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  Citation statistics : Table of Contents
   2014| July-September  | Volume 107 | Issue 3  
    Online since December 30, 2014

 
 
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ORIGINAL ARTICLES
Corneal indentation versus anterior chamber paracentesis as an adjuvant to medical treatment in controlling acute primary angle-closure glaucoma
Lamia S Elewa, Yasser A Elzankaloni, Hazem Elkholefy
July-September 2014, 107(3):142-147
DOI:10.4103/2090-0686.148114  
Purpose The aim of this study is to evaluate the therapeutic efficiency of the noninvasive corneal indentation (CI) procedure versus anterior chamber paracentesis (ACP) as an adjuvant to classic medical treatment in patients with acute primary angle-closure glaucoma (PACG). Design This was a prospective, interventional, comparative study. Place Ain-Shams university hospitals and Elmaghrabi eye institutes. Patients and methods We included 30 eyes of 30 patients who had an attack of acute PACG and presented to us within the first 24 h. All patients received mannitol infusion (20%, 300 ml) as the first line of treatment. CI using Posner gonioprism was applied in 10 eyes (group I), ACP was performed in 10 eyes (group II), and 10 patients received only medical treatment (group III). The severity of pain, intraocular pressure (IOP), best-corrected visual acuity, corneal edema, and pupil size were assessed at multiple time points. The waiting time for laser peripheral iridotomy (LPI) was recorded. All patients were followed up for a minimum of 6 weeks. Results Pain relief was achieved rapidly in group II, where IOP reduction was 31% (IOP was 22 ± 11.5 mmHg) and 64% (IOP was 19 ± 7.6 mmHg) at 30 min and 2 h of follow-up, respectively. The grade of corneal edema in group II was 0.8 ± 1.3 and 0.5 ± 0.5 at 30 min and 2 h, respectively, which was significantly lower compared with both group I and III (P < 0.005). This facilitated early LPI (6 ± 2 h) in group II. However, in terms of IOP and best-corrected visual acuity, all the groups showed the same results at 12 h. Conclusion CI is a noninvasive and easy adjuvant method of reducing elevated IOP in the setting of PACG; improves corneal clarity and enables LPI. ACP restores corneal clarity faster and would be the choice for selected patients for whom medical therapy is restricted. Medical therapy alone shows a delay in controlling acute PACG and is rather exhausting for the patient.
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Comparison of epithelium-off and transepithelial corneal collagen cross-linking for treatment of keratoconus
Mohammed I Hafez
July-September 2014, 107(3):181-186
DOI:10.4103/2090-0686.148163  
Purpose The aim of the study was to assess the safety and efficacy of epithelium-off corneal cross-linking (conventional cross-linking) versus epithelium-on cross-linking (epithelium-on cross-linking) in the treatment of keratoconus. Patients and Methods This study was a nonrandomized comparative trial. Forty-three eyes of 35 patients were included in this study. All eyes were subjected to the preoperative and postoperative measures including uncorrected visual acuity (UCVA) and best corrected visual acuity (BCVA), pachymetry, simulated keratometry, and corneal topography. The preoperative and postoperative data were analyzed at baseline and at 3, 6, and 12 months in all eyes. The epithelium-off cross-linking group (the CXL group) included 25 eyes of 20 patients, whereas the epithelium-on cross-linking group (the transepithelial CXL group) included 18 eyes of 15 patients. The thinnest corneal thickness was at least 400 μm in all eyes. Results In the epithelium-off CXL group, there was a remarkable improvement regarding postoperative UCVA and BCVA (one line or more). Average K showed a marked reduction reaching more than 2 diopters. The mean astigmatism showed unremarkable changes. The main central corneal thickness showed very marked corneal thinning with reduction in the corneal thickness reaching more than 50 um in many cases. In the epithelium-on CXL group, there was unremarkable improvement regarding postoperative UCVA and BCVA. Average K showed almost no changes during the 12-month follow-up period. The mean astigmatism showed minimal changes. In addition, the main central corneal thickness showed considerable corneal thinning with reduction in the corneal thickness reaching up to 30 μm. Conclusion This study has proved that epithelium-on CXL is superior to epithelium-off CXL regarding pain, complications, and early patient convalescence. However, epithelium-off CXL is superior to epithelium-on CXL regarding the efficacy in visual stabilization and improvement. In short, this study concluded that conventional epithelium-off CXL is better than epithelium-on CXL.
