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Middle East African Journal of Ophthalmology Middle East African Journal of Ophthalmology
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   Table of Contents - Current issue
Coverpage
January-March 2019
Volume 26 | Issue 1
Page Nos. 1-53

Online since Wednesday, April 24, 2019

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EDITORIAL  

A note from the Editor p. 1
Hassan A Al-Dhibi
DOI:10.4103/meajo.MEAJO_108_19  
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ORIGINAL ARTICLES Top

Assessment of macular pigment optical density using fundus reflectometry in diabetic patients p. 2
Mary Varghese, Joel Antony
DOI:10.4103/meajo.MEAJO_248_17  
PURPOSE: Diabetic retinopathy (DR) is a major cause of visual disability and may be associated with reduction in macular pigment (MP) density and insufficient data are available. We present MP optical density (MPOD) measured by fundus reflectometry in eyes with and without early and moderate DR. SUBJECTS AND METHODS: This was a cross-sectional study conducted in the year 2014–2015. Participants were divided into three groups: the normal individuals without diabetes constituted Group I, while diabetic patients without DR and the patients with mild-to-moderate DR constituted Group II and Group III, respectively. MPOD and maximum optical density (Max OD) were measured using a Visucam 500 fundus camera (Carl Zeiss Meditec AG, Jena, Germany). RESULTS: Fifty diabetic patients without DR, 50 with mild and moderate DR, and 50 healthy individuals underwent MPOD and Max OD measurements. The mean pigment density was the same in all the three groups (0.12). HbA1c levels were inversely correlated with MPOD (P = 0.01) and Max OD (P = 0.002). There was no relationship between MP density and age (P = 0.66), gender (P = 0.24), or duration of diabetes (P = 0.85). The duration of diabetes was compared between the two groups of diabetic patients with and without DR. CONCLUSIONS: The mean pigment density assessed by fundus reflectometry was 0.12 in each of the three groups studied. Higher HbA1c levels in diabetic patients correlated with decreased MPOD and Max OD. Better glycemic control may influence macular health in diabetic patients.
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Retinopathy of prematurity among syrian refugees: Incidence and severity Highly accessed article p. 7
Pehmen Yasin Ozcan
DOI:10.4103/meajo.MEAJO_50_18  
PURPOSE: The aim of this study is to compare the incidence and severity of retinopathy of prematurity (ROP) in premature newborns of Syrian refugees and those of Turkish origin. METHODS: This retrospective, the single-center study included 1545 premature infants assigned to two groups based on maternal origin. Group 1 comprised 1366 premature infants of Turkish origin, and Group II comprised 179 premature infants born to Syrian refugees. All the premature infants were screened for ROP by the same ophthalmologist who is experienced in the screening and treatment of ROP. All data including gestational age (GA), birth weight (BW), the presence of ROP, and severe ROP collected from 2014 to 2017 were recorded for each group. The outcomes were compared between the two groups. RESULTS: The mean GA at birth was 30.6 ± 2 weeks and was significantly lower in Group II (P = 0.03). The overall incidence of ROP was similar in both groups. The incidence of severe ROP in Group II was nearly seven times higher than in Group I (1.5% and 10%, respectively). The incidence of severe ROP seen in Group II evaluated according to different ranges of GA and BW was higher than in Group I. CONCLUSION: The higher incidence of severe ROP in the premature newborns of Syrian refugees could play an important role in identifying ongoing health problems of refugees.
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The outcome of corneal collagen cross-linking in patients with advanced progressive keratoconus: A 2-year follow-up study p. 11
Reza Soltani Moghadam, Mitra Akbari, Yousef Alizadeh, Abdolreza Medghalchi, Reza Dalvandi
DOI:10.4103/meajo.MEAJO_101_18  
