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ORIGINAL ARTICLES
One-year results of the triple procedure for primary pterygia
Hisham A Saad, Ahmed M Ghoneim, Waleed A Allam
July-December 2015, 16(2):45-49
DOI:10.4103/1110-9173.168526  
Purpose The aim of this work was to study the effectiveness and potential complications of adjunctive intraoperative mitomycin-C (MMC) application combined with limbal-conjunctival autografting after primary pterygium excision. Patients and methods Fifty-seven eyes of 43 patients with primary pterygia were randomized to receive pterygium excision, followed by either a free conjunctival autograft (control group, n = 27) or an adjunctive intraoperative MMC 0.02% application for 2 min and limbal-conjunctival autograft (triple procedure group, n = 30). All patients were followed for 12 months. Results After 1 year, the recurrence rate was 14.81 and 0% in the control and the triple procedure groups, respectively (P < 0.05). Most complications were transient and mild. The duration of surgery was significantly shorter in the control group (P < 0.01). The surgery did not significantly alter the corrected distance visual acuity or the average absolute astigmatism in either group. Conclusion Simple excision of pterygium combined with adjunctive intraoperative MMC 0.02% application for 2 min and limbal-conjunctival autografting is a safe and effective way of treating primary pterygia.
  637 1,700 -
N-butyl-2-cyanoacrylate tissue adhesive versus subcuticular skin closure in external dacryocystorhinostomy
Dikran G Hovaghimian, Khaled A Abou Sedira, Mohamed Y Farag
July-December 2015, 16(2):97-102
DOI:10.4103/1110-9173.165062  
Purpose The aim of this study was to compare the surgical efficacy and aesthetic outcome of using tissue adhesive N-butyl-2-cyanoacrylate 'Histoacryl' with subcuticular suture closure of skin incision in external dacryocystorhinostomy (DCR). Design The present study was conducted as an interventional study. Patients and methods A total of 60 chronic dacryocystitis patients undergoing DCR procedures at the Research Institute of Ophthalmology were included. The patients were randomly selected, irrespective of age, sex or race, and were divided into two groups of 30 patients each. A classic external DCR was done for all the patients. At the completion of the surgery, the skin incisions in group 'A' were closed with vicryl 6/0 subcuticular suture, whereas in group 'B' N-butyl-2-cyanoacrylate 'Histoacryl' (FDA approved) tissue adhesive was used to close the skin incisions. No subcutaneous sutures were placed to approximate the wound edges. After 20 s of drying time the adhesive was applied for the second time. All the patients were followed up on the first day, fourth day, first week, second week, first month, and then monthly thereafter for 6 months. The time of suturing the wound and the time of application of the tissue adhesive was recorded for all the patients in both groups. During follow-up the wound was examined for evidence of infection, pain and discharge, and an inquiry was carried out for patient satisfaction. Photographs of the wounds were taken at every visit. The photographs were then shown to a senior surgeon, who was oblivious of the method of closing the wound, and rated the quality of skin incision according to 'WES scale'. Results No intraoperative wound complications were encountered in any patient. Statistical analysis of the data available, at 1 month, showed no statistically significant differences between the two groups as regards duration of healing, inflammation or final incision appearance as rated by the senior surgeon. Skin closure time averaged 61 s in subcuticular suture and 52 s in N-butyl-2-cyanoacrylate skin glue, which was statistically insignificant. Conclusion Using N-butyl-2-cyanoacrylate glue is an effective and a reliable method for skin closure, yielding similar aesthetic results as skin closure with subcuticular sutures in clean incision for external DCR surgery. It is safe, quick, does not compromise wound integrity, is adequately tolerated by the patients and could be considered an excellent alternative and an improvement on the traditional method of wound closure, providing high level of satisfaction for both patient and surgeon.
  1,236 104 -
Posterior approach levator aponeurosis advancement in aponeurotic ptosis repair
Molham A Elbakary
January-June 2015, 16(1):32-36
DOI:10.4103/1110-9173.157787  
Purpose The aim of the study was to investigate the efficiency, advantages, and disadvantages of posterior approach advancement of the levator aponeurosis in the repair of aponeurotic ptosis. Patients and methods This is a prospective interventional study, which included 27 eyelids of 20 patients with aponeurotic ptosis. The study included only cases with good levator function of 11 mm or more. Patients with significant dermatochalasis were excluded from the study. All patients were treated by posterior approach levator aponeurosis advancement under local anesthesia. Patients were evaluated 1 week, 1 month, 3 months, and 6 months postoperatively for margin reflex distance 1 (MRD1), eyelid symmetry, and eyelid crease and contour. Results The study included 27 eyelids of 20 patients with aponeurotic ptosis. The patients' mean age was 44.36 ± 14.47 years. The mean preoperative MRD1 was 1.6 ± 0.5 mm, whereas the mean levator function was 12.6 ± 1.1 mm. The mean operative time was 32.6 ± 5.4 min. The postoperative MRD1 showed significant improvement to 3.7 ± 0.6 mm (P < 0.001). Eighty-five percent showed successful outcome with postoperative MRD1 within 1 mm symmetry with the other eye in unilateral cases or 3.5-4.5 mm in bilateral cases. All cases showed postoperative good natural-looking eyelid crease and contour. Success of the procedure showed no correlation to the results of the phenylephrine test (P = 0.762). Conjunctival granuloma was recorded in 3.7% of patients. Conclusion Posterior approach aponeurotic advancement is an effective procedure for correction of aponeurotic ptosis. It has the advantages of high success rate, good natural-looking eyelid contour, and short operative time, and the results are independent of the response to phenylephrine.