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Evaluation of the therapeutic effect of corneal collagen cross-linking in the treatment of resistant corneal ulcer
Mohammed I Hafez
July-September 2014, 107(3):187-190
DOI:10.4103/2090-0686.148168  
Purpose The aim of this study was to evaluate the therapeutic results of corneal collagen cross-linking (CXL) in terms of safety and efficacy in the treatment of resistant corneal ulcer. Design This study was designed as a noncomparative prospective clinical trial. Patients and methods Five eyes of five patients with resistant corneal ulcers that failed to heal after maximal topical treatment underwent CXL using UVA rays and transepithelial riboflavin. Preoperative and postoperative evaluation included slit-lamp examination of the cornea, corneal pachymetry, and visual acuity. Postoperative outcome included the degree of improvement of epithelization, relief of pain, disappearance of the corneal stromal edema, and improvement in visual acuity. Exclusion criteria were corneal thickness less than 400 μm, topical treatment less than 1 month, and impending corneal perforation or melting. Results Three eyes of the five eyes showed improvement in re-epithelization up to complete healing of the ulcer and development of corneal opacification with relief of ciliary injection, photophobia, pain, foreign body sensation, and lacrimation. Also, there was an improvement in corneal edema, but visual acuity showed no remarkable improvement. Most of these results were observed within 14 days after CXL. The remaining two eyes showed similar results, but after more than 1 month of CXL. Conclusion This study proved that CXL is a beneficial therapeutic procedure for healing of resistant corneal ulcers. Also, CXL seems to be a safe and effective method for healing of resistant corneal ulcers. Further studies on a large proportion of patients with a longer follow-up period are recommended.
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Nonincisional (threading) levator plication in mild and moderate blepharoptosis: a novel technique
Mohsen S Badawy, Osama M El Nahrawy, Ahmed A Abdelghany, Heba M Khalaf
July-September 2014, 107(3):191-199
DOI:10.4103/2090-0686.148171  
Purpose The aim of this study was to evaluate our technique of nonincisional (threading) levator plication operation in cases of mild to moderate blepharoptosis. Setting Ophthalmology Department, Suez Canal University Hospital, Ismailia, Egypt. Design This study was interventional in design. Patients and methods We perform nylon threading 7/0 through the skin using a guiding syringe needle gauge no. 21 and the superior levator palpebral muscle and Mόller's muscle are tucked in by sutures guided to the tarsus surface; then, threads are tightened till the lid margin is elevated to the correct level, and the thread is knotted and inserted under the skin and orbicularis muscle. A total of 21 eyelids of 18 patients were subjected to this procedure. Results A total of 18 patients (12 male and six female, mean age 40 years) were studied. Nineteen eyelids were normally corrected or within 0.5 mm of normal, yielding a success rate of 90.5%. One (4.8%) patient was elevated within 1 mm of normal, and it was accepted. One (4.8%) eyelid was undercorrected and it wasn't accepted. An excellent lid contour was noted in all cases, except one, in whom a slight irregularity of the lid margin was observed, which was corrected spontaneously within 1 month. Conclusion The nonincisional (threading) levator plication technique is a safe and effective surgery for the treatment of mild to moderate blepharoptosis. It has a high success rate and good cosmetic outcome.
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A study comparing ranibizumab monotherapy versus ranibizumab plus dexamethasone combination therapy for treatment of diffuse diabetic macular edema
Ahmed M Abdel Hadi
July-September 2014, 107(3):200-204
DOI:10.4103/2090-0686.148174  
Purpose The aim of the study was to evaluate the hypothesis that combination therapy of intravitreal ranibizumab and dexamethasone would be more effective than ranibizumab monotherapy in patients with diffuse diabetic macular edema (DME). Patients and methods The study included 24 eyes of 24 patients with center-involved DME. The study included eyes with central foveal thickness greater than 300 μm on cross-hair protocol, diffuse macular thickening of greater than two disc-areas on slit-lamp biomicroscopy. Eligible study participants in this prospective, nonrandomized, comparative, interventional case series were divided into two groups. The first group was chosen to receive 0.5 mg/0.05 ml ranibizumab, whereas the other group was chosen to receive 0.4 mg/0.1 ml intravitreal dexamethasone (IVD) and 0.5 mg/0.05 ml ranibizumab. Exclusion criteria included: (a) eyes with previous treatments (such as focal laser therapy, vitrectomy, and intravitreal injection of triamcinolone or antivascular endothelial growth factor injections) beyond a 6-month period; (b) evidence of proliferative diabetic retinopathy on fundus fluorescein angiography or clinical examination; (c) any evidence of macular ischemia on fundus fluorescein angiography; (d) presence of a taut posterior