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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 2020
Volume 27 | Issue 1
Page Nos. 1-67

Online since Wednesday, April 29, 2020

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EDITORIAL  

Keeping an eye on COVID-19: An ophthalmologist's perspective Highly accessed article p. 1
Abdullah S Al-Mujaini
DOI:10.4103/meajo.MEAJO_142_20  
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REVIEW ARTICLE Top

Updated systematic review and clinical spectrum of peripheral exudative hemorrhagic chorioretinopathy Highly accessed article p. 4
Abdulrahman H Badawi, Valmore A Semidey, Moustafa Magliyah, Hassan Al-Dhibi
DOI:10.4103/meajo.MEAJO_85_20  
Peripheral exudative hemorrhagic chorioretinopathy (PEHCR) is a rare retinal vasculopathy that might cause subretinal and/or vitreous hemorrhages. Although the primary etiology is still unknown, choroidal neovascularization is mainly involved in the pathogenesis. The main risk factors are age and systemic hypertension. Ancillary testing such as fluorescein angiography, indocyanine green angiography and ultrasonography can be of great value for diagnosing this entity and distinguishing PEHCR from other lesions as choroidal melanoma and retinal vasoproliferative tumor. Various treatments have been reported including photocoagulation, cryotherapy, intravitreal injection of anti-vascular endothelial growth factor (Anti-VEGF) and surgical intervention as pars plana vitrectomy. This review handles an up-to-date perspective regarding PEHCR.
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ORIGINAL ARTICLES Top

