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   Table of Contents - Current issue
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April-June 2018
Volume 19 | Issue 2
Page Nos. 87-161

Online since Thursday, June 7, 2018

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ORIGINAL ARTICLES  

Effect of the volume of anesthetic solutions and patient’s age on the efficacy of retrobulbar anesthesia Highly accessed article p. 87
Engy M Mostafa, Amr Mounir
DOI:10.4103/DJO.DJO_71_17  
Purpose The aim of this study was to monitor the effect of different anesthetic volumes and patients’ age on the efficacy of bulbar akinesia and analgesia induced by retrobulbar anesthesia (RBA). Patients and methods This was a prospective, comparative, and interventional study that enrolled 478 patients who had consecutive cataract surgery and received RBA. Patients were divided randomly into two groups according to the volume of anesthetic solutions used. In group 1, patients received 2.50 ml of RBA, whereas in group 2, patients received 4 ml of RBA. Each group was then subdivided according to the age of the patients less than 45 years and greater than or equal to 45 years (1a, 1b, 2a, and 2b, correspondingly). The efficacy of anesthesia was evaluated by the degree of ocular motility in both groups. Results The study included 478 eyes of 478 patients. Group 1a included 94 patients: 51 eyes showed no movement regarding globe akinesia, 27 eyes showed flicker movement, 10 eyes showed partial movement, and six eyes showed full movement. Group 1b included 131 patients: 84 eyes showed no movement, 30 eyes showed flicker movement, 10 eyes showed partial movement, and seven eyes showed full movement. Group 2a included 103 patients: 80 eyes showed no movement, 17 eyes showed flicker movement, four eyes showed partial movement, and two eyes showed full movement. Group 2b included 150 patients: 109 eyes showed no movement, 28 eyes showed flicker movement, eight eyes showed partial movement, and five eyes showed full movement. Conclusion This comparison of different injection anesthetic volumes showed significant differences regarding bulbar akinesia, where the larger volume of anesthetic solution (4 ml) yielded better ocular akinesia with no significant effect of age of the patient on the efficacy of RBA.
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Phacoemulsification versus manual small incision cataract surgery in hard nuclear cataracts p. 92
Hesham A Enany
DOI:10.4103/DJO.DJO_37_17  
Purpose The aim of this study was to compare the clinical outcomes of phacoemulsification with that of manual small incision cataract surgery (MSICS) in cases of hard nuclear cataract. Patients and methods Eighty eyes of 80 patients with gradual painless diminution of vision, diagnosed as senile nuclear cataract grade 4 or higher according to Lens Opacities Classification System III (brown cataract), were studied. These eyes were divided randomly into two groups: group A included 40 eyes treated by phacoemulsification by the vertical chopping technique and group B included 40 eyes treated by MSICS by the viscoexpression technique. Results One day postoperatively, the corrected distance visual acuity was at least 6/18 in 21 (52.5%) patients in the MSICS group and in nine (22.5%) patients in the phacoemulsification group. The difference was statistically significant (P=0.01). A postoperative increase in intraocular pressure was recorded in one (2.5%) case in the phacoemulsification group. On the first postoperative day, 11 (27.5%) cases in the MSICS group and 13 (32.5%) cases in the phacoemulsification group developed postoperative iritis, with no statistically significant difference between both the groups. Conclusion Both phacoemulsification and MSICS achieved comparable and excellent visual outcomes for treatment of hard brown cataract, with lower complications rates and earlier postoperative visual rehabilitation in small incision cataract surgery.
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NSAIDs eye drops versus steroidal eye drops after phacoemulsification cataract surgery p. 99
Safaa A.M Aboud
DOI:10.4103/DJO.DJO_11_17  
Purpose The aim of this study was to evaluate the efficacy NSAID eye drops in comparison with topical steroids following phacoemulsification cataract surgery. Patients and methods This prospective study included 120 patients with senile cataract who were subjected to phacoemulsification cataract extraction with foldable posterior chamber intraocular lens implantation. Postoperatively, patients were assigned to two groups: NSAIDs group and steroids group. All patients were subjected to preoperative and postoperative investigations including autorefractometer, slit-lamp examination, indirect ophthalmoscopy, tonometry, and Nassar color plates. Optical coherence tomography was performed for all patients in the last visit. Results No statistically significant differences were found between both groups in visual acuity (0.20±0.15 in the NSAIDs group and 0.20±0.13 in the steroidal group), corneal edema, or anterior chamber reaction (P>0.05). The mean macular thickness for the steroidal patient group was significantly higher than their counterparts in the NSAIDs group (P<0.05). However, both medications proved their efficacy in preventing complications throughout the study. Intraocular pressure showed spikes in the steroidal group patients from the third week till the end of the study. Conclusion Both topical NSAIDs and steroids have the same efficacy in preventing inflammation and corneal edema. However, patients subjected to topical steroids were more likely to develop intraocular hypertension and cystoid macular edema.
