Purpose The aim of this study was to evaluate the effect of adding ketorolac to peribulbar anesthesia versus conventional peribulbar anesthesia in cataract surgery. Patients and methods This is a prospective randomized comparative study that recruited patients with visually significant cataract and no other ocular or systemic conditions that may influence the ocular sensation. Patients were scheduled for phacoemulsification. They were randomly assigned into three groups. In the first group (GI), an anesthetic mixture of lignocaine, bupivacaine, hyaluronidase, and ketorolac was utilized. In the second group (GII), a mixture of lignocaine, bupivacaine, and hyaluronidase was used, whereas in the third group (GIII), a mixture of lignocaine, bupivacaine, and ketorolac was used. The onset of globe anesthesia and akinesia and the duration of globe akinesia were recorded. In addition, intraoperative pain and postoperative pain experienced by the participants were assessed using the numerical rating scale after patient instructions. Results The study included 114 patients. The onset of globe anesthesia was significantly faster in GI (6.5±1.3 min) compared with GII and GIII (8.1±1.5 and 8.8±1.9 min, respectively, P<0.0001). A significantly faster onset of globe akinesia was recorded in GI (9.5±1.4 min) and GII (9.6±1.4 min) compared with GIII (11.2±1.8 min) (P<0.0001). Concerning globe akinesia, there was no significant difference among the study groups (P=0.191). In addition, no significant difference was reported among the study groups regarding pain scores throughout the procedure. Conclusion Ketorolac was an effective adjuvant to peribulbar block. It effectively shortened the onset of globe anesthesia, with no significant effect on globe akinesia.

Aim The aim of this study was to determine the efficacy and safety of topical cyclosporine A (CsA) in treatment of moderate-to-severe dry eye. Setting and design This is a prospective randomized comparative clinical study that was carried out at Alexandria Main University Hospital, Alexandria, Egypt. Patients and methods The study included 80 eyes of 40 patients with moderate-to-severe dry eye. Patients were divided into two groups: group I received topical CsA 0.05%, and group II were controls. Patients were assessed at weeks 1, 4, and 12 during and after the treatment phase for changes from the baseline using Schirmer’s test, tear break-up time (TBUT), fluorescein staining, and Ocular Surface Disease Index (OSDI). Results There were greater improvements in group I than in group II in Schirmer’s test results (P=0.002), TBUT (P=0.001), and OSDI scores (P=0.009) at week 4. At week 12 posttreatment phase, the improvement in group I kept on more slowly toward stability for Schirmer’s test (P=0.004) and TBUT (P=0.002), whereas the improvement in fluorescein staining and OSDI scores was not significant (P=0.706 and 0.065, respectively). Conclusion CsA ophthalmic oily solution 0.05% was demonstrated to be effective. It decreased the manifestations of dry-eye disease. Additionally, its effect continued to occur significantly within the treatment periods and the improvement of the ocular condition kept on, actually, more slowly toward stability, although the drug was already discontinued.

