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   Table of Contents - Current issue
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July-September 2020
Volume 21 | Issue 3
Page Nos. 139-227

Online since Wednesday, September 23, 2020

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ORIGINAL ARTICLES  

Computer vision syndrome among individuals using visual display terminals for more than two hours Highly accessed article p. 139
Uzma Rafeeq, Mossab Omear, Lokesh Chauhan, Veenu Maan, Pradeep Agarwal
DOI:10.4103/DJO.DJO_65_19  
Purpose Nowadays exposure to visual display terminals (VDT) is an integral part of our daily life. Adolescents are also exposed to extended use of VDTs. This study aimed to assess the proportion of individuals experiencing various ocular symptoms according to their VDT usage and age. Patients and methods This cross-sectional comparative study was conducted from April 2017 to March 2018. Validated computer vision syndrome (CVS) questionnaire was used for the assessment of CVS. The questionnaire includes 16 symptoms that are scored using two rating scales, one for frequency and the other for intensity. Study participants were divided into two groups: group I included individuals using VDT more than or equal to 6 h per day and group II included those using VDT for less than 6 h per day. Results A total of 120 individuals were included in this study. The total symptom severity score of more than or equal to 6 (i.e. with CVS) was recorded in 83 (69.2%) patients. The median symptom severity score was 8 (SD: 10.2, range: 0–46). In CVS patients, headache (79 patients=95.2%) was the most prevalent symptom followed by blurred vision (70 patients=84.3%), dryness (57 patients=68.7%), heavy eyelid (57 patients=68.7%), eye redness (55 patients=66.3%), and eye pain (53 patients=63.9%). Among group I, 50 (68.4%) patients had CVS while in group II, 33 (70.2%) patients had CVS (P=1.0; c2 test). In adults, 57 (67.1%) patients had CVS compared with 26 (74.3%) patients among adolescents (P=0.001, Fisher’s exact test). Conclusion The proportion of CVS among individuals who were using VDT for more than 2 h was significantly higher in adolescents as compared with the adult age group.
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Corneal biomechanical properties after laser-assisted in situ keratomileusis and small-incision lenticule extraction in myopic eyes p. 146
Basma ElShourbagy, Alaa A El Dorghamy, Ahmed M Ghoneim, Hazem A Elbedewy
DOI:10.4103/DJO.DJO_22_20  
Purpose The aim of this study was to compare the differences in corneal biomechanical changes after laser-assisted in situ keratomileusis (LASIK) and femtosecond laser small-incision lenticule extraction (SMILE) using the corneal visualization Scheimpflug technology (Corvis ST). Patients and methods This is a prospective study that included two groups of myopic patients. Group 1 included 20 eyes that underwent LASIK surgery, and group 2 included 20 eyes that underwent SMILE surgery. The corneal biomechanical properties were assessed preoperatively and three months postoperatively using the Corvis ST in both groups. The main evaluated parameters included the first and second applanation (A1 and A2) time, absolute velocity and length, highest concavity (HC) time and radius, peak (P) distance, HC deflection amplitude, deformation amplitude, and Corvis biomechanical index. Results There was no significant difference between the two groups regarding all preoperative biomechanical parameters measured by Corvis ST. At the third postoperative month, there was no significant difference between the two groups regarding A1 length or absolute velocity, whereas A1 time, A2 time, A2 length, absolute A2 velocity, and HC time were significantly lower among patients in the LASIK group than patients in the SMILE group. On the contrary, HC radius, P distance, HC deflection amplitude, deformation amplitude, and Corvis biomechanical index were significantly higher among patients in the LASIK group than patients in the SMILE group. Conclusion SMILE and LASIK procedures substantially alter the corneal biomechanical properties measured by the Corvis ST. The LASIK procedure seemed to result in less tensile strength and more compliant cornea when compared with the SMILE procedure in myopic corrections. This denotes greater reduction in biomechanical stability in the LASIK procedure than in SMILE.