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Early changes of choroidal and macular thickness after uneventful phacoemulsification surgery p. 106
Sara M Abd El-Mawgoud, Shaimaa A.S Arfeen, Nehal S El-Gendy, Adel M Fathy
DOI:10.4103/DJO.DJO_58_17  
Purpose To evaluate the changes in choroidal and macular thickness after uneventful phacoemulsification surgery and to know whether optical coherence tomography (OCT) choroidal thickness normative data should be considered the same preoperatively and postoperatively or not. Patients and methods A prospective interventional study including 120 eyes of 90 patients with immature senile cataract was carried out. Retinal macular thickness and choroidal submacular thickness were measured preoperatively and 4 weeks after phacoemulsification using Optovue RTVue spectral domain OCT. Changes in thickness of the choroid and macula were evaluated. Results The mean preoperative choroidal thickness was 211.640±35.7 μm in horizontal and vertical scans, while the mean postoperative choroidal thickness was 239.927±51.33 and 231.789±42.6 μm in horizontal and vertical scans, respectively. There was a statistically significant difference between preoperative and postoperative choroidal thickness (P=0.003 and 0.006) in horizontal and vertical scans, respectively. However, there was no significant change in mean macular thickness (P=0.065). Conclusion Uncomplicated phacoemulsification induces a nonpathological increase in choroidal thickness probably due to the inflammatory effect of the surgery. However, these changes are not accompanied by significant changes in retinal macular thickness. Postoperative OCT choroidal thickness nomograms should be different from preoperative ones.
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Correlation between peripapillary choroidal thickness and nerve fiber layer thickness in primary open-angle glaucoma p. 111
Haitham Y Al-Nashar, Ahmad M.B Awad
DOI:10.4103/DJO.DJO_70_17  
Purpose The purpose of this study was to evaluate the peripapillary choroidal thickness (PPCT) and its correlation with nerve fiber layer thickness (NFLT) in eyes with primary open-angle glaucoma (POAG). Patients and methods Eighty eyes were included in this study. They were divided into two groups: group I (38 eyes) of normal individuals and group II (42 eyes) with POAG. All eyes underwent complete ophthalmic examination with visual field testing using Humphery visual field analyzer. NFLT was measured in all eyes using Heidelberg Spectralis-optical coherence tomography with a circle of 3.4-mm diameter around the optic disc. PPCT was measured using enhanced deep imaging (EDI) technique of Heidelberg Spectralis-optical coherence tomography. Results The mean age was 51.74±4.27 years in group I and 53.7±3.7 years in group II. Global NFLT in group I was 103.6±6.3 μm and in group II it was 76.9±8.5 μm with a significant difference between the two groups (P<0.001). The global PPCT was 175.1±8.4 and 129.5±10.1 μm in group I and II, respectively, with a significant difference (P<0.001). The correlation between PPCT and NFLT in group I was 0.84 (P<0.001) and in group II it was 0.9 (P<0.001). Conclusion The PPCT was decreased in eyes with POAG, and there was a significant correlation between it and NFLT in these eyes.