PURPOSE: The aim of this study was to evaluate the safety and efficacy of collagen cross-linking (CXL) in advanced progressive keratoconus with a maximum keratometry (Kmax) value of more than 58 diopters (D). METHODS: This prospective interventional case series involved patients with advanced progressive keratoconus with a Kmax of more than 58 D. The best-corrected visual acuity (BCVA), uncorrected visual acuity (UCVA), Kmax, mean keratometry (Kmean) value, corneal astigmatism, and thinnest corneal thickness before surgery and 24 months after CXL were determined for 30 eyes of 27 patients. A Pentacam was used to measure the paraclinical parameters. RESULTS: The mean age of the patients was 24.47 ± 3.33 years. The mean logarithm of the minimum angle of resolution (logMAR) of the uncorrected visual acuity UCVA decreased from 0.73 ± 0.36 D at baseline to 0.48 ± 0.30 D (P = 0.01), while the mean thinnest point thickness of the cornea decreased from 438.65 ± 40.11 μm to 431.43 ± 61.92 μm (P = 0.005) after 24 months. The decreases in the mean logMAR of the BCVA, Kmax and Kmean values, and corneal astigmatism were not statistically significant (P > 0.05) at the 24-month follow-up. Progression was halted in 29 eyes (96.6%); only 1 eye (3.3%) showed an increase in the Kmax value of more than 2.0 D, which was indicative of treatment failure. In contrast, most other eyes showed a decrease in the Kmax value although it was not statistically significant. There were no major complications in any of the patients during the study period. CONCLUSION: Standard CXL treatment was safe and stabilized both the visual acuity and tomographic parameters at the 2-year follow-up in eyes with advanced progressive keratoconus.
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Improved refractive outcomes of small-incision extracapsular cataract surgery after implementation of a biometry training course p. 17
Jay J Meyer, Hans R Vellara, Riyaz Bhikoo, Lucilla Ah-Ching Sefo, Salome Lolokabaira, Neil L Murray, Charles N J McGhee
DOI:10.4103/meajo.MEAJO_3_18  
PURPOSE: To determine whether a biometry training course could improve refractive outcomes of patients undergoing manual small-incision extracapsular cataract surgery (SICS). MATERIALS AND METHODS: This was a prospective, interventional, cohort study at the Pacific Eye Institute, Fiji. SICS refractive outcomes were evaluated before and after a structured biometry teaching course. Eyes that underwent evaluation and subsequent SICS with placement of a posterior chamber intraocular lens (IOL) were included. Axial length measurements were obtained using A-scan applanation ultrasound and keratometry with a handheld keratometer. Main outcome measures included mean absolute prediction error of IOL calculations, percentage of eyes within ±0.5 D and ±1.0 D of intended spherical equivalent, and proportion of eyes with ≥6/18 uncorrected visual acuity. RESULTS: A total of 240 eyes were analyzed: 120 eyes before and 120 eyes after the structured biometry training. The mean absolute prediction error was 50% lower following the training (1.13 ± 0.84 D pre vs. 0.56 ± 0.44 D post; P < 0.001). A higher percentage of the eyes had a postoperative spherical equivalent within ±0.5 D (26.7% pre vs. 52.5% post; P < 0.001) and ±1.0 D (55.0% pre vs. 90.0% post; P < 0.001) of the intended target. A higher proportion of the eyes achieved ≥6/18 uncorrected visual acuity (77.5% pre vs. 91.7% post, P = 0.004), while the proportion with ≥6/18 corrected visual acuity was similar (94.4% pre vs. 98.3% post; P = 0.28). CONCLUSIONS: A structured biometry training course may improve the accuracy of preoperative IOL calculations to achieve the postoperative refractive target. Ophthalmology training programs should include structured biometry teaching in their curricula.
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Ocular surface microbial flora in patients with chronic limbal stem cell deficiency undergoing cultivated oral mucosal epithelial transplantation p. 23
Srilathaa Gunasekaran, Rebika Dhiman, Murugesan Vanathi, Sujatha Mohanty, Gita Satpathy, Radhika Tandon
