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Middle East African Journal of Ophthalmology Middle East African Journal of Ophthalmology
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   2009| January-March  | Volume 16 | Issue 1  
    Online since March 24, 2009

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The SCHWIND AMARIS total-tech laser as an all-rounder in refractive surgery
Maria Clara Arbelaez, Samuel Arba Mosquera
January-March 2009, 16(1):46-53
DOI:10.4103/0974-9233.48868  PMID:20142960
Purpose: To describe and argument an overview of the main features and unique technical points of AMARIS Total-Tech Laser, coupled with patient outcomes supporting the decision to perform LASIK treatments with maximised outcomes. Settings: Dr. M.C. Arbelaez, Muscat Eye Laser Center, Muscat, Sultanate of Oman. Methods: The findings collected during 18-month experience using SCHWIND AMARIS Total-Tech Laser have been reviewed to provide arguments for supporting the decision to perform LASIK treatments with maximised outcomes. For updated clinical outcomes, the last 100 myopic astigmatism treatments, the last 100 hyperopic astigmatism treatments, the last 30 ocular-wavefront-guided treatments, and the last 30 corneal-wavefront-guided treatments, all with 6-month follow-up, were included. For all those, LDV femtosecond system was used to prepare the flaps, and AMARIS flying spot system was used to perform ablations. Clinical outcomes were evaluated in terms of predictability, refractive outcome, safety, wavefront aberration, and contrast sensitivity. Results: 6-month postoperatively, mean defocus was -0.14±0.31D and astigmatism 0.25±0.37D. 70% eyes were within ±0.25D of emmetropia. 43% eyes gained lines of best spectacle-corrected visual acuity. For Aberration-Free treatments, none of the aberration metrics changed from pre- to postoperative values in a clinically relevant amount. For ocular-wavefront-guided treatments, the surgery did not change coma or spherical aberration, and reduced trefoil (p<0.005). For corneal-wavefront-guided treatments, the trefoil, coma, and spherical aberrations, as well as the total root-mean-square values of higher order aberration, were significantly reduced (p<.05) when the pre-existing aberrations were greater than the repeatability and the biological noise. Conclusions: Although this review does not allow for evidence-based conclusions, following our strategy, LASIK results were excellent. LASIK surgery with AMARIS system yield excellent outcomes. Refractions were reduced to subclinical values with no induction of High-Order-Aberrations. Neither adverse events nor complications were observed.
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Microbial keratitis in Kingdom of Bahrain: Clinical and microbiology study
Nada Al-Yousuf
January-March 2009, 16(1):3-7
DOI:10.4103/0974-9233.48855  PMID:20142952
Background: Microbial keratitis is a potentially vision threatening condition worldwide . Knowing the predisposing factors and etiologic microorganism can help control and prevent this problem. This is the first study of its kind in Kingdom of Bahrain. Objective: To study the profile of microbial keratitis in Bahrain with special focus on risk factors, clinical outcome and microbilogical results. Methods: A retrospective analysis of all patients admitted in Salmaniya Medical Complex over a period of three years from January 2005 to January 2007 was performed. A total of 285 patients with keratitis were analysed. Non infectious corneal ulceration were excluded. Data collected from medical records were demographic features, predisposing factors, history of corneal trauma, associated ocular conditions, visual acuity at the time of presentation and the clinical course. Predisposing risk factors measured were contact lens use, presence of blepharitis, diabetes, lid abnormalities, dry eyes, keratoplasty and refractive surgery. For contact lens wearers any contact lens related risk factors that can lead to keratitis were measured . Pearson's chi-square test was used to carry out statistical analysis wherever required. Results: Contact lens wear, as a risk factor for microbial keratitis, formed 40% of the total study population. Other risk factors identified were dry eyes 24 cases (8%), 10 blepharitis (3%), 22 trauma (8%), abnormal lid position 14 cases (5%). 6 patients keratitis in a graft (2%), 3 had refractive surgery (1%). The most common causative organism isolated was pseudomonas aeroginosa (54%) followed by streptococcus 12%, staph 10%, other organisms 6%. 95% of contact lens wearers had pseudomonas Aeroginosa. This was statistically significant (p< 0.0001). The vast majority, 92% healed with scarring. 1% needed therapeutic keratoplasty and 7% lost to follow up. Risk factors in contact lens wearers were; 41 patients (36%) slept with the contact lenses.12 (8%) had contact lens related trauma and 8 (7%) had poor hygiene. Sleeping with the contact lenses was statistically significant (p<0.0001). Conclusion & Recommendation: Contact lens wear is the major risk factor for microbial keratitis in Bahrain. Pseudomonas aeroginosa was the commonest bacteria isolated. Sleeping with the contact lenses is the major risk factor among contact lens wearers. Majority of keratitis patients resulted in permanent scarring on the cornea. Educating the public, especially on contact lens care and precaution, can help reduce this visual morbidity.