Comparison of intraocular pressure changes due to exposure to mobile phone electromagnetics radiations in normal and glaucoma eye p. 10
Saeed Shokoohi-Rad, Mohammad-Rez Ansari, Fatemeh Sabzi, Rahim Saffari, Parisa Rajaei, Farshid Karimi
DOI:10.4103/meajo.MEAJO_20_19  
PURPOSE: The aim of this study is to investigate the effects of electromagnetic waves (EMWs) emitted by a mobile phone on the intraocular pressure (IOP) in the eyeball. METHODS: This quasi-experimental study was conducted on 166 eyes from 83 individuals in the 40–70 age range who referred to “Khatam-al-Anbia Hospital, Mashhad, Iran” in 2016. There were two groups of participants, and the first one consisted of 41 participants who had normal eyes, whereas the second one comprised 42 participants who suffered from open-angle glaucoma disease. The IOP in both groups was measured and recorded by a specialist before and after talking 5 min on the cellphone with the help of the Goldman method. Statistical analysis such as paired t-test and analysis of variance was performed and all tests are statistically significant at (P < 0.05). For this purpose, the SPSS software (version 16) was applied. RESULTS: IOP in the glaucoma eye (42 eyes) ipsilateral to mobile phone before and after the intervention was 18.64 ± 6.7 and 23.53 ± 6.3, respectively (P < 0.001). However, IOP in the control group (41 eyes) ipsilateral to mobile phone before and after the intervention was 12.95 ± 3.5 and 13.39 ± 2.8, respectively (P = 0.063). IOP change in the opposite glaucomatous eye to mobile phone in glaucoma group (39 eyes) and normal group (44 eyes) was not significantly different before and after the phone call (P = 0.065 and P = 0.85, respectively). CONCLUSION: We found that the acute effects of EMWs emitted from the mobile phones can significantly increase the IOP in glaucoma eye, while such changes were not observed in normal eyes.
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Pilot audit of trichiasis surgery outcomes using a mobile app in the Republic of Chad p. 14
Dezoumbe Djore, Djada Djibrine, Abdelkerim Bouka Ali, Harba Tyau, Doniphan Hiron, Barka Kali, Jean-Eudes Biao, Jerôme Bernasconi, Karim Bengraïne, Serge Resnikoff
DOI:10.4103/meajo.MEAJO_75_19  
PURPOSE: The purpose of the study was to assess the feasibility of a mobile data collection app for use in trichiasis surgical audits in the Melfi and Mangalme districts of the Guera region of the Republic of Chad and to perform a cost analysis to determine if the auditing mechanism could be implemented nationally. MATERIALS AND METHODS: Patients who underwent trichiasis surgery 6 months prior and who had follow-up 7–14 days after surgery were included in the study. Each surgeon had a sample of 20% of operated eyelids; nine surgeons with data for ≥20 eyelids were included. A trichiasis recurrence rate of ≥25% suggested that the surgeon needed retraining. Smartphones captured data using the data collection app, which transmitted data to an online server. Direct costs and supervision costs were collated and summed. RESULTS: There were 916 eyelids operated on; 170 patients (269 eyelids, 29% follow-up rate) participated in the audit. Twenty participants (11.8%) had recurrence. The mean recurrence rate among surgeons was 8.3% (standard deviation: 0.07%; range: 0%–17.9%). None had a recurrence rate of ≥25%; thus, no retraining was necessary. The total cost of the audit was US$15,111.25 ($12,882.28 in direct costs and $2,228.97 in supervision costs). CONCLUSIONS: The simple, easy-to-use, and low-cost mobile auditing mechanism is a practical solution for conducting surgical audits in remote and resource-limited settings and is undergoing national scale-up by the Chadian trachoma elimination program.
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A comparison of lower eyelid retraction in normal individuals with positive versus negative orbital vector p. 22
Mohammad Taher Rajabi, Minoo Malmir, Raziyeh Mahmoudzadeh, Mirataollah Salabati, Seyed Ziaeddin Tabatabaie, Mohammad Bagher Rajabi, Seyedeh Simindokht Hosseini
DOI:10.4103/meajo.MEAJO_233_18  
PURPOSE: The present study aimed to compare lower eyelid retraction (LER) in individuals with a positive orbital vector with that of individuals with a negative orbital vector. MATERIALS AND METHODS: This cross-sectional study was conducted on 123 normal individuals including 64 men and 59 women aged 20–80 years. After the individuals underwent Hertel exophthalmometry, two side-view and front-view photos were taken using a camera. The orbital vector angle and the extent of scleral show were then measured in millimeter, using the Photoshop software. Eventually, the recorded data were analyzed through statistical software. RESULTS: The findings of this study showed that LER has a significant correlation with orbital vector angle and the extent of proptosis (P < 0.05). The mean value of orbital vector angle in individuals without LER was 9.76°, while this figure was calculated to be − 13.65° in individuals with LER. The mean protrusion value based on Hertel exophthalmometry was 14.08 mm in individuals without LER and 16.27 mm in individuals with LER. The extent of scleral show had a significant correlation with proptosis and orbital vector angle (P = 0.01), with a mean value of − 0.41 mm in individuals without LER and 0.94 mm in participants with LER. CONCLUSIONS: The prevalence of LER and scleral show is positively correlated with the extent of proptosis and negatively correlated with orbital vector angle.
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Ocular alterations associated with primary congenital heart disease – A cross-sectional study p. 28
Manuel A P. Vilela, Carina G Colossi, Henrique P Freitas, Giulia Del Valle, Lúcia C
DOI:10.4103/meajo.MEAJO_89_19  
OBJECTIVE: The objective of the study was to asses ocular findings' prevalence in children with primary congenital heart disease (CHD). PATIENTS AND METHODS: This is a prospective cross-sectional study of children with CHD treated at a specialized center in the South of Brazil between 2013 and 2015. They underwent a complete ocular examination, including measurement of visual acuity, refraction test, external motility, anterior and posterior biomicroscopy, and binocular indirect fundoscopy with retinal photographs. Two experienced examiners independently assessed fundus findings: one at the time of examination and image capture, while the other assessed only the captured images. RESULTS: Of a total of 146 children examined, 124 were included in this analysis (16% loss). Seventy children were male (55.5%). The average age was 9.3 years (minimum 1 month and maximum 15 years). Caucasians race were 81.2%, African Descendants race were 11.1%, and others were 7.7%. About 57.1% had already had heart surgery. About 14.8% had visual acuity below 0.6 and 2.8% below 0.1. Strabismus was found in 7.4% and cataracts in 1.7%. Retinal alterations were recognized in 13.5%, of which 4.8% were related to vascular narrowing or dilation and/or abnormal arteriovenous crossing; 7.14% were related to increased vascular tortuosity, while 1.6% were related to active toxoplasmic chorioretinitis lesions. Concomitant abnormalities in ocular motility, biomicroscopy, or ophthalmoscopy were detected in 24% of the cases. CONCLUSION: Children under the age of 15 years old with primary CHD have a high prevalence of ocular alterations, with external ocular and retinal manifestations, with higher occurrence rate among cyanotic cases. This leads us to strongly recommend the performance of a complete ophthalmological examination in such cases.