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Corneal endothelial changes evaluation using specular microscope following collagen cross-linking in treatment of keratoconus p. 153
Akram F Elgazzar, Reem S Eid, Mona M Aly
DOI:10.4103/DJO.DJO_27_20  
Objective The aim of this study was to evaluate the corneal endothelial changes following corneal collagen cross-linking treatment of keratoconus using a specular microscope. Patients and methods The study included 30 eyes of 30 patients with keratoconus, comprsing 16 males and 14 females, with a mean age of 28 years. Patients had a standard corneal collagen cross-linking after removal of the corneal epithelium. They were evaluated before and 1 month after the procedure using the specular microscope. Results The mean preoperative central corneal thickness of the patients was 477.5±35.57 µm, and at 1 month postoperatively, it was 477.9±36.88 µm, with no statistically significant change (P=0.7821). The mean preoperative value of cell density was 2963.1±364.1 cells/mm2 and became 2956.96±363 cells/mm2 1 month postoperatively, with no statistically significant change (P=0.7091). The mean preoperative coefficient of variation value was 36.3±5.9%, whereas 1 month postoperatively, it became 36.2±5.6%, with no statistically significant change (P=0.6951). The mean preoperative value of hexagonal cells was 49.93±7.9% and became 48.5±7.3% 1 month postoperatively, with no statistically significant change (P=0.2078). Conclusion There were no significant changes in human corneal endothelial parameters, as evaluated with the specular microscope, following cross-linking in keratoconic eyes.
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Osteo-odonto keratoprosthesis in Egypt: a case series p. 159
Mohamed B Goweida
DOI:10.4103/DJO.DJO_2_20  
Purpose The aim of this study was to evaluate the preliminary results of osteo-odonto keratoprosthesis (OOKP) performed in Alexandria Main University Hospital, Alexandria, Egypt in eyes with end-stage cicatrizing conjunctivitis. Patients and methods OOKP surgery was done in two stages. Stage 1 included preparation of the globe, buccal mucous membrane harvesting, and preparation of osteo-odonto alveolar lamina with the cemented optical cylinder. The prepared lamina was then placed in the submuscular space for 2–3 months. In stage 2, the lamina–optical cylinder complex was implanted under the buccal mucous membrane and the posterior part of the optical cylinder was placed in a central corneal opening to act as an artificial cornea, transmitting image to the retina. Results Six eyes with end-stage ocular surface disease were included in this study. Anatomical success, in the form of retention of the prosthesis, was achieved in five eyes. The procedure failed in one eye due to unhealthy canines with a small amount of bone in the lamina. Functional success, defined as restoration of vision, was achieved in four eyes. Visual improvement was not attained in one eye (in addition to the eye with anatomical failure) due to optic atrophy despite good retention of the device. Conclusion OOKP is a promising procedure to regain vision in severe cases of end-stage corneal blindness, unsuitable for cadaveric corneal grafts. Proper selection of cases is crucial to achieve the best anatomical and functional results.
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The role of oral antioxidant supplementation in treatment of dry eye following phacoemulsification p. 167
Mohamed S Abd Elaziz, Mostafa K Nassar, Noha A.E.M Sharshar
DOI:10.4103/DJO.DJO_45_19  
Background Dry eye after uneventful phacoemulsification has been a common cause for patients’ dissatisfaction, despite good visual outcome. Tear film instability after cataract extraction has been attributed to multiple intraoperative and postoperative causes. Oral antioxidants have been proposed to decrease the objective and subjective symptoms of dry eye. Objective The aim of this study was to evaluate the effectiveness of oral antioxidant supplementation on dry eye after phacoemulsification. Patients and methods This is a randomized controlled clinical case series study that included 60 eyes of 60 patients. They were divided into two groups: group 1 was treated with oral antioxidants after surgery, whereas group 2 was not treated with oral antioxidants. The study was conducted at the Ophthalmology Department of Menoufia University Hospital in the period between January 2018 and January 2019. Follow-up for those patients were done by Schirmer’s test 1, break-up time test, and ocular surface disease index questionnaire preoperatively and at 1, 2, and 3 months postoperatively to evaluate oral antioxidant supplementation effect on dry eye after surgery. Results Three months after oral antioxidant supplementation following phacoemulsification, statistically significant differences (P<0.001) were noted in break-up time test scores (9.80±0.86 and 8.50±0.88 s) in group 1 and group 2, respectively. In addition, Schirmer’s scores improved to 9.65±0.97 mm in group 1 versus 8.60±0.87 mm in group 2. However, no statistically significant difference (P=0.599) was noted in ocular surface disease index score between group 1 and group 2 (15.18±3.29 and 15.56±2, respectively) . Conclusion Oral antioxidant supplementation caused significant improvement in objective manifestations of dry eye after phacoemulsification. Nevertheless, no significant difference was noted between the two groups in subjective symptoms.