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Directed therapy: An approach to the improved treatment of exfoliation syndrome
Allison Angelilli, Robert Ritch
January-March 2009, 16(1):35-40
DOI:10.4103/0974-9233.48866  PMID:20142958
Exfoliation syndrome (XFS) is an age-related, generalized disorder of the extracellular matrix characterized by the production and progressive accumulation of a fibrillar extracellular material in many ocular tissues and is the most common identifiable cause of open-angle glaucoma worldwide. Exfoliation syndrome plays an etiologic role in open-angle glaucoma, angle-closure glaucoma, cataract, and retinal vein occlusion. It is accompanied by an increase in serious complications at the time of cataract extraction, such as zonular dialysis, capsular rupture, and vitreous loss. It is associated systemically with an increasing number of vascular disorders, hearing loss, and Alzheimer's disease. Exfoliation syndrome appears to be a disease of elastic tissue microfibrils. Directed therapy simply means devising specific treatments for specific diseases. There was little incentive to attempt to distinguish between various open-angle glaucomas if the treatments were essentially the same. However, this view also prevented the application of directed therapy in those instances in which such was available and applicable. Pilocarpine has multiple beneficial actions in eyes with XFS. Not only does it lower IOP, but by increasing aqueous outflow, it should enable the trabecular meshwork to clear more rapidly, and by limiting pupillary movement, should slow the progression of the disease. Theoretically, miotics should be the first line of treatment. Pilocarpine 2% q.h.s. can provide sufficient limitation of pupillary mobility without causing these side effects. In 2007, two common single nucleotide polymorphisms in the coding region of the lysyl oxidase-like 1 ( LOXL1 ) gene located on chromosome 15 were specifically associated with XFS and XFG. LOXL1 is a member of the lysyl oxidase family of enzymes, which are essential for the formation, stabilization, maintenance, and remodelling of elastic fibers and prevent age-related loss of elasticity of tissues. LOXL1 protein is a major component of exfoliation deposits and appears to play a role in its accumulation and in concomitant elastotic processes in intra- and extraocular tissues of XFS patients. This discovery should open the way to new approaches and directions of therapy for this protean disorder.
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Neovascular glaucoma at King Khaled Eye Specialist Hospital - etiologic considerations
Hanan N Al-Shamsi, David K Dueker, Sawsan R Nowilaty, Sami A Al-Shahwan
January-March 2009, 16(1):15-19
DOI:10.4103/0974-9233.48860  PMID:20142954
Background: Neovascular glaucoma (NVG) is a severe form of secondary glaucoma caused by the growth of new vessels over the trabecular meshwork. The principal causes are associated with retinal ischemia. Ablative treatment of the retina can prevent, halt, and even reverse the growth of new vessels on the iris and angle. It is an essential part of the management in most cases. Aims: To determine the causes of NVG among Saudi patients, presented at the King Khaled Eye Specialist Hospital. Methods: A retrospective review of 337 Saudi patients with NVG was obtained. All cases were reviewed for the evidence and causes of the disease, and their basic demographic information. A subset of 100 diabetic patients with PDR was further studied in greater detail for clinical findings and treatment history. Results: The most common primary etiologic associations for NVG included diabetic retinopathy (DR) (56.06%), retinal venous obstruction (26.40%), and chronic retinal detachment (03.56%). A history of diabetes mellitus was reported in 65.04%, systemic arterial hypertension was noted in 61.00%, and evidence of renal impairment was documented in 22.00%. Vision was markedly reduced in most eyes with NVG (median: hand motion). The median best visual acuity in the fellow eye was 20/160. Among the 100 cases, with DR as a cause of NVG, 43 patients had bilateral neovascularization of the iris (NVI) and 72 had bilateral PDR. Sixty-one patients had no previous laser treatment before the diagnosis of NVG. Among these, who received treatment, the median number of total laser spots was 1,003. Conclusions: Diabetes is a major cause of NVG presented to this tertiary eye care center in the Kingdom of Saudi Arabia followed by retinal venous obstruction. Close monitoring and full pan-retinal photocoagulation (PRP) were absent in most of the diabetic cases. It is important to recognize that the "unaffected" fellow eye, particularly in diabetic patients, may require fairly urgent treatment as well.