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Correlation of peripapillary retinal nerve fiber layer thickness and ganglion cell complex thickness with the severity of diabetic retinopathy p. 117
Doaa A Mahmoud, Adel M Abdulwahab, Doaa A Ali
DOI:10.4103/DJO.DJO_69_17  
Purpose The aim of this study was to verify the role of peripapillary retinal nerve fiber layer thickness (RNFLT) and ganglion cell (GC) complex thickness in early detection of diabetic retinopathy (DR) using spectral domain optical coherence tomography (SD-OCT). Patients and methods This was a cross-sectional, case–control study. Twenty-nine eyes of patients with type 2 diabetes mellitus, either with no DR (16 eyes, group 1) or mild nonproliferative DR (13 eyes, group 2), and 14 eyes of healthy controls (group 3) were enrolled in the present study. All participants had a complete ophthalmic examination, including SD-OCT. Ganglion cell inner plexiform layer (GCIPL) and RNFLT values were calculated after automated segmentation of SD-OCT scans. Results Significantly reduced GCIPL and RNFLT values were demonstrated in both diabetic patients’ groups compared with healthy controls. Mean GCIPL thickness was 97.5 µm in group 1, 96.9 µm in group 2, and 107.9 µm in group 3 (P=0.04 and 0.04 compared with healthy controls, respectively). Average RNFLT was 104.12±9.6 µm in diabetes patients with no DR (group 1), 100.46±12.86 µm in group 2, and 111.35±6.15 µm in controls (P=0.02 and 0.009 compared with healthy controls, respectively). Conclusion Significantly reduced GCIPL and RNFLT values were demonstrated in both no DR and mild nonproliferative DR groups compared with healthy controls. This indicates that retinal neuronal degeneration occurs in the early stages of DR, even before microvascular abnormalities are visible.
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Early detection of hydroxychloroquine-related changes with fundus autofluorescence: confocal scanning laser ophthalmoscope versus fundus camera p. 122
Saber H El-Sayed, Asmaa M Ibrahim, Mohamed S Abd Elaziz, Naglaa M Mohamed
DOI:10.4103/DJO.DJO_1_18  
Objective The aim of this study was to detect early fundus changes accompanying hydroxychloroquine (HCQ) treatment by using fundus autofluorescence (FAF) with confocal scanning laser ophthalmoscope (CSLO) in comparison to fundus camera. Patients and methods This is a cross-sectional study of 80 eyes of 40 rheumatoid arthritis patients on HCQ treatment. All patients were subjected to full and detailed history taking and ophthalmic examination followed by fundus imaging using fundus camera (colored and FAF images) and the CSLO image. Results The mean age of the patients was 43.75±8.71 years. The HCQ treatment duration ranged from 2 to 60 months with a mean of 29.12±19.42 months. The FAF by fundus camera had a 57% sensitivity in detecting hyperfluorescent lesions and 96% specificity in detecting negative lesions in relation to fundus picture, whereas FAF by CSLO had a 43% sensitivity in detecting hyperfluorescent lesions, and 88% specificity in detecting negative lesions in relation to fundus picture. CSLO had a 29% sensitivity in detecting hyperfluorescent lesions and 86% specificity in detecting negative lesions in relation to FAF by a fundus camera. There were no significant associations between the duration of HCQ treatment and the findings detected by different methods. Conclusion FAF showed damage at a relatively early stage of HCQ toxicity, although it was not predicable which technique of FAF detection will be most definitive for any given individual. FAF by fundus camera was superior to FAF by CSLO as it had high sensitivity and less specificity.
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An economy-based study: vitrectomy versus scleral buckle for primary rhegmatogenous retinal detachment in poor population p. 128
Walid S Ibrahim, Ahmed H Mohamed
DOI:10.4103/DJO.DJO_20_17  
Purpose The aim of this study was to compare scleral buckling (SB) and primary pars plana vitrectomy (PPV) for the treatment of primary phakic rhegmatogenous retinal detachment (RRD). Patients and methods A prospective interventional study was conducted in the Department of Ophthalmology, South Valley University, Egypt, between January 2013 and May 2016. Patients suffering from primary phakic RRD were recruited. Eyes were divided into two groups: the SB group and the PPV group. The SB group underwent radial or encircling silicone sponge retinopexy with cryopexy, and evacuation of subretinal fluid in most cases with air injection. The PPV group underwent three-port 20-G PPV with sulfur hexafluoride or silicone oil (SO) as endotamponade agents. Cost was estimated for the vitreoretinal surgery, cataract surgery, and SO removal. Main outcome measures were anatomical and visual outcome, reoperation rate, and cost of initial surgery and reoperations. Results Forty-five eyes of 45 patients were included in the present study. Primary anatomical success was achieved in 17 (85%) eyes in the SB group and in 21 (84%) eyes in the PPV group. The final anatomical success rate was achieved in all eyes (100%) in both groups. The final best-corrected visual acuity improved in 14 (70%) eyes in the SB group and in 17 (68%) eyes in the PPV group. Reoperations included retinal reattachment surgery in three (15%) eyes versus four (16%) eyes in the SB and PPV groups, respectively. Cataract extraction with intraocular lens implantation was performed in four (20%) eyes in the SB group versus 16 (64%) eyes in the PPV group, and SO removal was performed in 12 (48%) eyes in the PPV group. SB operation cost was 4960 Egyptian Pounds, whereas PPV surgery cost was 6160 Egyptian Pounds. Conclusion SB and PPV for the treatment of RRD had comparable results as regards anatomical and functional outcomes. When considering other factors to decide which treatment method is better, such as cost of surgery, SB seems to be of lower cost compared with PPV.
