Pupil dilatation with Oasis ring increases the intraoperative additional time for pupil dilatation, but it provides stable and sufficiently dilated pupil, with less liability for intraoperative complications when compared with non-mechanical device dilatation methods.
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Combined intravitreal bevacizumab and posterior sub-Tenon’s triamcinolone acetonide injections for persistent diabetic macular edema p. 149
Mona M Aly, Abd Elmagid M Tag Eldin
DOI:10.4103/DJO.DJO_19_17  
Purpose The aim of this study was to investigate the effect of posterior sub-Tenon’s triamcinolone acetonide injection (PSTI) in conjunction with intravitreal bevacizumab for the treatment of persistent diabetic macular edema (DME). Patients and methods In a prospective, nonrandomized, interventional study, 30 eyes of phakic diabetic patients were diagnosed with persistent DME after being treated with at least two intravitreal bevacizumab injections. Eyes with a residual central macular thickness more than 300 µm were administered PSTI of 40 mg triamcinolone acetonide in conjunction with intravitreal bevacizumab. Best-corrected visual acuity, intraocular pressure, and foveal thickness were measured. Results Significant improvements in the mean central macular thickness measurements were observed at the 1-month and 3-month follow-up visits. Best-corrected visual acuity improvement in eyes with extrafoveal hard exudates (83.3%) was significant at the follow-up intervals of 1 and 3 months, although it was insignificant in eyes with subfoveal hard exudates (16.7%). Conclusion The combined use of intravitreal bevacizumab and PSTI of triamcinolone acetonide was effective in treating persistent DME.
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Efficacy of intravitreal triamcinolone acetonide with thermal combination therapy versus intravitreal triamcinolone acetonide monotherapy on diffuse diabetic macular edema p. 154
Ashraf M Gad Elkareem
DOI:10.4103/DJO.DJO_22_17  
Purpose The aim of this study was to compare the efficacy of intravitreal triamcinolone acetonide (IVTA) monotherapy with IVTA plus macular grid laser photocoagulation combination therapy on the treatment of diffuse diabetic macular edema. Patients and methods Fifty eyes of 38 patients exhibiting diffuse diabetic macular edema were evaluated in this prospective comparative study. The patients were divided into two groups: IVTA monotherapy group and combination therapy group (IVTA plus grid laser). The main outcome measures of the study were best-corrected visual acuity (VA) scored in logMAR and the central macular thickness (CMT) as estimated at 3 and 6 months after treatment. The study further assessed the potential complications associated with IVTA injection. Results The baseline logMAR VA and CMT were 0.46±0.22 and 445.2±123.91 µm for the IVTA monotherapy group and 0.57±0.27 and 456.91 ±134.32 µm for the combination therapy group, respectively. The post-treatment logMAR VA at 3 and 6 months were 0.24±0.12 and 0.28±0.09 for the IVTA monotherapy group and 0.22±0.13 and 0.18±0.16 for the combination therapy group, respectively. The CMT values at 3 and 6 months were 305.5±115.30 and 310.8±86.8 µm for the IVTA monotherapy group and 280.9±43.9 and 254.2±45.95 for the combination therapy group. Improvement in VA and CMT after treatment was statistically significant in both groups. Approximately 10% of patients developed cataract after 5 months of intravitreal injection. The mean pretreatment intraocular pressure and the mean post-treatment intraocular pressure were 15.49±2.47 and 14.56±2.26 and 14.92±2.80 and 13.55±2.02 mmHg in both the IVTA monotherapy and combination therapy groups, respectively. Conclusion Macular grid laser photocoagulation after IVTA effectively maintains the VA and macular thickness of the patients included in this study during the first 6 months of treatment.