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Effects of phacoemulsification on intraocular pressure and anterior chamber depth p. 173
Tarek A Hafez
DOI:10.4103/DJO.DJO_29_19  
Purpose The aim of this study was to investigate the effects of phacoemulsification and intraocular lens (IOL) implantation, in nonglaucomatous patients with cataract, on intraocular pressure (IOP) and anterior chamber depth (ACD) together with quantification of other anterior chamber parameters. Patients and methods A total of 76 patients (100 eyes) with senile cataract were included in this study. All patients had normal IOP. Patients with history of uveitis, glaucoma, other ocular diseases, or surgery were excluded. All patients underwent phacoemulsification with IOL implantation by the same surgeon from May 2018 to August 2018 and were followed up for 1 month. The ACD was measured with the use of Pentacam rotating Scheimpflug camera. Results There was a significant difference between the preoperative IOP (15.24±7.05 mmHg) and the postoperative IOP (11.83±3.75 mmHg) (t=6.259, P<0.01). This was associated with a significant increase in the ACD from a preoperative value of 3.1±0.8 mm to a postoperative value of 3.8±0.8 mm (t=0.870, P<0.0001). There was also a significant increase in the anterior chamber angle from a preoperative value of 34.1±9.3° to a postoperative value of 40.6±5.9° (t=5.760, P=0.003) and in the anterior chamber volume from a preoperative value of 161.3±36.7 mm3 to a postoperative value of 197.1±26.1 mm3 (t=36.200, P<0.0001). Conclusion The present study, performed with the Pentacam rotating Scheimpflug camera system, confirmed that, in normotensive eyes with open iridocorneal angles, the anterior chamber volume and ACD increased and the anterior chamber angle widened following uneventful phacoemulsification and IOL implantation. These changes were accompanied by a significant decrease in IOP 1 month postoperatively. Further studies are required to prove the safety and mechanism of lowering the IOP following phacoemulsification.
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Foveal avascular zone area measurements in a normal Egyptian population using Heidelberg optical coherence tomography angiography and its various correlations p. 180
Tamer A Refai, Olfat A Hassanin, Marwa A Fouly
DOI:10.4103/DJO.DJO_53_19  
Purpose The aim of this study was to measure the foveal avascular zone (FAZ) area at both superficial and deep retinal capillary plexus levels in normal emmetropic and highly myopic eyes, using the Heidelberg optical coherence tomography angiography (OCTA) and to find its correlation with central macular thickness and volume and best-corrected visual acuity. Patients and methods This is a prospective cross-sectional observational study that involved 69 normal emmetropic and highly myopic eyes of Egyptian patients. FAZ area (both at the superficial and deep capillary plexus levels), central macular thickness, and volume were measured by the Heidelberg OCTA. Best-corrected visual acuity in Illiterate E lines was also reported. Results In normal individuals, the mean value of the FAZ was 0.38±0.11 mm2 for the superficial FAZ and 0.29±0.10 mm2 for the deep FAZ, with higher statistically significant values for the superficial FAZ size (P<0.05, t test=13.64). Pearson correlation test revealed a statistically significant negative correlation (P<0.05) between central macular thickness and both the superficial FAZ size (r=−0.33) and deep FAZ size (r=−0.39) and a highly significant negative correlation (P<0.01) between central macular volume and both superficial FAZ size (r=−0.40) and deep FAZ size (r=−0.42). Best-corrected visual acuity showed an insignificant correlation (P>0.05) with both superficial and deep FAZ size. Neither high myopia nor sex influenced the results. Conclusion Using the Heidelberg OCTA in normal Egyptian individuals, the superficial FAZ size ranged from 0.19 to 0.85 mm2, which was larger than the deep FAZ, which ranged from 0.09 to 0.73 mm2. FAZ size measurements were strongly correlated with central macular thickness and volume. Neither high myopia nor sex influenced the results.
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Ganglion cell complex thickness in screening of hydroxychloroquine maculopathy p. 187
Yasmin M.M Amin, Moustafa K Nassar, Asmaa M Ibrahim
DOI:10.4103/DJO.DJO_23_20  
Background Screening of early hydroxychloroquine (HCQ) maculopathy is important to prevent permanent structural and functional retinal damage. Spectral domain optical coherence tomography (SD-OCT) ultra-high-resolution imaging and speed allows better visualization of retinal architecture and measurement of the thickness of the retinal layers. Objective The aim of this study was to evaluate the macular ganglion cell complex (GCC) thickness by using SD-OCT for screening of early HCQ maculopathy. Patients and methods A total of 128 patients were included in the present study. They were divided into two groups: HCQ group, comprising 128 eyes of 64 patients treated with HCQ, and a control group, comprising 128 eyes of 64 healthy individuals. Average, minimum, and sectorial macular GCC thickness and photoreceptor layer (PL) integrity were compared between the two study groups. Correlations between GCC thickness and duration of HCQ use, PL integrity, uncorrected visual acuity, and best-corrected visual acuity in the HCQ group were analyzed. Results There were no statistically significant differences between the two groups regarding the average, minimum, and sectorial macular GCC thickness. However, a statistically significant difference between the two groups was found regarding the PL integrity. In addition, the PL integrity was found to have the highest independent correlation with the average macular GCC thickness, followed by the duration of treatment with HCQ, and lastly, the uncorrected visual acuity. Conclusion Unique SD-OCT findings in the retina can identify early HCQ retinopathy and may play a role as a complementary objective tool in HCQ maculopathy screening.