  5,515 496 2
Neuro-ophthalmic afferent system diagnoses a general ophthalmologist should (almost) never make alone
Andrew G Lee
January-March 2009, 16(1):41-45
DOI:10.4103/0974-9233.48867  PMID:20142959
The general ophthalmologist might be called upon to make the diagnosis of neuro-ophthlamic conditions which are either rare or require extensive testing to exclude alternative diagnoses. This paper reviews some common afferent system neuro-ophthlamologic diagnoses that the general ophthalmologist should rarely if ever make alone.These include posterior ischemic optic neuropathy, chronic optic neuritis, retinal migraine, and optic atrophy. Although these diagnoses do exist they are typically diagnoses of exclusion that require neuroimaging and ancillary testing and have no diagnostic test to confirm the diagnosis.
  4,960 424 2
Low vision Aids provision for visually impaired Egyptian patients - a clinical outcome
Sherin Shaaban, Ahmad Rashid El-Lakkany, Ashraf Swelam, Ghada Anwar
January-March 2009, 16(1):29-34
DOI:10.4103/0974-9233.48865  PMID:20142957
Purpose: To evaluate a low vision rehabilitation service implemented for heterogeneously diverse group of Egyptianpatients with vision loss in terms of improving their visual performance and fulfilling their visual needs. Methods: Fifty patients with low vision were included in a prospective study. History taking, ophthalmic examinationand evaluation of the visual functions were performed for all patients. The required magnification was calculated, andsubsequently a low vision aid was chosen after counseling with patients. Low vision aids were tried in office, followedby a period of training before patients received their own low vision aids. Follow up was done for 6 months. Results: All patients who were referred to the low vision unit were not satisfied with their current spectacles or lowvision aids. After training and prescription of suitable LVAs, the improvement in distance and near visual acuity wasstatistically significant (p<0.001). Fifty-six per cent of the patients (n=28) showed improvement in distance visualacuity of 5 lines or more, and 57% of the patients (n=27) could discern N8 print size or better. The most commonlyused aids were high powered near adds. Despite the complaints about the appearance and use of LVAs, 76% of thepatients reported being moderately to highly-satisfied with their aids. Conclusions: The significant improvement in the visual performance of patients with low vision after the prescriptionand training on the use of LVAs, associated with patients' satisfaction, confirms the importance of expanding lowvision rehabilitative services and increasing the public awareness of its existence and benefits.
  4,838 408 1
Subjective and quantitative measurement of wavefront aberrations in nuclear cataracts - a retrospective case controlled study
Upender K Wali, Alexander A Bialasiewicz, Nadia Al-Kharousi, Syed G Rizvi, Habiba Baloushi
January-March 2009, 16(1):9-14
DOI:10.4103/0974-9233.48858  PMID:20142953
Purpose: To measure, quantify and compare Ocular Aberrations due to nuclear cataracts. Setting: Department of ophthalmology and school for ophthalmic technicians, college of medicine and health sciences, Sultan Qaboos University, Muscat, Oman. Design: Retrospective case controlled study. Methods: 113 eyes of 77 patients with nuclear cataract (NC) were recruited from outpatient clinic of a major tertiary referral center for Ophthalmology. Patients having NC with no co-existing ocular pathologies were selected. All patients were subjected to wavefront aberrometry (make) using Hartmann-Shack (HS) aberrometer. Consents were taken from all patients. Higher order Aberrations (HOA) were calculated with Zernike polynomials up to the fourth order. For comparison 28 eyes of 15 subjects with no lenticular opacities (control group) were recruited and evaluated in an identical manner. No pupillary mydriasis was done in both groups. Results: Total aberrations were almost six times higher in NC group compared to control (normal) subjects. The HOA were 21 times higher in NC group, and coma was significantly higher in NC eyes compared to normal (control) group. The pupillary diameter was significantly larger in control group (5.48mm ± 1.0024, p<.001) compared to NC (3.05mm ± 1.9145) subjects (probably due to younger control age group). Amongst Zernike coefficients up to fourth order, two polynomials, defocus (Z2 0 ) and spherical aberration (Z4 2 ) were found to be significantly greater amongst NC group, compared to normal control group. Conclusion: Nuclear cataracts predominantly produce increased defocus and spherical aberrations. This could explain visual symptoms like image deterioration in spite of normal Visual acuity.