  1,096 102 -
Scanning electron microscopy of human corneal lenticules at variable corneal depths in small incision lenticule extraction cases
Ihab M Osman, Amira Y Madwar
October 2016, 17(3):109-113
DOI:10.4103/1110-9173.195261  
Purpose The aim of this study was to evaluate the surface quality of corneal lenticules at variable corneal depths in cases of small incision lenticule extraction using scanning electron microscopy. Patients and methods Forty eyes of 20 myopic patients were included. One eye was randomly assigned for lenticules at 100 µm depth (group I), whereas the other eye was assigned for lenticules at 160 µm depth (group II). The VisuMax femtosecond laser system was used for the procedure. An established scoring system and a new scoring system at higher magnification levels for surface regularity were used. Results The mean overall diameter of the lenticules as seen on electron microscopy was 6.54±0.17 and 6.73±0.20 mm in group I and group II, respectively (P=0.003). In both groups, around 50% of cases showed a smooth surface at ×10 magnification. The mean score was 14.90+1.74 and 13.25+2.77 in group I and group II, respectively (P=0.031). Conclusion The VisuMax femtosecond laser system creates predictable good-quality surface refractive corneal lenticules at superficial depth. Deeper corneal lenticules showed more irregular surfaces, especially at higher magnification levels. Energy settings still need further adjustment to be able to create deeper predictable lenticules in small incision lenticule extraction cases.
  283 888 -
Accuracy of corneal power measurements for intraocular lens power calculation after myopic laser in-situ keratomileusis
Mohammad A.M. El-Hifnawy, Mohamed Shafik Shaheen, Amr F Abou El-Kheir, Hany A Helaly
January-June 2015, 16(1):10-15
DOI:10.4103/1110-9173.157780  
Purpose The aim of the study was to evaluate the accuracy of corneal power measurements for intraocular lens (IOL) power calculation after myopic laser in-situ keratomileusis (LASIK). Setting The study was conducted at the Faculty of Medicine, Alexandria University, Egypt. Patients and methods The study was conducted on 45 eyes that had undergone myopic LASIK previously. Corneal power was measured using manual keratometry, automated keratometry, IOLMaster, and Pentacam. Different hypothetical IOL power calculation formulas were used in each case. Results The steepest mean K value with manual keratometry (37.48 ± 2.86 D) followed by automated keratometry (37.31 ± 2.83 D) and the IOLMaster mean K value (37.06 ± 2.98 D) were steeper than any other mean K value measured by Pentacam. Using 4 mm Holladay equivalent K reading (EKR) with the double-K SRK/T formula, the refractive outcome was good, with 97.8% of cases within ± 2 D, 80.0% of cases within ± 1 D, and 42.2% of cases within ± 0.5 D. The best combination of formulas was 'Shammas-PL+double-K SRK/T using EKR 4 mm'. Conclusion Pentacam Scheimpflug imaging using EKR at 4 mm improved the accuracy of IOL power calculation in post-LASIK eyes. The best option is a combination of formulas. It is recommended to use the mean of the combination of 'Shammas-PL+double-K SRK/T with EKR 4 mm'.
  974 120 -
Punctotomy augmented by the use of perforated punctal plugs for the management of canaliculitis
Ayman Abd El Ghafar, Hossam Al-Sharkawy
July-December 2015, 16(2):89-92
DOI:10.4103/1110-9173.168537  
Purpose The aim of this study was to evaluate the use of perforated punctal plugs with punctotomy for the management of canaliculitis with preservation of punctal and canalicular patency. Patients and methods This was a prospective interventional case series including 12 consecutive patients with unilateral canaliculitis. Punctotomy was performed for all cases with curettage of canalicular contents followed by application of a perforated punctal plug. Plugs were removed after 3 months and all patients were followed up for 6 months. Results This study included 12 cases of canaliculitis, eight female (66.7%) and four male (33.3%), with a mean age of 60.33 ± 4.6 years (ranging from 48 to 73 years). The lower canaliculus was affected in 83.33% of cases, whereas the upper canaliculus was affected in 16.67% of cases. Sulfur granules were present in six cases (50%) and six cases (50%) were negative. Gram staining of the expressed contents revealed the following: 50% Actinomyces israelii, 30% Staphylococcus aureus, and 20% mixed infection. Improvement in inflammation and epiphora occurred in 11 cases (91.67%), whereas persistence of epiphora occurred in one case (8.33%). One case (8.33%) showed inflammatory granuloma at the site of punctotomy and one case (8.33%) showed extrusion of the plug after 1 month of surgery. Conclusion This study showed that punctotomy combined with implantation of perforated punctal plug is an effective technique for the management of canaliculitis, with improvement in manifestations and preservation of punctal and canalicular patency.
  958 61 -
Minimally invasive pterygium surgery versus air-assisted dissection technique for excision of primary pterygium
Hesham A Enany
January-June 2015, 16(1):1-4
DOI:10.4103/1110-9173.157771  
Purpose The aim of this study was to assess and compare minimally invasive pterygium surgery with air-assisted dissection technique for excision of primary pterygium. Patients and methods This prospective randomized comparative study was carried out on 20 eyes of 16 patients with primary pterygium. The cases were randomly divided into two equal groups: group I included 10 eyes in which pterygia were excised with minimally invasive pterygium surgery, and group II included 10 eyes in which pterygia were excised with air-assisted dissection technique. Postoperative examination and follow-up for 3 months were carried out. Results The mean age of the patients was 46.1±3.8 years. Successful dissection was recorded in 80% of cases in group I and in 70% of cases in group II. Recurrence occurred in 10% of cases in each group, with a follow-up duration of 3 months. Conclusion The minimally invasive pterygium surgery is superior to air-assisted dissection of pterygium as it keeps the tenon capsule intact.