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Optic disc pit maculopathy – case series, clinical approach, and management p. 34
Dimitrios Kalogeropoulos, Soon Wai Ch'ng, Rynn Lee, Ibrahim Elaraoud, Vinaya Felicida, Maninee Purohit, Maggie Mathew, Naduviledeth Ajith-Kumar, Ash Sharma, Arijit Mitra
DOI:10.4103/meajo.MEAJO_181_19  
PURPOSE: The purpose of this study was to analyze the diagnostic and therapeutic approach of five cases with optic disc pit (ODP) maculopathy. MATERIALS AND METHODS: This was a retrospective study of five patients diagnosed with ODP maculopathy. Four of these cases had unilateral involvement, whereas one case had bilateral findings. The medical notes of these individuals were reviewed in order to record the presenting symptoms, clinical signs, visual acuity (VA), imaging, management, and the final visual outcome on their last follow-up appointment. RESULTS: The first patient (53-year-old female) underwent a left pars plana vitrectomy (PPV) combined with inner retinal fenestration, endolaser, and perfluoropropane (C3F8) gas tamponade and her VA improved from 6/24 to 6/9 Snellen. A focal retinal laser treatment was carried out on our second patient leading to decrease of the subretinal fluid but had a poor visual outcome due to the underlying secondary glaucoma from iris melanoma treatment in the past. The third patient was an asymptomatic 7-year-old girl in which the maculopathy resolved spontaneously without any surgical intervention with a final VA of 6/5. The fourth and fifth patients were asymptomatic with good vision in both eyes and were, therefore, only monitored with follow-ups. CONCLUSION: ODP maculopathy remains a challenging clinical entity for a vitreoretinal surgeon. The current management for ODP maculopathy involves surgical procedures with PPV being a common treatment of choice. Spontaneous resolution of ODP maculopathy has also been reported. Our study highlights the contrasting management that can be adopted in the treatment of ODP maculopathy, and there is not one definite treatment for this condition.
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Safety and efficacy of ahmed valve on intractable glaucoma in Saudi population p. 40
Essam A Osman, Norah F Alkheraiji, Mohammad A Abouammoh, Ahmed Mousa, Saleh Al-Obeidan
DOI:10.4103/meajo.MEAJO_249_19  
PURPOSE: The study aims to assess the efficacy and safety of Ahmed glaucoma valve implant in eyes with intractable glaucoma and to evaluate the risk factors for failure. METHODS: A retrospective evaluation of 83 patients (117 eyes) with intractable glaucoma who underwent silicone Ahmed glaucoma valve implant was done in a tertiary care center in Riyadh, Saudi Arabia, between January 2014 and December 2016. Complete success was defined as intraocular pressure (IOP) ≤21 mmHg without medication after a minimum follow-up of 6 months. RESULTS: Eighty-three patients (117 eyes) with intractable glaucoma were evaluated. After a mean follow-up duration of 20.8 ± 3.1 (12–24) months, the overall success rate was achieved in 104 eyes (88.9%). Thirty-six eyes (30.8%) had a complete success rate, whereas 68 eyes (58.1%) had a qualified success rate. Thirteen eyes (11.1%) failed to achieve controlled IOP. The postoperative probability to fail was found to be increasing with time from 0.9% (0.9) in the 1st month to 11.1% (9.9) after 1 year. Complications included a hypertensive phase in 25 eyes (21.4%), encapsulation in 10 eyes (8.5%), hyphema in 7 eyes (6%), hypotony in 2 eyes (1.7%), and blood clots in the implanted tube in 2 eyes (1.7%). The presence of hyphema, scleral patch, and coronary heart diseases was found to increase the risk of failure after Ahmed valve implantation (P = 0.006, 0.040, and 0.014, respectively). CONCLUSIONS: Ahmed glaucoma valve implant was safe and effective in treating cases of intractable glaucoma.
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Intraoperative evaluation of phacoemulsification cataract surgery with and without the use of ophthalmic viscosurgical devices p. 47
Rajesh Subhash Joshi, Sanoja Rangnath Naik
DOI:10.4103/meajo.MEAJO_140_19  
PURPOSE: The purpose of this study was to compare the efficacy and safety of cataract surgery by the phacoemulsification technique with and without the use of ophthalmic viscosurgical devices (OVDs). SETTING: This study was conducted at a tertiary eye care center in a rural area of Central India. DESIGN: This was a prospective, randomized, observational study. METHODS: In this study, 220 patients underwent phacoemulsification for cataract surgery with OVDs (OVD group) or without OVDs (BSS group) (n = 110 in each group). Patients with operable, nuclear Grade 2–4 cataracts were included in the study. The study was conducted from June 2017 to September 2018. The frequency of intraoperative complications, surgical time, and ease of the surgical procedure (easy, difficult, or very difficult) were recorded. RESULTS: There was no statistically significant difference in the nuclear opalescence, axial length, and intraocular lens (IOL) power between the two groups. Capsulorhexis extension was seen in two eyes in the OVD group and none of the eyes in the BSS group. The problems that occurred during IOL implantation included flip (OVD group, 2; BSS group, 1), haptic breakage (OVD group, 1; BSS group, 1), sulcus implantation (OVD group, 0; BSS group, 2), and stuck haptic (OVD group, 1; BSS group, 3). The total surgical time was almost equal in the two groups (OVD group, 9.2 min ± 3; BSS group, 9.5 min ± 3.5; P = 0.521). None of the patients had iris trauma or posterior capsular rupture. CONCLUSIONS: OVD-less phacoemulsification surgery is a safe and effective technique for treating age-related cataracts that requires no additional instrumentation and saves the cost of the OVD.
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BRIEF COMMUNICATION Top