  4,263 332 1
Non-traumatic ocular findings in industrial technical workers in Delta state, Nigeria
AE Omoti, OT Edema, FB Akinsola, P Aigbotsua
January-March 2009, 16(1):25-28
DOI:10.4103/0974-9233.48864  PMID:20142956
Purpose: To determine the pattern of non-traumatic ocular disorders in industrial technical workers in the Delta state, Nigeria. Methods: A cross-sectional study of the pattern of non-traumatic ocular disorders among industrial technical workers in 3 factories in Ughelli North local Government Area of Delta state, Nigeria was conducted between February, 2002 and May, 2002. In addition to the demographic, the workers were studied for the presence of any non-trauma related ocular findings. Visual acuity of these workers was obtained as well as ocular examination was performed by using the Snellen's chart, pen torch, ophthalmoscope, Perkins hand-held tonometer, Ishihara plates. Patients were refracted if their visual acuity was less than normal. Results: Five hundred technical workers were screened that included 200 (40%) from the construction industry, 180 (36%) from the rubber factory and 120(24%) from the oil mill. All the workers studied were males. Ocular disorders were seen in 664 (66.4%) of the eyes. The most common ocular disorders were pingueculum 215 (21.5%), presbyopia 97 (9.7%), refractive error 94 (9.4%), pterygium 86 (8.6%) and chronic conjunctivitis 45 (4.5%). None of the workers was blind from non-traumatic causes. Only 36 (7.2%) workers wore any protective eye devices at work. Conclusion: Non-traumatic ocular disorders are common in the industrialized technical workers in the Delta state of Nigeria. The use of protective eye devices is low in these workers and suggests that measures to implement ocular safety should be undertaken in these industries.
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Celebrating the past and looking ahead
Deepak P Edward
January-March 2009, 16(1):1-2
DOI:10.4103/0974-9233.48851  PMID:20142951
  2,877 278 -
Bleb-related endophthalmitis: Clinical presentation, isolates, treatment and visual outcome of culture-proven cases
Basel T Ba’arah, William E Smiddy
January-March 2009, 16(1):20-24
DOI:10.4103/0974-9233.48862  PMID:20142955
Purpose: To investigate clinical features, causative organisms and their antibiotic sensitivity, management, and visual acuity outcomes of eyes with bleb-related endophthalmitis (BRE). Design: Retrospective, noncomparative, consecutive eye series. Methods: Clinical and microbiological records of patients with culture positive bleb-related endophthalmitis treated at a single institution between April 1995 and February 2002 were revised retrospectively. Main Outcome Measures: Final visual acuity, loss of eye and complications. Results: There were 34 cases with presenting visual acuities ranging from 20/200 to light perception. Decrease of visual acuity was the most frequent sign (94%) followed by pain (79%) and hypopyon (53%). Associated features included pseudophakia (79%), vitreous wick (29%), and wound leak (12%). The most frequent organisms isolated from vitreous specimens, were streptococcus species (55%) and gram positive coagulase negative staphylococci (20%). Polymicrobial growth was noted in 27% of cases. The cultured organisms were sensitive to antibiotics used in 94% of cases. Treatment modality used was vitreous tap with antibiotic injection without (65%) or with vitrectomy (35%). The most common intravitreal antibiotics combination was vancomycin with ceftazidime, Intravitreal dexamethsone was administered in 56% of cases. Final visual outcome of 20/400 or better was noticed in 50% of cases without and 33% with vitrectomy, but this was not statistically significant (p=0.45). The difference in final visual acuity of cases infected by gram-positive coagulase-negative staphylococci and streptococcus species were not statistically significant (p= 0.18). Overall, final visual outcome of 20/400 or better was noticed in 47% of cases, while no light perception was recorded in 8 (24%) cases. Of no light perception cases 7 underwent evisceration or enucleation. Overall, 32% of the cases experienced other complications like retinal detachment with dislocated intraocular lens, phthisis bulbi, and epiretinal membrane formation. Conclusion: BRE is associated with substantial visual morbidity. Prompt treatment of BRE with intravitreal vancomycin and broad spectrum antibiotics recommended while culture results are pending. Neither tap-injection with vitrectomy nor tap-injection without vitrectomy proved superior in the management of this condition.
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