Purpose The purpose of this study was to detect single or multiple best-performing parameters of corneal tomography and dynamic corneal biomechanics with high sensitivity and specificity in the diagnosis of keratoconus, subclinical keratoconus (SCKC), and forme fruste keratoconus (FFKC). Design This was a prospective observational study. Patients and methods In this study, one eye of each of 40 participants was included. They were divided into four groups: keratoconus, SCKC, FFKC, and a normal control group, with 10 participants in each group. All participants underwent a full ophthalmologic examination, analysis of corneal tomography using Pentacam HR and analysis of corneal biomechanical response using the Corvis ST at the initial visit and after 3 months. Results For the diagnosis of keratoconus, the 100% sensitive and specific parameters were Belin/Ambrósio Enhanced Ectasia Display (BAD d), Ambrósio’s relational thickness maximum (ARTmax), and tomographic biomechanical index (TBI) with cutoff values of 1.905, 344, and 0.785, respectively. For detection of SCKC, the 100% sensitive parameters were maximum keratometry and thickness profile index with cutoff values of 44.7 and 0.945, respectively. After 3 months of follow-up, maximum keratometry, index of surface variance, deflection amplitude, and deflection area showed 100% sensitivity with specificities of 90, 80, 70, and 60%, respectively. The highest percentage of change over time was for the index of highest decentration by 200%, followed by TBI by 133%. For FFKC, the deformation amplitude and corneal velocity 1 showed sensitivity of 90 and 80%, respectively, and specificity of 83 and 90%, respectively. After follow-up BAD d, deformation amplitude, deformation amplitude ratio, and TBI showed 100% sensitivity and specificity. Conclusion This study illustrated the efficacy of Corvis parameters for the diagnosis of keratoconus, but with lower discriminative ability than corneal tomography. It could also be used as a supplementary tool for the diagnosis and follow-up of SCKC and FFKC patients.

Purpose The aim of this study was to analyze the effectiveness, predictability, and aberrometric changes of implanted intracorneal ring segments (ICRSs) with sequential cross-linking (CXL) in keratoconus patients during a 24-month follow-up period. Patients and methods This is a prospective cohort study that was carried out on 21 eyes of 17 keratoconus patients. ICRS were implanted in these eyes during the period from 2013 to 2017. Mechanical dissection of the lamellar pockets was the technique used. This was followed by CXL 6 weeks later. Patients were followed up to assess refraction, topography, and aberrometry at 6, 12, and 24 months postoperatively. Aberrometry used coefficient settings in the NIDEK OPD-Scan for more sensitivity. The main outcome measures included uncorrected visual acuity, best-corrected visual acuity, refraction, keratometric values, total root mean square at the 3 mm zone, coma order (7), coma order (8), and trefoil order (6) of high-order aberrations. Results There was a statistically significant improvement in uncorrected visual acuity and best-corrected visual acuity, with a significant reduction in the refractive error and the mean keratometry values (P<0.001). In addition, there was a statistically significant improvement in total root mean square, 6-Trefoil, 7-Coma, and 8-Coma coefficients (P<0.001) only at the sixth postoperative month. Coma 7 progressively improved till 24 months. The mean keratometry values showed a small, insignificant regression at the 12-month follow-up, but stabilized at the 24th month postoperatively. Conclusions ICRS, followed by CXL was an effective method for improving and stabilizing visual, keratometric, and aberrometric values in keratoconus.

Purpose The aim of this study was to assess the safety profile and efficacy of a new implantable phakic contact lens (IPCL V2.0) in patients with a high degree of myopia. Patients and methods This is a prospective study that was carried out to evaluate the surgical outcome of IPCL V2 implantation in 46 eyes of 32 patients with a high degree of myopia. The refractive results, visual acuity (LogMar values), endothelial cell count of the cornea and intraocular pressure were evaluated at baseline and at 1, 6, and 12 months postsurgery. Any complications either during or after surgery were assessed. Results A significant improvement in the uncorrected distance visual acuity was achieved. It improved from 1.2±0.21 at baseline to 0.36±0.20 at 12 months postoperatively (P=0.002). The index of efficacy [uncorrected distance visual acuity at 12 months postoperatively/corrected distance visual acuity (CDVA) at baseline) was 1.1 and the safety index (CDVA at 12 months/CDVA at baseline] was 1.5. The mean spherical equivalent at baseline was −13.8±4.1 diopters (D) and improved to −0.6±0.7 D at 12 months postoperatively (P<0.003). The average endothelial cell count was 2479±173 cells/mm² preoperatively and decreased to 2399±156 cells/mm² at 12 months postoperatively, which was a statistically insignificant change (P=0.14). The mean preoperative intraocular pressure was 14.7±2.6 mmHg and mmHg at 12 months postoperatively, it was 14.9±2.5 mmHg, a statistically nonsignificant change (P=0.14). No cases of cataract were noticed during the follow-up period. Conclusion The IPCL V2.0 implantation to correct high myopia showed a stable visual outcome and safety profile. Moreover, it provided a more economical alternative to correct high myopia. Long-term studies are required to further assess the efficacy and outcome of this lens.