hyaloid, vitreomacular traction or epiretinal membrane on optical coherence tomography (OCT); and (e) presence of subfoveal hard exudates. All patients were followed up for 6 weeks postinjection; changes of retinal thickness, visual acuity, and intraocular pressure were evaluated. Results Twelve eyes of 12 patients were treated with ranibizumab (group 1), and 12 eyes of another 12 patients were treated with IVD + ranibizumab (group 2). In group 1, the postinjection central macular thickness showed a statistically significant improvement from a baseline of 500.1 ± 40.1 to 456.7 ± 28.4 μm (reduction of 43.4 μm, P < 0.001) at 6 weeks. Similarly, the postinjection best-corrected visual acuity (BCVA) showed a trend toward improvement from a baseline of 0.17 to 0.22 at 6 weeks. In group 2, the postinjection central macular thickness showed a statistically significant improvement from a baseline of 508.4 ± 36.4 to 468.1 ± 33.1 μm (reduction of 40.3 μm, P < 0.001) at 6 weeks. Similarly, the postinjection BCVA showed a trend toward improvement from a baseline of 0.17 to 0.21 at 6 weeks. The difference in postinjection intraocular pressure, BCVA, and central macular thickness between the two groups at 6 weeks was not statistically significant. Conclusion A single injection of intravitreal ranibizumab (IVR) demonstrated similar efficacy compared with IVD + ranibizumab in terms of OCT macular thickness reduction in selected cases of diffuse DME after 6-week follow-up.
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Role of triamcinolone acetonide in the treatment of secondary macular edema
Tamer H El-Sersy
July-September 2014, 107(3):148-152
DOI:10.4103/2090-0686.148118  
Aim of the work The aim of the work is to evaluate the efficacy of an intravitreal injection of triamcinolone acetonide in cases with secondary macular edema. Patients and methods A total of 24 eyes with secondary macular edema were included in this study. Patients were classified into three groups. Group A included 10 patients with macular edema secondary to nonproliferative diabetic retinopathy, group B included eight patients with macular edema secondary to branch vein occlusion, and group C included six patients with macular edema secondary to central retinal vein occlusion. Further classification of the three groups was performed according to the nature of macular edema, whether perfused or ischemic. All groups received a single intravitreal injection dose of 4 mg of triamcinolone acetonide. Ophthalmological assessments performed were best-corrected visual acuity, intraocular pressure measurement using applanation tonometry, and fundus biomicroscopy. Also, optical coherence tomography and fundus fluorescein angiography were performed to evaluate the progression of macular edema. All examinations and investigations were performed regularly during follow-up visits. All data were analyzed and recorded. Results There was significantly greater improvement in macular edema in group B than in groups A and C. Perfused macular edema showed better results than ischemic edema in the three groups. Conclusion An intravitreal injection of triamcinolone acetonide seems to be an effective and harmless treatment for macular edema, especially following branch vein occlusion.
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Comparison between the Scheimpflug camera and the topographic modeling system in the corneal assessment before refractive surgery
Mohamed M. A. Lolah, Ahmed A El Massry
July-September 2014, 107(3):153-159
DOI:10.4103/2090-0686.148123  
Purpose To compare corneal measurements by a Scheimpflug camera and a topographic modeling system (TMS 5) in patients seeking refractive surgery. Design Prospective comparative study between two instruments. Setting RoayaLasik Center, Alexandria, Egypt. Patients and methods This study included 30 eyes of patients seeking refractive surgery, selected randomly, between 18 and 35 years old without any history of corneal surgery. An informed consent was obtained from all patients before participation in the study. All the eyes were assessed by the Scheimpflug camera (WaveLight ALLERGO Oculyzer) and the TMS 5. The corneal measurements of the two assessments were compared. Results The mean central corneal thickness (CCT) measurements by the Scheimpflug camera and the TMS 5 were 549.3 ± 28.8 and 537.3 ± 26.6 μm, respectively, with a statistically significant difference between the two devices (P < 0.001). There was a statistically significant difference between their mean keratometric readings (P < 0.001). Astigmatism and the anterior maximum elevation mean readings showed no statistically significant difference between the two devices, although the difference between posterior maximum elevation mean readings in the two devices was statistically significant (P < 0.001). Conclusion CCT readings of the TMS 5 were thinner than the CCT readings of the Scheimpflug system. The keratometric readings were higher in the TMS 5. No statistically significant differences were found in astigmatism or maximum anterior elevations readings between the two devices, whereas there was a statistically significant difference in the maximum posterior elevations readings between the two devices.