  720 168 -
IOL master and A-scan biometry in axial length and intraocular lens power measurements
Soheir H Gaballa, Riham S. H. M Allam, Nahla B Abouhussein, Karim A Raafat
January-April 2017, 18(1):13-19
DOI:10.4103/1110-9173.201623  
Purpose The purpose of this paper is to evaluate differences between IOL master and A-scan regarding axial length (AXL) and predicted IOL power in different types of cataract. Patients and methods Forty eyes of 40 patients underwent examination by IOL master and A-scan, where average K-reading, AXL and predicted IOL power were compared. Results Forty eyes of 40 patients were included. The mean AXL measured by IOL master was higher (26.18±2.92 mm) than that with A-scan (26.02±2.99 mm) with a mean difference of 0.2±0.44 mm (P=0.07). The mean predicted IOL power was 11.61±8.33 D with IOL master versus 12.01±8.23 D with A-scan (P=0.03). However, no statistically significant difference was found regarding average K-readings and predicted postoperative refraction (P=0.4 and 0.7, respectively). Bland–Altman plots showed almost perfect agreement between both methods regarding AXL and predicted IOL power. Further subgroup analysis revealed a statistically significant difference in AXL between both devices only in nuclear cataract with no significant difference in cases with complicated cataract to myopia or silicone oil (P=0.013, 0.2 and 0.1, respectively). No statistically significant difference was found between the three groups regarding the calculated IOL power (P=0.34, 0.13 and 0.15, respectively). Bland–Altman analysis showed almost perfect agreement for the mean difference of AXL and IOL power in the three subgroups. Conclusion There is no significant difference between IOL master and A-scan biometry, with the noncontact IOL master being preferred by patients; however, there exists certain situations where A-scan is still mandatory.
  728 125 -
Decapsulation versus valve reimplantation in cases with an encysted Ahmed valve in refractory glaucoma
Salah M Al-Mosallamy
January-June 2015, 16(1):22-26
DOI:10.4103/1110-9173.157784  
Purpose The aim of the study was to evaluate the efficacy and safety of decapsulation of the fibrous capsule around the valve body versus valve reimplantation in another site in refractory glaucoma cases. Patients and methods We studied 25 cases with refractory glaucoma that had been implanted with an Ahmed glaucoma valve; their intraocular pressure (IOP) was greater than 21 mmHg and had undergone additional maximum topical antiglaucoma therapy. Patients were divided into two groups according to the surgical treatment that had been performed: group I included 12 eyes that had been treated by surgical decapsulation of the cyst around the valve body without removal of the valve and group II included 13 eyes treated by removal of the valve and reimplantation in another quadrant of the eye. Results Of the 25 patients included in the study, 15 were male and 10 were female, with a mean age of 19.2 ± 9.2 years in group I and 22.1 ± 10.3 years in group II. Recurrent congenital glaucoma was the most common preoperative diagnosis in both groups (50 and 53.8% in groups I and II, respectively). There was no statistically significant difference between the two groups regarding preoperative patient demographic characteristics (P < 0.05). The surgical results revealed that the mean operation time was significantly lower in group I than in group II (30 ± 12 and 45 ± 13.5 min, respectively; P = 0.023). However, there were no statistically significant differences in the success (complete and partial) and failure rates between the two groups (P < 0.05). There was marked reduction in IOP from preoperative values in both groups but there were no significant differences in IOP levels between the two groups over the follow-up visits. Tube-related complications occurred in group II only and included corneal tube touch in one (7.7%) case and erosion of the tube covering in two (15.4%) cases. One of them developed endophthalmitis and then lost the perception of light (PL) and ended in phthisis bulbi. Recurrence of encapsulation occurred more in group I (three cases, 25%) than in group II (two cases, 15.4%), after a mean postoperative time of 23 ± 2 weeks. The incidence of valve re-encapsulation was statistically insignificant between the two groups (P = 0.09). Conclusion Both surgical techniques were effective in controlling IOP in cases with encapsulated Ahmed valve; however, the decapsulation technique was simpler with shorter operation time and no probability for tube-related complications. Although the other technique of valve reimplantation had a longer operation time and more tube-related complications, it was associated with less incidence of re-encapsulation. However, larger multicenter studies with longer follow-up are needed for validation of these treatment strategies.