Purpose The aim of this study was to compare the changes in pupillary size, postoperative inflammation, and macular thickness in patients who were subjected to phacoemulsification and received different topical and intracameral NSAIDs. Patients and methods This was a prospective randomized study that recruited 284 patients with visually significant cataract for whom uneventful phacoemulsification with intraocular lens implantation was performed. Candidates were randomly assigned to receive preoperative topical nepafenac, topical ketorolac, intraoperative intracameral ketorolac, or no NSAIDs. Results Topical nepafenac, topical ketorolac, and intracameral ketorolac had significantly maintained less intraoperative pupil size fluctuation than the placebo group (P=0.033, 0.001, and 0.048, respectively). In addition, topical nepafenac-treated, topical ketorolac-treated, and intracameral ketorolac-treated groups had less postoperative anterior chamber cells than the placebo group at 1 day (P=0.019, 0.421, and 0.515, respectively) and at 1 week, postoperatively (P=0.037, 0.089, and 0.298, respectively). However, at 1 month postoperatively, all study groups had similar minimal anterior chamber reaction with an insignificant difference (P=0.237, 0.379, and 0.342, respectively). Retinal thickness increased in all study groups 1 month after cataract surgery. However, topical and intracameral ketorolac groups had significantly less central macular thickness change as compared with the placebo (P=0.009 and 0.004, respectively). Conclusion The use of topical or intracameral NSAIDs yielded less intraoperative fluctuation in pupil size and lower postoperative inflammation than the placebo group. The topical nepafenac group had less postoperative inflammation, whereas the ketorolac-treated patients had the least changes in retinal thickness.

Aim The aim of this study was to report the epidemiology, clinical characteristics, causes, management, and outcome of neovascular glaucoma (NVG) in a tertiary facility in Egypt (Glaucoma Care Clinic at Cairo University Hospitals). Patients and methods The demographic and clinical data of 251 eyes diagnosed with NVG were retrospectively studied. The antiglaucoma medications and interventions used for management were reviewed with analysis of the outcome in the form of success rate, final visual acuity (VA) and intraocular pressure (IOP). Complete success was defined as an IOP between 6 and 21 mm Hg without topical or systemic glaucoma medications with preservation of presenting VA. Results NVG was diagnosed in 7.9% of all glaucoma patients in our clinic. The prevalence was more in men (58.8%), and the mean age was 56.5±11 years. Diabetic retinopathy was the most common cause for NVG (61.4%), followed by central retinal vein occlusion (21.4%). The presenting VA was light perception (LP) or less in 45% of the eyes. Diode laser cyclophotocoagulation was the most common treatment modality used (57%), followed by antiglaucoma medications only in 28% and finally surgery in 15% of the patients. Complete success in the diode group was achieved in 73.43% of the cases compared with 68.42% in the surgery group, with no statistically significant difference (P=0.522). The effect of an intravitreal injection of antivascular endothelial growth factor on the final IOP was significant (P=0.024). Conclusions NVG has a high prevalence in our glaucoma patients. The patients presented very late, with nearly half of the patients having VA of LP or less. This led to decreased resort to surgical intervention. Diode laser cyclophotocoagulation was the main treatment modality used, with significant control of the IOP.