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Role of multifocal electroretinogram in the prediction of visual prognosis in patients with occult macular dystrophy p. 194
Marwa Abdelshafy, Ahmed Abdelshafy
DOI:10.4103/DJO.DJO_19_20  
Background Occult macular dystrophy (OMD) is a rare hereditary macular dystrophy characterized by severe bilateral progressive loss of central vision with normal fundus appearance and normal fundus fluorescein angiography. Aim The aim of this study was to assess the correlation between multifocal electroretinogram (mf-ERG) parameters and best-corrected visual acuity (BCVA) in patients with OMD. Patients and methods In all, 20 eyes of 10 patients with OMD and 20 eyes of 10 age-matched and sex-matched normal individuals were included in this study. Full ophthalmic examination, fundus fluorescein angiography, optical coherence tomography, full-field ERG and mf-ERG were performed for all participants. The average amplitude density of P1 wave, amplitude, and implicit time of P1 and N1 waves were recorded in the five concentric hexagonal rings. Correlation between these mf-ERG parameters and BCVA (LogMAR) was analyzed. Results There were no statistically significant differences in age, sex, and refraction between the studied groups (P=0.54, 1.0, and 0.82, respectively). Mf-ERG parameters in OMD patients showed significant central depression with less affection of peripheral rings. The average amplitude density of P1 wave and the amplitude of P1 and N1 waves were significantly reduced in the central rings (rings 1, 2, and 3), with less impairment in paracentral areas (rings 4 and 5). The implicit time of P1 and N1 waves were significantly delayed across the central rings in OMD patients. The BCVA (LogMAR) was significantly negatively correlated with the amplitude of P1 and N1 waves (P≤0.001). The BCVA (LogMAR) was significantly positively correlated with the implicit time of P1 and N1 waves (P≤0.001). Multiple regression analysis demonstrated that the amplitude and latency of P1 and N1 waves in the central rings (1 and 2) were the most important determinants for BCVA. Conclusion Mf-ERG has a key role in the detection of OMD and can be considered as a valuable objective test for the detection of central/macular dysfunction. The amplitude and latency of P1 and N1 waves in rings 1 and 2 may be used as biomarkers for the prediction of visual prognosis in these patients.
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Evaluation of anterior segment parameters in pars plana vitrectomy and silicone oil injection p. 204
Moataz H Osman, Shaimaa A Arfeen, Ghada A Nassar
DOI:10.4103/DJO.DJO_20_20  
Purpose The aim of this study was to compare the changes in anterior segment parameters induced by pars plana vitrectomy (PPV) and silicone oil injection in phakic and pseudophakic eyes. Patients and methods This is a prospective comparative study that included 40 eyes with rhegmatogenous retinal detachment that underwent vitrectomy and silicone oil injection. They were divided equally into two groups. Group 1 included phakic eyes and group 2 included pseudophakic eyes. Anterior segment parameters were documented by using a CSO Camera (Costruzione Strumenti Oftalmici) before and 1 month after surgery. The changes in the following parameters were compared between the two groups: anterior chamber depth (ACD), anterior chamber volume (ACV), anterior chamber angle (ACA), central corneal thickness (CCT), corneal volume (CV), horizontal anterior chamber diameter, and surgically induced astigmatism. Results At 1 month postoperatively, in group 1, there was a significant decrease in the mean of ACA and ACV as compared with the preoperative values (P=0.024 and 0.011, respectively). In group 2, there was a significant decrease in the 1-month postoperative mean of ACD, ACA, and ACV as compared with the preoperative values (P=0.021, <0.0001 and 0.015, respectively) and a significant increase in the mean of CCT and CV values (P<0.0001 and 0.002, respectively). In group 2, there was more reduction in ACD, less reduction in ACA, and higher increase in CCT and CV as compared with group 1 (P=0.021, 0.001, <0.0001, and 0.023, respectively). Conclusion The presence of the crystalline lens acts as a barrier which decreases the changes in the anterior segment parameters and improves the functional outcome following PPV and silicone oil injection as compared with pseudophakia. Therefore, it may be useful to stabilize the anterior segment in patients with PPV and silicone oil injection.