  692 93 -
Refractive meridional corneal collagen cross-linking: a new modified technique for treatment of astigmatism
Mohamed Iqbal Hafez
January-June 2015, 16(1):5-9
DOI:10.4103/1110-9173.157776  
Purpose The aim of the study was to evaluate the efficacy and safety of using corneal collagen cross-linking as a refractive procedure to correct corneal astigmatism. Setting This study was conducted in Sohag University Hospital (Egypt). Design This is a prospective, nonrandomized, clinical trial study. Patients and methods Fifteen eyes of 11 patients complaining of astigmatism were treated with refractive meridional cross-linking (RMCXL). Group A included eight eyes that had undergone previous cross-linking and implantation of intracorneal rings that failed to correct the astigmatic component of keratoconus. Group B included seven eyes with astigmatism without corneal ectasia. All eyes were subjected to examination of the preoperative and postoperative uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and manifest refraction, as well as slit lamp examination of the anterior segment, keratometry, and pachymetry by corneal topographies at 1 week and at 1, 3, and 6 months' follow-up. Results In group A, the preoperative mean UDVA was 0.90 ± 0.33 (log MAR ± SD), whereas the postoperative mean UDVA was 0.78 ± 0.27. The preoperative mean CDVA was 0.60 ± 0.38, whereas the postoperative mean CDVA was 0.48 ± 0.26. The mean postoperative astigmatic correction was 1.8 ± 0.36. In group B, the preoperative mean UDVA was 0.78 ± 0.53, whereas the postoperative mean UDVA was 0.52 ± 0.23. The preoperative mean CDVA was 0.52 ± 0.26, whereas the postoperative mean CDVA was 0.30 ± 0.15. The mean postoperative astigmatic correction was 0.90 ± 0.29. Conclusion RMCXL showed good refractive correction for astigmatism in both ectatic and nonectatic corneas. RMCXL proved to be a promising new simple, effective, and safe procedure for the treatment of corneal astigmatism with reasonable patient satisfaction.
  647 105 -
Visual acuity, fundus changes, and electroretinographic findings in Egyptian children with Bardet-Biedl syndrome
Dina El-Fayoumi, Rasha Helmy, Marwa Nabhan, Nevien Soliman
February 2016, 17(1):29-34
DOI:10.4103/1110-9173.178769  
Purpose The aim of the present study was to assess visual acuity, measure the degree of visual impairment, and examine fundus changes in Egyptian children with Bardet-Biedl syndrome (BBS), and to correlate these findings with the results of flash electroretinography (ERG). Materials and methods A cross-sectional study was conducted on infants and children with BBS. Diagnosis was carried out by a specialized pediatrician. Full ophthalmological examination, including slit-lamp examination, refraction, and indirect ophthalmoscopy, was carried out. Best-corrected visual acuity was measured and full-field flash ERG was performed. Results This study included 20 patients with BBS. The median age was 9 years (ranged from 1 day to 18 years). The mean age of onset of symptoms in the whole group was 6.5 ± 4.3 years. Visual impairment, defined as a best-corrected visual acuity in the better seeing eye of 20/60 (6/18) or less, was present in 11 patients (55% of the cases), and night blindness as a symptom was present in nine patients (45%); pigmentary retinopathy was clinically detected in 35% of the patients and retinal dystrophy as an ERG finding was detected in 60% of the patients. Conclusion Visual impairment in BBS is mainly caused by rod-cone dystrophy, which is one of the major criterion of diagnosis, which manifests with age. Before the age of 6, children rarely present with ocular manifestations, and usually have normal fundus examination; on the other hand, retinitis pigmentosa-like picture is usually seen in children older than 6. However, the electrophysiological changes may precede the fundus changes.
  646 45 -
Evaluation of the use of blind disfiguring eye as a natural implant for artificial eyes
Mohammed Iqbal Hafez
January-June 2015, 16(1):37-41
DOI:10.4103/1110-9173.157790  
Purpose The aim of this study was to evaluate the use of the blind disfiguring eye as a natural implant for artificial eyes instead of evisceration or enucleation with synthetic implants. Patients and methods Ten eyes, which were painless and blind with disfiguring appearance, were included in this study. All eyes were subjected to a new simple surgical technique by simply converting the eye into a natural implant. The main outcome measure was the cosmetic appearance, patient satisfaction, and psychological impact. All patients were followed up at 1 and 2 weeks and 1, 3, and 6 months postoperatively. Results Ten eyes of 10 patients were included in this study with a male-to-female ratio of 1 : 4. Two (20%) eyes developed lid edema and ecchymosis, one (10%) eye complicated with conjunctival hematoma, and another eye (10%) had postoperative shallow fornices. Seven (70%) patients had good postoperative cosmetic appearance with good prosthesis motility and patient satisfaction. Two (20%) patients were not satisfied, as they had poor cosmetic appearance with restricted prosthesis motility. One (10%) patient had failed surgery. Conclusion The use of the painless blind disfiguring eye as a natural implant for artificial eye proved to be an efficient and cheap procedure with excellent cosmesis. Great patient satisfaction was noted as regards the prosthesis movements and final new look.
  610 72 -
Outcome after cataract surgery in patients with traumatic cataract
Akshay J Bhandari, Shobhana A Jorvekar, Pranay Singh, Surekha V Bangal
June 2016, 17(2):56-58
DOI:10.4103/1110-9173.189074  
Purpose The aim of the study was to investigate visual outcome in patients with traumatic cataract after cataract surgery and to study the various etiological factors. Patients and methods A prospective study was carried out on all patients with traumatic cataract who underwent cataract extraction with primary intraocular lens implantation at a tertiary eye hospital between January 2012 and December 2014. Data were collected on age, sex, preoperative vision, postoperative vision at 3–6 months, and postoperative complications responsible for decreased visual acuity. Results Fifty eyes in 50 patients were studied. The study population comprised 36 male and 14 female patients. The preoperative visual acuity was less than 6/60 in all 50 eyes. The postoperative visual acuity in 28 eyes was 6/6–6/12, whereas 20 eyes had visual acuity of 6/18–6/36 and two eyes had visual acuity less than 6/60. The cause of poor visual acuity was mainly corneal opacity and posterior capsular opacity. Conclusion Our study shows that good visual results can be achieved with traumatic cataract surgery if the posterior segment is not involved and the corneal scar does not block the optical axis.