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Evaluation of topical α-2 agonist in the treatment of mixed diabetic maculopathy p. 134
Basem M Ibrahim, Haitham Y Al-Nashar
DOI:10.4103/DJO.DJO_77_17  
Purpose To evaluate the efficacy of topical α-2 agonist (brimonidine) in the treatment of mixed diabetic maculopathy (with edema and ischemia). Design This is a prospective randomized case series. Patients and methods Thirty eyes of 30 patients were included in this study. All eyes had mixed diabetic maculopathy as diagnosed by fluorescein angiography and spectral domain optical coherence tomography. The cases were divided into two groups: group I (15 eyes) was treated by intravitreal triamcinolone injection and topical brimonidine twice daily for 3 months, and group II (15 eyes) was treated only by intravitreal triamcinolone injection. Visual acuity, fluorescein angiography, and optical coherence tomography were done for all patients before the beginning of the treatment and every month for 3 months to detect the changes in logarithm of minimal angle of resolution (logMAR) visual acuity and the changes in the size of the foveal avascular zone and macular thickness. Results The mean logMAR visual acuity improved from 0.9±0.012 to 0.4±0.1 in group I and from 0.8±0.1 to 0.5±0.02 in group II after 3 months of treatment, with a statistically significant difference between the two groups (P=0.01). The mean central macular thickness improved from 475±25 to 395±11 μm in group I and from 480±14 to 387±9 μm in group II after 3 months of treatment, with no statistically significant difference between the two groups (P=0.5). There was more improvement in the size of the foveal avascular zone with fewer disturbances of its edges in group I when compared with group II throughout the follow-up period. The mean intraocular pressure after 3 months of treatment was 11.5±0.1 mmHg in group I and 18.5±0.02 mmHg in group II, with a significant difference between the two groups (P=0.01). Conclusion α-2 Agonist (brimonidine) has a role in the treatment of mixed diabetic maculopathy.
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Aflibercept for macular edema after branch retinal vein occlusion p. 140
Mahmoud Abouhussein
DOI:10.4103/DJO.DJO_84_17  
Purpose The aim was to evaluate the real-world results of aflibercept in the treatment of macular edema due to branch retinal vein occlusion (BRVO) without prior treatment. Patients and methods The study included patients with treatment-naive symptomatic BRVO causing macular edema with a best corrected visual acuity (VA) of 0.1 or better, central macular thickness (CMT) of more than 300 μm, and a duration less of than 6 months. Patients received intravitreal 2.0 mg of aflibercept. Follow-up examinations were performed monthly after the first injection for at least 6 months. At each visit, complete examination and optical coherence tomography scans were performed with recording of the best corrected VA and CMT on optical coherence tomography. At the monthly follow-up visits, additional Aflibercept injections were given as needed (pro-re-nata) when intraretinal/subretinal fluid was still present. Results A total of 25 patients were included in the study. Their age ranged from 42 to 75 years with a mean of 61.12±8.34 years. There were 16 men and nine women. Duration of vein occlusion ranged from 10 to 50 days with a mean of 21.8±12.29 days. Baseline logarithm of the minimal angle of resolution VA mean was 0.790±0.16. It improved at the 6-month follow-up visit to 0.244±0.22, which was statistically significant (P=0.001). Baseline CMT mean was 538.84±186.96 µm. It improved at the end of follow-up to 284.680±68.22 µm, which was statistically significant (P=0.001). Conclusion Aflibercept given with pro-re-nata regimen was safe and effective in the treatment of macular edema after BRVO.