Background Diabetic retinopathy (DR) represents the leading cause of blindness in working-age people. It affects about one in every three diabetic patients. This visual loss can be prevented by early detection and proper management. Purpose The aim of this study was to assess the ability of optical coherence tomography angiography (OCTA) to detect subclinical changes in parafoveal capillaries in diabetic patients without DR. Patients and methods This prospective case–control study was conducted upon 50 participants who were divided into two groups: group A (25 diabetic patients without clinical manifestation of DR) and group B (25 healthy control participants of matched age and sex with group A). The two groups were compared regarding the parameters of the foveal avascular zone (FAZ) area, perimeter, and FD (flow density of retinal capillaries within 300 µm surrounding the FAZ) in addition to the parafoveal vessel density of superficial and deep capillary plexuses (SCP and DCP) on macular scans (3×3 mm) centered on the fovea by OCTA. Results There were statistically significant differences in FAZ area, perimeter, and FD together with parafoveal vessel density of SCP and DCP between healthy controls and diabetic patients without DR. The mean FAZ area of the healthy control group B was 0.27±0.08 mm² compared with 0.32±0.11 mm² in the diabetic group A (P=0.01). In addition, the FAZ perimeter was significantly increased (P=0.003) in the diabetic patients without DR (2.39±0.56 mm) compared with the control (2.11±31 mm). Statistically significant decreases of vessel density in the FD-300, SCP, and DCP were observed in diabetic patients without DR compared with controls (all P<0.001). Regarding the FD-300, the mean value in the control group was 49.98±2.67%, whereas in the diabetic group it was 48.11±0.58%. The mean VD of the SCP in the healthy control group B was 47.62±2.58% compared with 44.32±3.01% in the diabetic group. The mean VD of the DCP in the healthy control group B was 56.13±2.23% versus 50.21±2.56% in the diabetic group. Conclusion OCTA is an effective tool in the early detection of microvascular changes of diabetic patients with no clinical manifestations of DR. Vessel density and FAZ metrics were proven to be early biomarkers for DR before becoming clinically evident.

Aim This is a prospective comparative study of the macular morphology and visual outcome after epiretinal membrane (ERM) removal with and without internal limiting membrane (ILM) peeling in cases of idiopathic ERM. The study was carried out in the Research Institute of Ophthalmology, Giza, Egypt from February 2015 to February 2017. Patients and methods A total of 40 eyes of 40 patients with visually significant idiopathic ERM were included in the study. A standard three-port 23-gauge pars plana vitrectomy (PPV) was conducted in all patients. Twenty eyes (Group A) were subjected to ERM removal only, while ILM peeling with ERM removal was performed in the other 20 eyes (Group B). Central macular thickness (CMT) and foveal contour on optical coherence tomography (OCT) in addition to best-corrected visual acuity (BCVA) were obtained at baseline and at 1, 3, 6 and 12months postoperatively. Results The mean BCVA significantly improved in both groups, with no statistically significant difference between the two groups at 12 months postoperatively (P=0.053). The mean preoperative and postoperative BCVA were 0.19 and 0.50 decimal units, respectively, in group A, while in group B, the mean preoperative and postoperative BCVA were 0.13 and 0.44 decimal units, respectively. Despite a statistically significant more reduction of CMT in group A compared with group B at 1 month postoperatively (324.80 and 403.95 µm, respectively, P=0.01), no statistically significant difference was found between the two groups at 12 months postoperatively (277.40 and 306.20 µm, respectively). Normal foveal contour was achieved in 13 (65%) and 6 (30%) eyes in groups A and B, respectively. Conclusion Anatomical and functional improvements could be achieved in both groups, with no statistically significant difference at 12 months postoperatively. Adding ILM peeling to idiopathic ERM removal did not appear to improve the outcome in this cohort. Therefore, ILM should not be routinely peeled as safety remains controversial.