  538 134 -
Correlation between optical coherence tomographic patterns and visual acuity in eyes with diabetic macular edema
Hossam T Al-Sharkawy
February 2016, 17(1):35-41
DOI:10.4103/1110-9173.178773  
Purpose The aim of the present study was to investigate the correlation between different features of optical coherence tomography, macular thickness, and visual acuity (VA) in patients with diabetic macular edema. Patients and methods In total, 168 eyes with clinically significant diabetic macular edema were included in the study. Best-corrected VA was measured and converted to the logarithm of the minimum angle of resolution (logMAR). Optical coherence tomography was carried out and morphology at the presumed fovea was used to classify eyes into four groups: group I, in which the eyes had only noncystoid sponge-like diffuse retinal thickening (DRT); group II, in which the eyes had DRT with cystoid macular edema (CME); group III, in which the eyes had DRT with serous retinal detachment (SRD); and group IV, in which the eyes had DRT with CME and SRD in the same eye. Retinal thickness at the central fovea [center point thickness (CPT)], average macular thickness (AMT), and the height of the cystoid space and the SRD at the fovea were measured. Results DRT was found alone in 65% of the eyes, CME in 16%, SRD in 13%, and CME and SRD in 6%. Mean logMAR was 0.68 with DRT, 1.16 with CME, 0.89 with SRD, and 1.05 with CME and SRD. Mean CPT was 299 μm in DRT, 573 μm in CME, 354 μm in SRD, and 483 μm in CME and SRD, whereas mean AMT was 309 μm with DRT, 374 μm with CME, 344 μm with SRD, and 390 μm with CME and SRD. There was a positive significant correlation between logMAR and CPT in DRT (0.357, P = 0.001), whereas the correlation was less in CME, SRD, and CME and SRD (0.373, P = 0.087; 0.463, P = 0.053; and 0.082, P = 0.847; respectively). The positive correlation between logMAR and AMT was significant in DRT, CME, and SRD but not in CME and SRD (0.314, P = 0.002; 0.605, P = 0.003; 0.646, P = 0.004; and 0.327, P = 0.429, respectively). The height of the SRD was positively correlated with logMAR (0.516, P = 0.028), whereas the correlation between the height of the cystoid space in CME and logMAR was less (0.360, P = 0.099). Conclusion DRT was the most common feature. CME had worst visual outcome and greatest CPT and AMT. In DRT, worse VA correlated more with CPT than with AMT, whereas in CME and SRD, correlation of VA was more with AMT than with CPT. VA correlated with height of lesion in eyes with SRD but not with CME. The height of cystoid space correlated with CPT but not with AMT, whereas the height of SRD correlated with both CPT and AMT.
  537 114 -
Value of fibrin glue use with Ahmed valve implantation in refractory glaucoma
Salah M Al-Mosallamy
January-June 2015, 16(1):16-21
DOI:10.4103/1110-9173.157783  
Purpose This study aimed to evaluate the efficacy and safety of the fibrin glue use with Ahmed glaucoma valve (AGV) implantation in refractory glaucoma. Patients and methods Twenty-two eyes of 22 patients diagnosed with refractory glaucoma were scheduled to receive an AGV and were grouped into two groups: group I included 12 eyes in which fibrin glue was used to secure the scleral flap and conjunctiva over the valve tube. Group II included 10 eyes in which sutures were used as the standard technique for valve implantation. Results The mean age of the patients was 29.5 ± 13.4 and 27.1 ± 10.3 years in groups I and II, respectively, and there was no statistically significant difference between the two groups (P > 0.5). Congenital glaucoma was the most common preoperative diagnosis in each group. The surgical outcome of both groups showed a statistically significant reduction in the mean operation time in group I (37 ± 6 min) than in group II (43 ± 5 min) (P < 0.05). In addition, upper limbal inflammation was less in group I than in group II (17 and 40%, respectively), which was statistically significant (P < 0.05). Complete success was achieved in nine cases (75%) and qualified success was achieved in two cases (17%) in group I; in group II, complete success was achieved in eight cases (80%) and qualified success was achieved in one case (10%). There was no statistically significant difference between both groups in complete success and failure (P > 0.05). There was no statistically significant difference in the mean final intraocular pressure between the two groups (18.1 ± 2.2 and 17.4 ± 3.5 mmHg) in groups I and II, respectively (P > 0.05). The operative complications were hyphema, which occurred in one case in group I (8%) and in two cases in group II (20%). Suprachoroidal hemorrhage occurred in one case in group II. Shallow anterior chamber occurred in two cases (17%) in group I and in two cases (20%) in group II. One case in group I developed choroidal detachment. Tube exposure occurred in three cases, two cases in group I (17%), and one case (10%) in group II. Encysted valve occurred in three cases, two of which belonged to group I (17%) and one case belonged to group II (10%). Conclusion The use of fibrin glue with AGV implantation in refractory glaucoma makes its implantation easier, with a shorter operation time and less postoperative pain and inflammation, but its added cost usually limits its use. However, larger multicenter studies with longer-term follow-up are needed before the widespread use of this surgical technique.