DOI:10.4103/meajo.MEAJO_172_16  
PURPOSE: The purpose of this study is to analyze the ocular surface microbial flora in patients with chronic limbal stem cell deficiency (LSCD) due to Stevens–Johnson Syndrome (SJS) and ocular chemical injury undergoing cultivated oral mucosal epithelial transplantation (COMET). METHODS: Patients of SJS and chemical injury who had bilateral total LSCD planned for COMET were studied. Conjunctival swab was taken before surgery. Parameters evaluated were organism cultured, sensitivity pattern, frequency of positive culture, and clinical impact on management strategy. RESULTS: Thirteen patients were included in which nine were males and four females. All patients had positive conjunctival swab culture. Most common organism isolated was Staphylococcus epidermidis, followed by Staphylococcus aureus and Pseudomonas aeruginosa. The staphylococcal species isolated were sensitive to all the conventional antibiotics while Pseudomonas cultured showed resistance to cefuroxime, ceftriaxone, and ceftazidime. Repeat conjunctival swab sent after a week of topical antibiotic therapy yielded positive culture of the same organism twice in 25% (3/12), thrice in 58.3% (7/12), and four times in 16.6% (2/12) of the patients. One patient had a polymicrobial flora with positive yield of S. aureus (thrice), S. epidermidis (twice), and P. aeruginosa (twice) in consecutive conjunctival swab culture in the absence of clinical infection. Two patients with persistent positive cultures had to undergo repeat oral mucosal harvesting as the transplantation of the cultivated explants had to be deferred. CONCLUSION: Ocular surface in LSCD patients yielded pathogenic organisms on culture. Poor ocular surface with absent tear film could be the contributing factors. It is important to perform the conjunctival swab culture before COMET surgery.
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Prevalence and determinants of dry eye disease among 40 years and older population of Riyadh (Except Capital), Saudi Arabia p. 27
Ziaul Haq Yasir, Deepti Chauhan, Rajiv Khandekar, Ches Souru, Sejo Varghese
DOI:10.4103/meajo.MEAJO_194_18  
PURPOSE: The prevalence and determinants of dry eye disease (DED) among 40 years and older population of Riyadh (except capital), Saudi Arabia. SUBJECTS AND METHODS: A population-based survey was conducted in Riyadh district between 2013 and 2017. All Saudi aged >40 years attended at the Primary Health Center were the study population. McCarty Symptom Questionnaire was adopted. A representative sample was examined. The best-corrected visual acuity and anterior and posterior segment assessment were performed. DED was graded as absent, mild, moderate, and severe. RESULTS: We examined 890 participants. The age- and sex-adjusted prevalence of DED was 45.1% (95% confidence interval [CI] = 44.8–45.4). One-third of the participants had DED. However, two-third of DED cases were of mild grade. The prevalence of DED among females was significantly higher. The variation of DED by age group was not statistically significant (χ2 = 2.6, Degree of freedom = 3, and P = 0.1). Presence of glaucoma was significantly associated to DED (odds ratio [OR] = 2.6, [95% CI = 1.2–5.6], and P = 0.01). Use of topical glaucoma medication was significantly associated to DED (OR = 4.6 [95% CI = 1.8–11.8], and P = 0.001). However, severity of DED was not found to be associated with glaucoma medication (χ2 = 2.6, P = 0.1). Associations of diabetes and hypertension to DED were not statistically significant (OR = 0.97 [95% CI = 0.73–1.3], and P = 0.84) (OR = 1.1 [95% CI = 0.8–1.4], and P = 0.6). The severe visual impairment was not associated to the grade of DED (P = 0.55). CONCLUSION: The prevalence of DED among Saudi is high, but severe DED is found to be less. Association with female gender, glaucoma, and topical glaucoma medications was reported. Association with diabetes, hypertension, and age group variation was not significant.
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BRIEF COMMUNICATION Top