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Can orbicularis oculi excision improve the long-term success of trachomatous upper lid entropion correction? p. 210
Amr M Awara, Osama E Shalaby, Heba M Shafik
DOI:10.4103/DJO.DJO_17_20  
Background Management of trachomatous cicatricial entropion of the upper eyelid continues to be a challenging problem. Long-standing cicatrization induces a spasm of orbicularis muscle which adds to the severity of the condition. We supposed that orbicularis muscle excision, if added to the standard technique of correction, may improve the outcome and long-term stability of the lid margin. Patients and methods The study included 61 patients suffering from moderate to severe degrees of upper lid trachomatous cicatricial entropion. They were divided into two groups: group A included 31 cases (56 eyelids) for whom bilamellar tarsal rotation procedure with orbicularis muscle dissection and excision from all over the tarsal plate was done to allow for free rotation and group B included 30 cases (50 eyelids) for whom the same technique without orbicularis muscle excision was performed. All cases were followed up for 12 months postoperatively. Lid margin and eyelash position, eyelid closure, improvement of symptoms, aesthetic appearance, overcorrection or undercorrection, and recurrence were assessed at each visit. Results The short-term results showed anatomical success, adequate lid closure, and regular lid margin in all cases of both groups with 12.5% of cases having moderate overcorrection in group A, which regressed without any surgical intervention. The long-term recurrence rate was significantly lower in group A (7%) than in group B (24%) after 1 year of follow-up (P=0.031). There were no cases of secondary lagophthalmos or retraction, and the aesthetic alterations were accepted by all patients. Conclusion This modified technique proved to be safe, quick, and easy to perform. It increased the long-term stability of the eyelid margin after correction, resulting in high patient satisfaction with good cosmetic and functional outcomes for a long period.
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Conventional vs noninvasive upper lid blepharoplasty in upper lid dermatochalasis: a comparative case series study p. 216
Ahmed Tharwat, Wael M Saudi, Omar Solyman, Kareem B Elessawy
DOI:10.4103/DJO.DJO_10_20  
Purpose The aim of this study was to compare the efficiency of fractional plasma with conventional surgical upper lid blepharoplasty in the management of upper lid dermatochalasis. Patients and methods This is a prospective, comparative, interventional case series study that included 10 patients with bilateral upper lid dermatochalasis. Surgical upper eyelid blepharoplasty was performed on one side and fractional plasma (Blepharoplasma, Plasmage) was performed on the other side for each patient. The outcome was compared between both sides of each patient in terms of the amount of residual excess skin, patient satisfaction with lid contour, scar line, and pretarsal platform, in addition to the duration of the procedure and postoperative complications. Results No statistically significant difference was found in terms of patient satisfaction between the two techniques. Lid edema was noted in both groups. However, ecchymosis was significantly more obvious in the eyelid that underwent surgical blepharoplasty compared with the lid that underwent fractional plasma, but it resolved within the first week. Conclusion Fractional plasma may offer a less invasive alternative to surgical upper lid blepharoplasty in mild to moderate cases with some limitations regarding fat prolapse and the severity of dermatochalasis.
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Transconjunctival levator muscle plication in mild to moderate congenital ptosis p. 223
Mohammad E Abdel Fattah, Omar E Basiony, Mahmoud E Saleh, Reem A.K Dessouky
DOI:10.4103/DJO.DJO_26_20  
Purpose The aim of this study was to evaluate the efficacy, cosmetic result, and safety of transconjunctival plication of the levator muscle in the correction of simple congenital ptosis. Patients and methods This is a prospective interventional study that was performed on 23 eyelids (17 unilateral and three bilateral) of 20 patients with simple congenital ptosis and fair to good levator muscle function. All patients were subjected to transconjunctival levator plication. Preoperative history taking and ophthalmological examination were performed. Degree of ptosis was evaluated using the marginal reflex distance 1 (MRD1). Levator muscle function was evaluated using the Berke’s method. Serial follow-up was performed for all patients. Results The mean age of the patients was 6.65±3.13 years. Anatomical success (MRD1 of 3–5 mm and intereyelid difference of <1 mm) was achieved in 20 (86.96%) eyelids, whereas undercorrection occurred in three (13.04%) eyelids. A good cosmetic outcome was obtained in 21 (91.3%) eyelids. A statistically significant improvement was found between the preoperative MRD1 values and the 1- and 6-month postoperative values (P<0.001). There was no significant difference between MRD1 at 1 and 6 months, postoperatively (P=0.07). No major postoperative complications were reported. Conclusion Levator plication using the posterior transconjunctival approach is safe and effective for correcting simple congenital blepharoptosis with a good cosmetic outcome. This technique is especially useful for mild and moderate cases of congenital ptosis associated with good to fair levator muscle function.
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