  530 120 -
Trabeculectomy augmentation in primary open-angle glaucoma: Mitomycin-C versus Ologen implant
Tamer I Salem, Tarek N Attia, Salah A Mady, Asaad A Ghanem
July-December 2015, 16(2):70-76
DOI:10.4103/1110-9173.168534  
Introduction Trabeculectomy is the most commonly performed surgical intervention to reduce intraocular pressure (IOP) for medically uncontrolled glaucoma. Different augmentation procedures have been proposed to increase success rate and reduce postoperative complications. Purpose The aim of this study was to evaluate the results of different augmentation procedures used with trabeculectomy in patients with primary open-angle glaucoma. Patients and methods The study included 60 patients. Patients were randomly divided into three groups: the first group underwent trabeculectomy with low-dose mitomycin-C (MMC) (0.1 mg/ml); the second group underwent trabeculectomy with collagen matrix implant (Ologen) TM; and the third group underwent trabeculectomy with both low-dose MMC and Ologen implant. IOP was the primary outcome measure and the target level was set at less than 18 mmHg. Secondary outcome measures included bleb evaluation, number of glaucoma medications, and frequency of postoperative adjunctive procedures and complications. Results Postoperatively, there was a significant decrease in IOP in all studied groups when compared with their corresponding preoperative values, and there was no significant difference between the studied groups at any point of time except at 1 month, when there was a significant decrease in IOP in the MMC group compared with the Ologen or Ologen plus MMC groups. In addition, the Ologen plus low-dose MMC group had better bleb scoring. There was no significant difference between the groups as regards complications. The success was complete in 46 cases (76.7%), and qualified success was reported in 14 cases (23.3%). Complete success was equally reported in the MMC group and in the Ologen plus MMC group (85.0%), whereas it was 60.0% in the Ologen group. Conclusion Both MMC and Ologen appear to be safe, effective, and promising as augmentation procedures with trabeculectomy in patients with primary open-angle glaucoma.
  491 100 1
Macular and retinal nerve fiber layer thickness changes after small-incision lenticule extraction and femto-LASIK
Asaad A Ghanem, Salah A Mady, Tarek N Attia, Tamer I Salem
July-December 2015, 16(2):50-57
DOI:10.4103/1110-9173.168528  
Introduction Femtosecond laser flap creation exerts less intraocular pressure (IOP) fluctuation but requires more procedural time compared with microkeratome flap creation. This IOP elevation during suction may affect the macular and retinal nerve fiber layer thickness that can be assessed with optical coherence tomography. Purpose The aim of this study was to compare the influence of the transient elevation of IOP during suction on the macular and retinal nerve fiber layer thickness after small-incision lenticule extraction (SMILE) and femtosecond laser-assisted in-situ keratomileusis (femto-LASIK). Patients and methods A total of 80 and 75 eyes that received SMILE and femto-LASIK procedures for myopia and myopic astigmatism, respectively, were enrolled in this study. Spectral-domain optical coherence tomography was used to measure macular and peripapillary retinal nerve fiber layer thickness preoperatively, at 1 week, and 1, 3, and 6 months postoperatively. Results The study included 155 eyes. In both the SMILE group and the femto-LASIK group, the mean foveal, parafoveal, and perifoveal retinal thickness did not change significantly from the preoperative to any postoperative timepoint (P > 0.05). The mean foveal retinal thickness was significantly greater in the femto-LASIK group than in the SMILE group (P<0.05). The retinal nerve fiber layer thickness did not change significantly from the preoperative to any postoperative timepoint in either group (P > 0.05). The differences in the retinal nerve fiber layer between the SMILE group and the femto-LASIK group were not statistically significant at any follow-up visit (P > 0.05). Conclusion Both SMILE and femto-LASIK procedures had no significant effects on the macular and retinal nerve fiber layer thickness postoperatively.
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Comparison between trabeculectomy with Ologen implant and trabeculectomy alone in open-angle glaucoma
Tharwat H Mokbel, Mohamed A El-Malah, Hossam T Al-Sharkawy
July-December 2015, 16(2):65-69
DOI:10.4103/1110-9173.168532  
Purpose The aim of this study was to compare surgical outcomes of trabeculectomy with Ologen implant to trabeculectomy alone in terms of intraocular pressure (IOP), postoperative medications, bleb function, and postoperative complications in open-angle glaucoma. Patients and methods Setting : Mansoura Ophthalmic Centre and Al-Azhar University Hospital, Egypt. Design: Prospective study. Forty-two eyes of 30 patients with primary open-angle glaucoma (34 eyes, 80.95%) or pseudoexfoliation glaucoma (eight eyes, 19.05%) were included in this study. Twenty-one eyes were treated by subscleral trabeculectomy with a subconjuctival implant of Ologen over the closed scleral flap (Ologen or study group) and the other 21 eyes were treated by subscleral trabeculectomy alone (control group). One-year follow-up was completed for all eyes. Results Preoperatively, the mean IOP was 29.51 ± 2.85 mmHg in the Ologen group and 30.64 ± 2.36 mmHg in the control group. Postoperative mean IOP was13.26 ± 2.45 mmHg in the Ologen group and 16.85 ± 3.56 mmHg in the control group (P = 0.031). The mean number of postoperative antiglaucoma medications in the Ologen group was 0.43 ± 0.59 compared with 1.06 ± 0.85 drugs in the control group (P = 0.005). Conclusion The new degradable collagen implant (Ologen) improves and normalizes filtering surgical wound healing with more loosely organized and healthy bleb tissue and better IOP control than blebs formed with trabeculectomy alone in primary open-angle and pseudoexfoliation glaucomas.