  - 1,363 133
Effects of an autostable bicanaliculus intubation stent in the management of acquired punctal stenosis
Mohamed Y Farag, Dikran Hovaghimian, Olfat A Hassanin, Ahmed Ismail
July-September 2014, 107(3):160-165
DOI:10.4103/2090-0686.148128  
Objectives To study the success rate of an autostable bicanaliculus intubation stent in the management of acquired punctal stenosis. Patients and methods Twenty-one eyes of 12 patients who underwent stent implantation using disposable sizers, from December 2012 till March 2013, were studied. In all patients, the superior and inferior puncti, with a 1 mm calibrated dilator supplied with the stent, was performed carefully to prevent damage to the ampulla; before the insertion of the stent, it was necessary to verify the absence of canalicular obstruction by probing and patency of the nasolacrimal duct by irrigation. An initial clinical examination indicated that tearing was not ocular in nature. For the management of acquired punctal stenosis and punctal obstruction, patients were evaluated retrospectively in terms of sex and age, the duration and severity of epiphora, associated blepharitis or trachoma, and the success of treatment. Stents were removed 2 months after insertion. Results Twenty-one eyes had punctal stenosis, causing epiphora. The mean age of the patients was 55 (±20) years. The mean interval between the onset of epiphora and stent implantation was 18.4 (±12.7) months. Associated chronic blepharitis was detected in four eyes and trachoma complication in three eyes. The patients were examined on the first day postoperatively, and at 1 week, 1 month, and 2 months. Success was achieved in 19 eyes (90%). We encountered four cases of minor conjunctival irritation that was resolved in 1 week and two cases of diminished palpebral fissure; in one case, we replaced the stent. Spontaneous stent loss was noted in five eyes between the 1-week and the 2-month follow-up. One patient had residual epiphora. Conclusion Autostable bicanaliculus intubation stent implantation is very effective for the treatment of acquired punctal stenosis and obstruction. However, careful punctum dilation should be performed and patients should be provided with proper instructions to wear protective eyeglasses following the procedure to decrease spontaneous stent extrusion.
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Comparative study between DALK using the big-bubble technique and penetrating keratoplasty in corneal stromal opacities
Amr S Abdel Hakeem, Tarek A Katamish, Dalia H Abdel Raouf, Hoda A Abdel Monem
July-September 2014, 107(3):166-172
DOI:10.4103/2090-0686.148133  
Objectives To compare between deep anterior lamellar keratoplasty (DALK) using the big-bubble technique and penetrating keratoplasty (PK) in terms of visual and refractive outcomes, endothelial cell density (ECD), and contrast sensitivity in patients with corneal stromal opacities. Design A prospective interventional comparative study was carried out from April 2011 to August 2012. The follow-up duration was 12 months postoperatively. Patients and methods Thirty eyes of 30 patients presenting to the outpatient clinic in Kasr El Aini Hospital, Cairo University who fulfilled the inclusion criteria were studied. The inclusion criteria were as follows: best-corrected visual acuity (BCVA) less than 6/36, with an intact endothelium/descemet membrane complex by ultrasound biomicroscopy. The exclusion criteria were as follows: full-thickness corneal pathology involving the descemet membrane, endothelial dysfunction, intraocular pathology, ectatic corneal conditions, previous intraocular surgeries, lid abnormalities, active keratitis, or dry eye. They were divided into two groups: group A included 15 patients in whom the big-bubble technique was used successfully and group B included 15 patients operated upon by PK. Postoperative follow-up was carried out with group masking in terms of the following: BCVA, refraction, ECD contrast sensitivity using the Functional Acuity Contrast test, contrast sensitivity chart, intraocular pressure, and ultrasound biomicroscopy assessment of graft thickness. Results All patients completed the 12-month follow-up. The significance level was set at P-value less than or equal to 0.05. ECD showed a greater decrease in the PK group, with the mean ECD attained at 3 months in the DALK group compared with the PK group reaching a statistically significant level at the end of the 12 months (P = 0.001). The mean refractive astigmatism and the mean number of days needed for the cornea to clear were significantly less (P = 0.035 and 0.001 respectively) in the big-bubble DALK group. In terms of BCVA, the final mean graft thickness, postoperative contrast sensitivity, and intraocular pressure, there was no significant difference between both groups (P > 0.05). Conclusion The big-bubble technique is superior to PK in terms of ECD, mean refractive astigmatism, and early corneal clarity.