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Changes in the tear film production and quality after 20- and 23-G vitrectomy: a prospective comparative study p. 147
Tamer Wasfy, Elham A Gad, Shaimaa S Soliman
DOI:10.4103/DJO.DJO_81_17  
Background Dry eye is a common condition affecting many patients after different ocular surgeries. The recent technique of pars plana vitrectomy as 23- or 25-G vitrectomy has an overt advantage over the traditional 20-G vitrectomy in causing less damage to the conjunctival tissue. Patients and methods This is a prospective randomized study, which enrolled 16 eyes that underwent traditional 20-G vitrectomy (group 1) and were compared with 15 eyes that underwent 23-G vitrectomy (group 2). Preoperative and postoperative (first day, first week, first month, and third month) Schirmer 1 (ST1) test and tear break-up time test (TBUT) were used to evaluate the tear film amount and quality. The postoperative symptoms and signs of dry eye were observed and compared in both groups. Results No significant differences were found between the two groups regarding the mean age, sex distribution, comorbidities, and preoperative ST1 or TBUT tests. Both groups experienced excess tears at the first postoperative day. At the end of the first postoperative month, group 1 showed significantly lower values of ST1 and TBUT tests than group 2 (P=0.002 and <0.001, respectively), but by the end of the third postoperative month, there was no significant difference between the two groups regarding ST1 or TBUT test (P>0.05 for both tests). Patients in the 23-G group reported significantly less incidence of ocular pain and red eye at the first week and first month after surgery. Conclusion 23-G vitrectomy has less damaging effects on the conjunctival tissue, reflected as less reduction in the tear film quantity and lower rates of dry eye, than the traditional 20-G method.
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Minimally invasive strabismus surgery versus fornix-based incision technique p. 153
Nermeen M Badawi
DOI:10.4103/DJO.DJO_56_17  
Purpose The aim of the present study was to compare the minimally invasive strabismus surgery (MISS) and the Parks’ fornix-based incision technique. Patients and methods A total of 60 horizontal muscles of 50 eyes of 30 consecutive patients in need for horizontal rectus muscle surgery were included in the present study. They were divided into two groups: group A included surgeries performed with the MISS technique and group B included those performed using the fornix-based incision technique. The comparison addresses both the surgical techniques and the postoperative results, with a follow-up period of 6 months. Results The operative time was relatively longer in cases of MISS (51.79 min) compared with the fornix incision (30.71 min, P<0.05). The wound size and the number of sutures required to close the wounds were 2–4 sutures (1–2 for each incision) in MISS surgeries, whereas 1–2 sutures were required in the fornix incision technique (P>0.05). Regarding postoperative visibility of the conjunctival signs, signs were hardly visible in 75% of small-sized incisions of MISS cases and in 100% of small-sized incisions in cases of fornix-based incision cases (P<0.05). In medium-sized incisions, both techniques were comparable to each other with moderate signs (P>0.05). Finally, in large-sized incisions, the MISS technique showed better results with less visibility of severe postoperative conjunctival signs (66.7%) than those of fornix-based incision (96%, P<0.05). By the end of the follow-up period, 13 (86.6%) of 15 cases became orthophoric (i.e. angle of deviation less than 10 diopters) in group A, whereas 14 (93.3%) of 15 cases became orthophoric in group B (P>0.05). Conclusion Each of the two techniques has its advantages. A definite superiority cannot be confirmed. However, it may be safer to use the MISS in elderly people with inelastic conjunctival tissue.
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RETINAL IMAGING SECTION Top

Optical coherence tomography angiography in choroidal neovascular membrane p. 159
Moemen S El-Nawawy
DOI:10.4103/DJO.DJO_48_17  
Optical coherence tomography angiography is a new, noninvasive imaging technique that generates volumetric angiography images. It is quick and noninvasive and provides volumetric data, with the clinical capability of specifically localizing and delineating pathology along with the ability to show both structural and blood flow information in tandem. It shows detailed vascular information that is promising to patients with age-related macular degeneration. We present optical coherence tomography angiography findings in a case with active choroidal neovascular membrane in one eye and inactive disease in the other eye.
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