Managing challenges of phacoemulsification in vitrectomized eyes: A new technique p. 53
Saleh A Al Amro
DOI:10.4103/meajo.MEAJO_257_19  
AIM: This study aimed to describe a novel approach to manage the challenges of phacoemulsification in vitrectomized eyes. METHODS: Intraoperative titrated intravitreal injection of balanced salt solution (BSS) through pars plana was done using a 30G needle hooked to a 1 cc syringe to build up the vitreous pressure. RESULTS: Five eyes of five patients who had previous vitrectomy were given intraoperative injection. This led to the prevention of lens–iris diaphragm retropulsion and routine completion of phacoemulsification. The preoperative visual acuity was < 6/60 in all patients. The postoperative visual acuity was 6/9 or better in all patients, except in one patient which was 6/60, which is explained by diabetic ischemic maculopathy. Neither injection-related intraoperative nor postoperative complications were noted. CONCLUSION: Challenges of phacoemulsification in vitrectomized eyes can be prevented by a simple titrated intraoperative injection of BSS intravitreally through pars plana.
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CASE REPORTS Top

Spontaneous resolution of foveal sub-internal limiting membrane hemorrhage with excellent visual and anatomical outcome in a patient with acute myeloid leukemia p. 56
Osama Saeed Alamri, Raed Eid Alsulami, Bader Saad Alqahtani, Abdullah Alqahtani
DOI:10.4103/meajo.MEAJO_32_20  
Sub-internal limiting membrane (sub-ILM) hemorrhage is a distinct type of retinal hemorrhage in which the blood accumulates between ILM and nerve fiber layer. Little is known about visual prognosis as well as ideal management of foveal sub-ILM hemorrhage in patients with acute leukemia. Herein, we presented a case of acute myeloid leukemia with foveal sub-ILM hemorrhage. Observation alone resulted in complete resolution of hemorrhage with good visual and anatomical outcome.
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Corneal thinning induced by self-administered alum substance: A case report and analysis of the active components p. 59
Huda Al-Ghadeer, Mohammed Al-Amry
DOI:10.4103/meajo.MEAJO_215_19  
We report a case of severe ocular injury and impaired vision after self-administration of alum. A 56-year-old female administered an alum substance in the left eye and experienced severe corneal thinning, a scar, and decreased vision. The active compounds in the alum substance were analyzed using scanning electron microscopy. When topically administered, alum may cause severe ocular injury. Public awareness, early recognition of the injuries, and timely intervention may prevent permanent ocular damage.
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An unusual case of solitary idiopathic pigmented vitreous cyst p. 62
Aditya Sethi, Parul Lokwani, Vaibhav Sethi, Sahebaan Sethi, Arun Sethi, Reena Sethi
DOI:10.4103/meajo.MEAJO_101_19  
Vitreous cysts are a rare finding and rarely cause any visual disturbances. They are often classified as idiopathic when their etiology cannot be determined. They may be congenital or acquired and pigmented or nonpigmented. In previous reports, it has been suggested on the basis of electron microscopy that these pigmented vitreous cysts may have originated from the pigment epithelium. We present the case of a 46-year-old female, with complaints of an oval-shaped floater, causing some visual disturbance in her right eye. On examination, it was found to be a pigmented, round, and nonlobulated cyst floating freely in the vitreous cavity with no attachments to the retina. This was documented and confirmed by the fundus images and optical coherence tomography findings. Laboratory tests in the patient were found to be negative for any Toxoplasma, cysticercoids, Echinococcus, and Toxocara, among others. She was on follow-up for the past 6 months with no change or disturbance in the cyst or the retinal findings. We describe a rare case of idiopathic pigmented vitreous cyst with no persistent hyaloid artery or connection between the cyst and the ocular structures.
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Frontal bone infarctions masquerading as bilateral orbital cellulitis in a patient with sickle cell disease p. 65
Abdulaziz I Al Somali, Halah S Bin Helayel, Saeed A Jubran, Jumana T Hariri, Hala M Nassim Ali
DOI:10.4103/meajo.MEAJO_264_18  
Repeated vaso-occlusive crises (VOCs) are the hallmark of sickle cell disease (SCD). These repeated crises can lead to bone infarcts, necrosis, and, over time, degenerative changes in the bone marrow. Orbital complications in SCD patients are infrequent and usually present as orbital cellulitis. We report the appearance of orbital bone infarction intraoperatively in the case of an 18-year-old Saudi male patient who has been diagnosed with SCD and presented with severe headaches and generalized body aches. He was admitted with a case of SCD with acute VOC and started on the hospital sickle cell protocol. During the admission, the patient developed bilateral periorbital swelling and left inferior dystopia secondary to bilateral frontoparietal bone infarction, which was evident on the magnetic resonance imaging.
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