  - 1,252 118
Outcomes of intravitreal bevacizumab injection versus conventional laser as first-line treatment in stage III retinopathy of prematurity
Abeer M. S. Khattab, Magda A Torky
July-September 2014, 107(3):173-180
DOI:10.4103/2090-0686.148135  
Purpose The aim of the study was to evaluate the outcomes of intravitreal bevacizumab (IVB) monotherapy compared with conventional laser therapy in preterm infants with stage III and plus disease retinopathy of prematurity (ROP) who had zone I or II posterior disease. Patients and methods This was a prospective randomized comparative interventional pilot study. Twenty-four eyes of 12 preterm infants suffering from ROP were included. All eyes had bilateral stage III ROP with 'plus disease' affecting zone I or zone II posterior. Infants were assigned to receive conventional laser therapy in their right eyes and IVB in their left eyes. Follow-up period was 6 months following treatment. Results The study included five female infants and seven male infants. The gestational ages ranged from 26 to 33 weeks (mean 29 weeks), and the birth weights ranged from 750 to 1390 g (mean 1005 g). The postmenstrual age at which threshold ROP was detected ranged between 34 and 41 weeks (mean 36.75 weeks). All 24 eyes had stage III ROP with plus disease; 10 eyes had zone I, whereas the other 14 eyes had zone II posterior. Regression of neovascularization occurred in all 24 eyes following both treatment modalities and remained stable during follow-up. No local or systemic side effects of bevacizumab were observed, and no further treatment was necessary. Conclusion IVB injection seems to be as effective as conventional laser in treating stage III ROP. It provides the advantages of preservation of peripheral visual field and complete peripheral retinal vascularization.
  - 1,158 125
Double bicanalicular silicone intubation versus single intubation with mitomycin C in conjunction with canaliculo-dacryocystorhinostomy for the management of common and distal canalicular obstruction
Mohamed F Khalil, Sahar T Abdelrazik
July-September 2014, 107(3):136-141
DOI:10.4103/2090-0686.148110  
Introduction Canalicular obstruction is one of the most difficult lacrimal conditions to treat and conjunctivo-dacryocystorhinostomy with a Jones tube is the standard treatment with a high rate of anatomic success, but with a relatively high rate of complications. Canaliculo-dacryocystorhinostomy (canaliculo-DCR) was performed for the management of distal and common canalicular obstruction, and the results depend on the distance of obstruction from the lacrimal sac; restenosis of the canaliculus around the silicone tube is the most common reason for the failure of canaliculo-DCR. Objective The aim of this study was to examine the effect of two separate adjunctive methods used in conjunction with canaliculo-DCR: the use of double intubation of the canaliculi and the use of single intubation plus administration of intraoperative mitomycin C 0.2 mg/ml in cases with membranous and fibrous obstruction of the common and distal canaliculi. Design This prospective nonrandomized comparative interventional case-series study was carried out in the Ophthalmology Department, Minia University Hospital, in the period from March 2009 to December 2011. Patients and methods One hundred and twenty-eight eyes of 109 patients were studied. All cases had distal or common canalicular obstruction with at least 8 mm of patent proximal canaliculi. Canaliculo-DCR operations were carried out. After intraoperative identification of the type of obstruction, membranous or fibrous, we divided the patients into four groups: group 1 included 23 patients with membranous obstruction who received double silicone tubes, group 2 included 23 patients with membranous obstruction who received a single tube plus intraoperative mitomycin C, group 3 included 41 patients with fibrous obstruction who received double silicone tubes, and group 4 included 41 patients with fibrous obstruction who received a single tube plus intraoperative mitomycin C. Silicone tubes were removed after 6 months and patients were followed up monthly for at least another 6 months with evaluation of the patency of the lacrimal passages subjectively and objectively. Results After a mean follow-up of 18.90 months, 79.7% of the patients showed successful results. Membranous groups (group 1 and 2) had an 86.9% success rate, which is higher than that of patients in fibrous groups (75.6%). Patients in group 1 had a lower success rate (82.6%) than patients in group 2 (91.3), but patients in group 3 had a higher success rate (80.5%) than patients in group 4 (70.7%); however, these differences were not statistically significant (P = 0.6 and 0.4, respectively). Patients who received double silicone tubes (group 1and 3) had a success rate of 81.2%, whereas only 78.1% of the patients who received a single tube plus mitomycin C (group 2 and 4) achieved successful results Conclusion Mitomycin C with single intubation is better than double intubation in case of membranous obstruction of the common canaliculus, whereas double intubation is superior to mitomycin C with single intubation in case of fibrous obstruction of the distal and common canaliculus.
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