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Evaluation of intravitreal corticosteroids as an adjuvant to bevacizumab for diabetic macular edema using electroretinogram
Hesham A Enany
January-June 2015, 16(1):27-31
DOI:10.4103/1110-9173.157786  
Purpose The aim of this study was to investigate electroretinogram changes after intravitreal injection of bevacizumab with or without adjuvant intravitreal corticosteroids for diabetic macular edema. Patients and methods This prospective randomized study evaluated multifocal electroretinogram (MFERG) changes in 60 eyes of 45 diabetic patients who had clinically significant macular edema after treatment with intravitreal bevacizumab (IVB) with or without corticosteroids. Preoperative and postoperative clinical examination, fluorescein angiography, optical coherence tomography, and MFERG were carried out for all cases. The patients were divided into three groups and each group included 20 eyes. The first group was treated with IVB injection alone, the second group was treated with IVB and triamcinolon injection, and the third group was treated with IVB and dexamathosone. The follow-up was carried out up to 3 months. Results The mean visual acuity improved in the three groups, and the mean foveal thickness was reduced in the three groups. As regards MFERG-C, P1 amplitudes increased and P1 peak time (ms) was shortened in the three groups. Intraocular pressure rise occurred in 10% of cases in the second group and in 5% of cases of the third group. Conclusion Diabetic macular edema can be treated with bevacizumab alone, as the use of adjuvant corticosteroids has many complications.
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Efficacy and safety of the use of freeze-dried (lyophilized) amniotic membrane transplantation with combined trabeculotomy-trabeculectomy for congenital glaucoma
Salah M Al-Mosallamy
July-December 2015, 16(2):58-64
DOI:10.4103/1110-9173.165060  
Purpose The aim of the study was to evaluate the outcome of the surgical technique that utilizes freeze-dried (lyophilized) amniotic membrane transplantation (AMT) with combined trabeculotomy-trabeculectomy in cases of primary congenital glaucoma with respect to its efficacy and complications. Patients and methods This was a prospective controlled study that included 25 eyes of 19 patients with primary congenital glaucoma. The patients were categorized into two groups: group I included 14 eyes that were treated with combined trabeculotomy-trabeculectomy with AMT and group II included 11 eyes that were treated with combined trabeculotomy-trabeculectomy without adjunctive (control group). Results Nineteen patients were included in the study: 13 were male and six were female. The mean age was 6.2 ± 3.5 months and 5.7 ± 2.9 months in groups I and II, respectively; there were no statistically significant differences between groups I and II regarding the patient demographics and preoperative characteristics. The surgical outcome of the two groups showed that absolute success was achieved in 71.4% and qualified success in 14.3% in group I, and in group II absolute success was achieved in 45.5% and qualified success in 27.2%. This difference was highly significant in terms of absolute success and significant in terms of total success between the two groups. The mean intraocular pressure (IOP) in this study was markedly decreased from preoperative values in both groups during postoperative follow-up visits, with statistically significantly lower IOP in group I than in group II at all postoperative visits. The complications encountered were hyphema in 28.6% of patients in group I and in 27.3% of patients in group II. Shallow anterior chamber associated with hypotony occurred in 21.4 and 18.2% of patients in groups I and II, respectively. One case in each group developed serous choroidal detachment. Flat nonfunctioning bleb with high IOP occurred in 14.3% of patients in group I and in 27.3% in group II. The complication rates were statistically insignificant between the two groups. Conclusion AMT-enhanced combined trabeculotomy-trabeculectomy appears to be an effective procedure for the treatment of primary congenital glaucoma with better long-term control of IOP and without added complications.
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Pars plana vitrectomy with endolaser barrage 360° versus pars plana vitrectomy with scleral buckle for treatment of primary retinal detachment with inferior breaks
Mahmoud A Al-Aswad, Hesham A Enany
July-December 2015, 16(2):84-88
DOI:10.4103/1110-9173.165059  
Purpose The aim of the study was to compare intraoperative and postoperative complications and the recurrence rate after pars plana vitrectomy (PPV) with endolaser barrage 360° compared with PPV with scleral buckle (SB) for primary retinal detachment (RD) with inferior breaks. Patients and methods This prospective randomized study evaluated postoperative results in 40 patients with primary RD with inferior breaks. They presented with primary RD with inferior breaks and were divided into two groups, each group including 20 patients; the first group was treated by means of PPV with endolaser barrage 360°, and the second group was treated by means of PPV with SB. Intraoperative and postoperative complications and recurrence rate were recorded. Follow-up was carried out for 3 months. Results The mean age of patients in the first group was 56.2 years, whereas the mean age of patients in the second group was 55.3 years. Recurrent RD occurred in 10% of cases in the first group and in 5% of cases in the second group. Success rate was 90% (18 of 20 cases) in the first group and 95% (19 of 20 cases) in the second group. Conclusion Acceptable success rates can be achieved using PPV with endolaser barrage 360° to treat RD with inferior breaks. Supplementary SB is unnecessary to support the inferior retina as endolaser barrage with silicon oil and good positioning achieve tempo nade of the inferior breaks satisfactorily. Further, PPV with endolaser barrage 360° has fewer intraoperative and postoperative complications compared with PPV with SB.