Fibrin glue-assisted intraocular lens fixation in weill–Marchesani syndrome p. 33
Charudutt Kalamkar, Nishant V Radke, Amrita Mukherjee, Snehal N Radke
DOI:10.4103/meajo.MEAJO_162_16  
PURPOSE: To report visual and intraocular pressure (IOP) outcomes of 4 eyes in 2 patients with Weill Marchesani Syndrome having ocular fearures of spherophakia and secondary glaucoma who underwent fibrin glue assisted intrascleral fixation of intraocular lens (IOL). METHODS: Detailed anterior and posterior segment evaluation assessing best corrected visual acuity (BCVA), IOP, central corneal thickness was done in all. Lensectomy, vitrectomy with glued Intrascleral fixation of 3 piece intraocular lens was done. Post operative BCVA and IOP were assessed. RESULTS: Visual acuity and IOP control improved post-operatively. CONCLUSIONS: Glued IOL implantation is an effective method to visually rehabilitate and control glaucoma in patients with Weill Marchesani Syndrome.
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CASE REPORTS Top

Marcus gunn jaw-winking syndrome associated with morning glory disc anomaly p. 37
Abdulaziz A Alshamrani, Fahad A Alghulaydhawi, Mohammed Al Shamrani
DOI:10.4103/meajo.MEAJO_279_18  
Marcus Gunn jaw-winking syndrome (MGJWS) is a rare form of congenital blepharoptosis and one of the congenital cranial dysinnervation disorders (CCDD). In addition, morning glory disc anomaly (MGDA) is a congenital optic disc anomaly of unknown etiology. The present report is the first to describe an association between MGJWS and MGDA in an otherwise healthy 7-year-old boy. He also had counting finger vision, anisometropia, esotropia, and monocular elevation deficiency in the same eye. In the literature, both MGJWS and MGDA have been reported to be associated with Duane retraction syndrome, a form of CCDD.
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Corneal toxicity after self-application of Calotropis procera (Ushaar) Latex: Case report and analysis of the active components p. 40
Huda Al Ghadeer, Ahmad Al Gethami, Hamad Al Sulaiman, Thamer Bukhari
DOI:10.4103/meajo.MEAJO_180_18  
Calotropis procera (ushaar) produces a copious amount of latex, which has both inflammatory and anti-inflammatory pharmacological properties. Local application produces an intense inflammatory response and causes significant ocular morbidity. We report corneal toxicity following self-application of latex from C. procera in a 74-year-old man. He reported painless decreased vision in the affected eye with diffuse corneal edema, and specular microscopy revealed a reduced endothelial cell count. After he was treated with topical corticosteroids, his visual acuity improved from hand motion to 20/80. The composition of the active compounds in the latex was analyzed. When topically administered, the latex may cause severe ocular injuries and a loss of endothelial cells over a period of time. Public education, early recognition of such injuries, and timely intervention may prevent permanent ocular damage.
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Inverted flap technique for large macular hole secondary to chronic uveitis p. 43
Parveen Sen, Haard Shah, Amala George
DOI:10.4103/meajo.MEAJO_271_16  
Macular hole is a defect in the neurosensory retina at the center of the fovea, seen in 8.3% of the postuveitic cases. In such cases, macular holes tend to be large and are associated with structural damage in the outer retinal layers. Here, we report a case of bilateral chronic intermediate uveitis treated with sub-Tenon steroids that developed a full-thickness macular hole in the right eye. We treated it surgically with inverted flap technique of internal limiting membrane peeling. Postoperatively, the patient showed Type-1 closure of the hole with visual improvement.
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Iris crystals: A rare clinical finding in chronic anterior uveitis p. 46
Padmamalini Mahendradas, Sujay Chauhan, Ankush Kawali, Somshekar Nagappa, Rohit Shetty
DOI:10.4103/meajo.MEAJO_227_16  
Iris crystals are a rare clinical entity seen in cases of chronic anterior uveitis (CAU). We report one such case with crystal deposition on iris as well as corneal endothelium and anterior lens capsule. No significant change in the crystals was seen over a period of 11 years despite multiple episodes of exacerbation and resolution. Anterior segment optical coherence tomography (AS-OCT) showed crystals as hyperreflective deposits over the corneal endothelium. On confocal microscopy, the crystals were seen as ill-defined hyperreflective lesions on endothelium between 525 and 604 μm. Reduction in the number of crystals was seen after cataract surgery. In conclusion, AS-OCT and confocal microscopy can be used as additional diagnostic tools to analyze iris crystals in CAU.
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Combined parafoveal telangiectasia, multifocal central serous chorioretinopathy, and choroidal hemangioma p. 49
CK Nagesha, Pratyusha Ganne
DOI:10.4103/meajo.MEAJO_92_18  
The exact pathogenesis of parafoveal telangiectasia (PFT) is unknown, but various associations have been reported in literature such as diabetes and hypertension. Coexisting pathologies like diabetic retinopathy with PFT are not uncommon. We encountered a unique combination of PFT with multifocal central serous chorioretinopathy and choroidal hemangioma in a patient with diabetes mellitus. Multimodal imaging confirmed the findings and focal treatment to central serous chorioretinopathy leaks led to resolution of the subretinal fluid. This unique combination has been rarely reported so far. The long-term follow-up of such cases can help us to understand if there exists common pathogenesis of these varied diseases.
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LETTERS TO EDITOR Top

Botryoid rhabdomyosarcoma of the conjunctiva in a young boy p. 52
Mahmood Dhahir Al-Mendalawi
DOI:10.4103/meajo.MEAJO_184_18  
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Authors' Reply p. 53
Justin D Pennington, R Joel Welch, Sara E Lally, Jerry A Shields, Ralph C Eagle, Carol L Shields
DOI:10.4103/meajo.MEAJO_294_18  
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