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Retinal ellipsoid zone/external limiting membrane restoration after diabetic macular edema treatment p. 160
Nehal M. Samy El Gendy
DOI:10.4103/DJO.DJO_13_17  
Purpose The aim of this study was to determine which clinically significant diabetic macular edema treatment modality results in early restoration of the ellipsoid zone and external limiting membrane (EZ/ELM). Patients and methods This was a retrospective study where the medical records of patients with type 2 diabetes mellitus and clinically significant diabetic macular edema were reviewed. Patients who had valid scans before treatment and 6 months after treatment were included. Disruption of EZ/ELM was graded and compared. Patients were divided into six groups according to the treatment received: group A received argon laser treatment; group B received micropulse diode laser treatment; group C received antivascular endothelial growth factor (anti-VEGF) treatment; group D received anti-VEGF+laser therapy; group E received triamcinolone acetonide injection (TAI); and group F received TAI+laser therapy. Results A total of 293 eyes of 200 patients were included (group A: 47, group B: 40, group C: 52, group D: 54, group E: 51, and group F: 49 eyes). Improvement in EZ/ELM integrity was 38.3% in group A, 45% in group B, 59.6% in group C, 37% in group D, 54.9% in group E, and 44.9% in group F. The difference between groups A and B was not statistically significant (P=0.3). The differences between group A and groups C, D, and E were statistically significant (P=0.002, 0.006, and 0.02, respectively). The difference between groups A and F was not significant (P=0.2). The difference between groups C and D was significant (P=0.001), whereas the difference between groups E and F was not significant (P=0.15). Conclusion Anti-VEGF monotherapy showed the highest percentage of early EZ/ELM restoration. Argon laser alone or argon laser combined with anti-VEGF delayed EZ/ELM healing. Micropulse laser therapy was equivalent to argon laser therapy. TAI results were comparable with anti-VEGF results. Laser addition did not compromise TAI results.
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Evaluation of the lamina cribrosa morphology in correlation to retinal nerve fiber layer thickness p. 166
Ayser Abd El-Hameed Fayed
DOI:10.4103/DJO.DJO_21_17  
Aim The aim of this study was to assess the correlation between lamina cribrosa (LC) morphology and glaucoma severity using spectral domain optical coherence tomography. Patients and methods This is a comparative cross-sectional study that included 40 eyes divided into 20 eyes having primary open-angle glaucoma and 20 normal control eyes. Serial horizontal B-scan images of the optic nerve head were obtained using enhanced depth imaging optical coherence tomography. Images were analyzed using the Cirrus HD software. Statistical analysis was conducted to compare the lamina cribrosa depth (LD) and lamina cribrosa thickness (LT) with retinal nerve fiber layer (RNFL) thickness and visual field mean deviation. Results The mean±SD values of the LD, LT, and visual field mean deviation were 533.5±66.8, 188.4±15.8 µm, and −4.3±3.4 dB, respectively. On linear regression analysis, LD, LT, and intraocular pressure were significantly correlated with RNFL thickness (P<0.001, 0.001, and 0.01, respectively). The mean LD was significantly greater in the glaucoma group compared with the normal control group (P<0.001). In eyes with glaucoma, the LC was thinner and located more posteriorly compared with the normal control eyes. Conclusion There was a generalized decrease in LT and posterior displacement of the LC in the glaucomatous patients compared with healthy controls. Thus, the LC morphology can help differentiate glaucomatous from normal eyes.
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Optical coherence tomography (OCT) changes after achieving target intraocular pressure p. 170
Mohamed Y.S Saif, Mohamed O Abd Elkhalek, Moustafa M Tawfeek
DOI:10.4103/DJO.DJO_7_17  
Purpose The aim of this study was to evaluate the ability of optical coherence tomography (OCT) to detect the changes in retinal nerve fiber layer (RNFL) after reaching target intraocular pressure (IOP) in glaucomatous patients. Patients and methods Thirty-two (58 eyes) patients with a clinical diagnosis of primary open-angle glaucoma were assessed as regards peripapillary RNFL thickness and optic nerve head parameters by 3D-OCT for a follow-up period of 6 months. The drugs used to reach target IOP were Twinzol (dorzolamide 2%/timolol 0.5%) eye drops 5 ml and Ioprost (Latanoprost) 0.005% (50 mcg/ml) eye drops 3 ml. Eleven patients were treated with Twinzol only and reached target IOP after adding Ioprost. Eight patients were treated with Ioprost only and reached target IOP after adding Twinzol, and 13 patients had no added treatment, where four reached target IOP by Ioprost only, six reached target IOP by Twinzol only, and three reached target IOP by both drugs. OCT was done for all patients after achieving target IOP and was repeated after 6 months of medical control. Results The mean IOP before treatment was 29.89 mmHg and decreased significantly (P<0.001) after treatment to 12.17 mmHg. There was a significant (P<0.05) difference regarding the superior RNFL thickness before and after treatment (100.31 vs. 101.15). There was also a significant (P<0.05) difference in the nasal RNFL thickness before and after treatment (73.37 vs. 74.34). The cup-to-disc area ratio (CDR) mean had decreased significantly (P<0.01) after treatment (0.51 before treatment vs. 0.47 after treatment). Vertical CDR and cup volume had the same trend (0.69 vs. 0.66 for vertical CDR and 0.42 vs. 0.39 for cup volume). There was a highly significant (P<0.01) strong positive correlation between IOP changes and rim volume (r=0.81). Conclusion Achieving target IOP in patients with glaucoma results in a significant change in the RNFL and ganglion cell complexes layer as shown by spectral-domain OCT.