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CLINICAL QUIZ
Clinical quiz
Amgad M Dowidar
January-June 2015, 16(1):42-43
DOI:10.4103/1110-9173.157791  
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ORIGINAL ARTICLES
Combined cross-linking with femtosecond laser Myoring implantation versus combined cross-linking with femtosecond laser Keraring implantation for treatment of keratoconus
Mohammed I Hafez
February 2016, 17(1):1-8
DOI:10.4103/1110-9173.178760  
Purpose The aim of this study was to compare the results with regard to efficacy, safety, and patient satisfaction between two combined procedures: combined femtosecond laser Myoring implantation with cross-linking (CXL) and combined femtosecond laser Keraring implantation with CXL for treatment of keratoconus. Setting This study was conducted in Sohag University Hospital, Sohag University, Egypt, in association with Sohag Future Femtosecond Laser Center. Design This was a prospective nonrandomized clinical comparative study. Patients and methods A total of 46 eyes of 30 patients with keratoconus were included in this study. Group A included 27 eyes of 17 patients who were subjected to combined CXL with femtosecond laser Myoring implantation, and group B included 19 eyes of 13 patients who were subjected to combined CXL with femtosecond laser Keraring implantation. All eyes were subjected to preoperative and postoperative uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), manifest refraction, slit lamp examination of anterior segment, intraocular pressure, fundus examination, and keratometry and pachymetry assessment with Pentacam corneal topographies at 3 and 6 months of follow-up. Results In group A, the preoperative mean ± SD UCVA was 1.30 ± 0.28 (logMAR), whereas the postoperative mean UCVA was 0.90 ± 0.12. The preoperative mean BCVA was 0.70 ± 0.23, whereas the postoperative mean BCVA was 0.30 ± 0.17. The preoperative keratometric average ± SD was 53.27 ± 0.62 D, whereas the postoperative keratometric average was 45.83 ± 0.64 D. The postoperative astigmatic correction was 1.51 ± 0.42 D. In group B, the preoperative mean UCVA was 1.30 ± 0.33, whereas the postoperative mean UCVA was 1 ± 0.16. The preoperative mean BCVA was 0.90 ± 0.46, whereas the postoperative mean BCVA was 0.60 ± 0.32. The preoperative keratometric average was 50.97 ± 0.48, whereas the postoperative keratometric average was 49.01 ± 0.32. The postoperative astigmatic correction was 3.07 ± 0.15. Conclusion This study proved that combined CXL with Myoring implantation is effective in the correction of the myopic component of keratoconus. Combined CXL with Keraring implantation is effective in the correction of the astigmatic component in keratoconus. The type and the site of keratoconus cone together with the K readings can help in the preoperative decision of which type of ring is best in each keratoconus case. This study proved that there is a synergistic action when CXL is combined with intracorneal rings (Myoring or Keraring).
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Secondary Artisan iris-fixated intraocular lens implantation for correction of aphakia
Ahmed H Mohamed
February 2016, 17(1):9-13
DOI:10.4103/1110-9173.178761  
Purpose The aim of this study was to assess the visual and refractive outcome after Artisan lens secondary implantation for correction of aphakia and to report the incidence of complications. Patients and methods A total of 24 eyes of 24 patients rendered aphakic after complicated phacoemulsification and extracapsular cataract extraction were implanted with Artisan aphakia lens in Qena University Hospital. All patients underwent complete ophthalmic examination including uncorrected visual acuity, best-corrected visual acuity (BCVA), and manifest refraction both preoperatively and at 1 day, 1 week, 1 month, 2 months, and 6 months after surgery. Any intraoperative or postoperative complications were recorded. Results A total of 24 eyes of 24 patients were included, 16 of whom were men and eight were women. The mean follow-up was 7.2 ± 1.1 months (range = 6-9 months). The cause of aphakia was a complicated phacoemulsification (13 cases) and extracapsular cataract extraction (11 cases). At the final follow-up, the mean postoperative BCVA improved from 0.55 ± 0.19 preoperatively to 0.68 ± 0.20 postoperatively. Analysis of the final BCVA compared with that measured preoperatively demonstrated that 13 eyes (54%) improved, 12 eyes (50%) matched preoperative BCVA, and one eye (4%) decreased due to the occurrence of cystoid macular edema. The mean postoperative spherical equivalent was 1.00 ± 0.67 D, whereas it was 9.50 ± 1.7 D preoperatively. Of the 24 eyes, two developed high intraocular pressure in the early postoperative period. Conclusion Secondary implantation of Artisan iris-claw fixated lens is an effective and safe modality for correction of aphakia in eyes lacking sufficient capsular support.
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Micropulse laser for diabetic macular edema
Mahmoud A Abouhussein
October 2016, 17(3):167-171
DOI:10.4103/1110-9173.195258  
Aim The aim of this study was to evaluate the effects of subthreshold micropulse yellow 577-nm laser photocoagulation on eyes with diabetic macular edema (DME). Patients and methods In this prospective interventional case series, 20 eyes of 20 patients with previously treated centre involving DME received one single session of yellow micropulse 577-nm laser photocoagulation. Treatment was delivered using the IQ 577-nm laser system. Fixed treatment parameters were used in all cases: 200-µm spot size, 200-ms exposure duration, 400-mW powers, and a 5% duty cycle. Confluent applications with no spacing were administered over the entire edematous area including the fovea. Results The baseline best-corrected visual acuity was 0.42±0.15 logMAR, which improved to 0.3±0.26 logMAR at the final follow-up (P<0.043). The central subfield thickness was 354.3±32.96 μm at baseline and the final central subfield thickness was 310.7±52.62 μm (P<0.002). Conclusion Subthreshold micropulse yellow 577-nm laser photocoagulation is effective in treating DME.
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