Purpose The aim of this study was to determine the prevalence and types of color vision deficiency (CVD) among primary school students in Alexandria, Egypt. Setting This study was carried out at three primary schools in Alexandria, Egypt. Patients and methods This cross-sectional study was carried out among three primary school students in Alexandria, Egypt. Ocular examination including visual acuity and color vision testing with Ishihara plates (38-plate edition) was performed for all the students included. Further assessment using the Farnsworth–Munsell 100-hue test was performed for students who failed the Ishihara plates test. Results A total of 1000 (495 males and 505 females) school students were screened for CVD. The mean age of the students was 9±2.16 years. The overall prevalence of CVD was 1.9%, with a prevalence of 2.8 and 0.9% in males and females, respectively, a statistically significant difference (P=0.04). Among the CVD students, 36.8% had deuteranopia, 31.5% had deuteranomaly, 26.3% had protanopia, and 5.3% had tritanopia. Conclusion The prevalence of CVD was 1.9%, with a male predominance, among primary school students in Alexandria. Deutan color vision defects were the most prevalent.

Aim The aim of this study was to report the experience of performing bilateral levator disinsertion followed by bilateral frontalis sling among patients having unilateral Marcus-Gunn jaw winking and ptosis (MGJWP). Setting and design This is a retrospective study that was conducted at Elsafwa Eye Centre, Alexandria, Egypt. Patients and methods The medical records of 24 patients with significant unilateral MGJWP were retrospectively reviewed. Full ophthalmological examination included external eye examination, extraocular muscle motility testing, best-corrected visual acuity, margin reflex distance (MRD) in mm, levator muscle excursion in mm, and amount of jaw winking in mm. All patients in the study had significant winking phenomenon. Bilateral levator disinsertion followed by bilateral frontalis sling was performed. Postoperatively, the patients were examined for MRD in both eyelids, amount of wink, degree of lagophthalmos, eyelid contour, patient satisfaction, and presence of complications or undercorrection. Results More than 2 mm of winking was considered cosmetically unacceptable to the patient and/or the parents. Postoperative follow-up periods ranged from 6 to 52 months, with an average of 16.9 months. After bilateral levator myotomy and bilateral frontalis advancement flap, 22 eyelids (91.66%) showed complete resolution of jaw winking and 2 eyelids (8.33%) showed mild winking (2 mm or less). Surgery was redone in two patients (8.33%) for undercorrected ptosis after 6 months of follow-up, whereas two patients (8.33%) had contour problem in the operated ptotic eyelid. All patients had immediate postoperative lagophthalmos that totally resolved in all patients after 6-month follow-up. Conclusion Bilateral levator muscle disinsertion followed by bilateral frontalis suspension using frontalis muscle advancement flap is an effective surgical technique for the treatment of unilateral MGJWP, resulting in satisfactory symmetrical outcome and resolution of jaw winking and ptosis in most of the cases.

Aim The aim of this study was to evaluate the efficacy of buccal mucous membrane graft-assisted-dacryocystorhinostomy (DCR) for the treatment of refractory acquired nasolacrimal duct (NLD) obstruction. Patients and methods This is a prospective, interventional case series study that included 10 patients with acquired NLD obstruction (12 eyes), associated with expected poor mucosal flaps (either due to previous failed DCR or atrophic rhinitis). In nine eyes failed previous DCR procedures were reported, while three eyes had associated atrophic rhinitis evidenced by nasal examination. Two patients had bilateral obstruction. All eyes had symptomatic epiphora. All eyes were treated with modified DCR using a buccal mucous membrane graft. The outcome was assessed in terms of relief of epiphora, patency of irrigation testing, and patency of the osteotomy site assessed by rhinoscopy at the third postoperative month, in addition to the duration of the procedure and the postoperative complications. Results After a minimum follow-up period of 6 months, in 11 (91.7%) out of the 12 eyes with epiphora, there was complete relief of tearing. Lacrimal passages were patent to irrigation testing postoperatively. One case with late advanced atrophic rhinitis showed recurrence of tearing after silicone tube removal. No complications to the donor graft site or surgical site were observed. Conclusion Buccal mucous membrane grafting-assisted DCR (at the level of the flaps) is a safe and effective technique for the treatment of cases of refractory acquired NLD obstruction.