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Suspension recession of inferior oblique versus graded recession technique in V-pattern strabismus with primary inferior oblique overaction p. 176
Reham H Taha, Heba A El Gendy, Mahmoud A Kamal, Fadia M El Guindy
DOI:10.4103/DJO.DJO_3_17  
Purpose The aim of this study was to evaluate the efficacy of inferior oblique suspension recession ‘modified hang-back’ in cases with V-pattern strabismus and primary inferior oblique overaction (IOOA), compared with standard graded recession technique. Patients and methods Thirty patients (60 eyes) presenting with V-pattern strabismus with primary IOOA were enrolled and randomized for inferior oblique weakening intervention − that is, suspension recession (group A), or standard graded recession (group B). Results In group A, the mean postoperative V-pattern exotropia was 4.8±2.7 PD as compared with a mean of 26.42±6.26 PD preoperatively (P≤0.001). Meanwhile, for the esotropic subgroup, the values were 2.57±1.13 and 15.62±4.17 PD, respectively (P≤0.001). For group B patients, the mean V-pattern exotropia was 2±1.5 PD, compared with a preoperative mean value of 23.12±10.66 PD (P≤0.001), and the mean pattern esotropia was 2.28±1.79 PD, compared with a preoperative mean value of 17.14±3.93 PD (P≤0.001), with a highly significant statistical difference between patients within the same group (P≤0.001), as well as between the two groups as regards the exotropic subgroups (P≤0.02). A significant improvement in IOOA was noted in group B, whereas the postoperative hypertropia in lateral gaze was 0.97±1 PD, compared with 5.06±2 in group A (P≤0.001). Conclusion Although considerable results were achieved with the suspension recession technique, the postoperative impact of the procedure as regards the control of IOOA may be still questionable, with significant superior results of the standard recession technique.
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CASE REPORTS Top

Misinterpretation of topographic early keratoconus, with consequent post small-incision lenticule extraction ectasia p. 182
Sherif A Eissa
DOI:10.4103/DJO.DJO_1_17  
The purpose of this paper is to describe an infrequent complication of small-incision lenticule extraction. Bilateral corneal ectasia that was discovered 6 months postoperatively is described here. The case has shown that the procedure can aggravate early keratoconus cases without any advantage over laser in-situ keratomileusis or surface ablation procedures. Placido disk imaging with correct scaling and color coding of Scheimpflug images is essential in the preoperative assessment of small-incision lenticule extraction patients.
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Hypertensive uveitis: an initial presentation for primary antiphospholipid syndrome p. 185
Riham S.H.M Allam, Basma Medhat Ali
DOI:10.4103/DJO.DJO_4_17  
The authors aim to report a case of hypertensive uveitis-associated primary antiphospholipid antibody syndrome (APS). A 25-year-old woman presented with unilateral painless diminution of vision. Examination revealed right chronic anterior uveitis, complicated cataract, and appositional angle-closure glaucoma uncontrolled with medications, for which sequential phacoemulsification–trabeculectomy was performed. Rheumatological consultation revealed the diagnosis of primary APS according to revised Sapporo criteria. Accordingly, systemic steroids and hydroxychloroquine were prescribed. The patient experienced an attack of posterior uveitis 2 years later, which necessitated a maintenance dose of an immunomodulator. Following systemic treatment and intravitreal triamcinolone, the patient’s vision improved from hand motion good projection to 0.3 with no inflammation 8 months following the last relapse. We conclude that hypertensive uveitis can be a presenting feature of primary APS. Antiphospholipid laboratory profile could be added to the workup of uveitis whenever clinical suspicion is present. Thromboprophylaxis could be added when antiphospholipid is positive.
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