BULL. OPHTHALAMOLOGICAL SOCEITY EGYPT, 1997; VOL. 90, NUMBER 2

Purpose: Studying the structural details of filtering blebs after trabeculectomy using ultrasound biomicroscopy (UBM).

Methods: The study has been done on 35 patients with history of traheculectomy. An ultrasound biomicroscopy was performed and the images were evaluated according to an established protocol.

Results: All patients have been divided into three groups according to their postoperative lOP. The visibility of the aqueous route under the scleral flap and the reflectivity inside the bleb were highly significant in relation to lOP.

Conclusion: Ultrasound biomicroscopy proved a valuable new non invasive technique in the evaluation of filtering blebs affer trabeculectomy.

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Purpose: In ophthalmic literature we find a little about the effect of intraocular pressure reduction on macular functions The aim of this study is to evaluate changes in macular functions in glaucoma patients after surgical control of intraocular pressure.

Methods: Landolt's broken rings (visual acuity), Cambridge contrast sensitivity gratings (contrast sensitivity), Farnsworth D-15 Panel Test (colour discrimination), and central 30-2 threshold program (Humphrey visual field analyzer, model 630) were used to evaluate some macular functions and visual field in thirty glaucomatous eyes after surgical control of their intraocular pressure.

Results: Surgical control of the intraocular pressure was accompanied by reduction of visual acuity (0.0005 <p <0.005), diminution of contrast sensitivity (p <0.05) and no changes of colour vision. On the other hand, glaucoma surgery had variable effect on visual field, where improvement occur in 2 eyes (6.67%), deterioration in three eyes (10%) and stabilisation in the remaining 25 eyes (83.33%).

Conclusion: Although, we believe that trabeculectomy is one of the most important methods used to reduce intraocular pressure and to prevent significant optic nerve damage and consequent losses of vision, this operation may be accompanied by certain decrease in visual field and in some macular functions. Both the surgeon and patients should share in this knowledge. However, this risk is in the context of a probably greater chance of visual field and macular functions losses if the pressure remains elevated.

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Purpose: Evaluation of the filtering surgery effect on the visual field in patients with advanced chronic glaucoma.

Methods: 24 eyes of 22 patients with advanced chronic glaucoma were treated surgically. Preoperative and serial postoperative visual field testing were performed using the single field analysis of the central 30-2 program (Humphrey FA, model 640).

Results: Of the 24 eyes, 8 eyes showed improvement in the mean defect index, while 16 eyes showed worsening. 5 eyes showed improvement in their corrected pattern standard deviation index, while 19 eyes showed worsening of the same index.

Conclusion: The prognosis is poor in advanced chronic glaucoma in spite of surgical reduction of intraocular pressure.

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Purpose: Modification to maintain and create potential spaces in trabeculectomy operation.

Methods: Monofilament threads are used.

Conclusion: This is a primary report of this new modification which is the subject for further study and evaluation.

Mounir A. Khalifa.

Risk Factors in Post-Keratoplasty Glaucoma.

Amr Salah-Eddin Abdel-Hakim , and Mohamed Sami Mahmoud

Glaucoma is a serious problem that may endanger a successful graft in 20-50% of penetrating keratoplasties . Several preoperative , intraoperative and postoperative risk factors may he responsible. Analysis of 104 cases of penetrating keratoplasty (PK) performed by the authors over a period of 2 years. Possible risk factors as well as steps of management and control have heen studied Postoperative glaucoma occurred in 25 eyes (24%). Young age (42.8%), previous limbal cataract section (44.8%) and inability to repair the iris and create a round pupil due to extensive tissue loss (88.9%) were the leading factors responsible for postoperative glaucoma in this series. Postoperative medical control succeeded in 32% of cases and surgery in 44% of cases. Six eyes (24%) were lost. Young age groups are particularly susceptible to glaucoma. Previous limbal section and extensive loss of iris tissue are strong risk factors. Eyes with successful graft surgeries may be lost through glaucoma and/or its management.

BULL. OPHTHALMOL SOC. EGYPT, 1997; VOL 90, NUMBER 2, 195-200

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Purpose: Glaucoma drainage implants are an important option in the management of refractory glaucomas. Schocket implant combosed of an anterior chamber tuhe attached to an encircling band.

The aim of this work is to evaluate a modified 900 Schocket implant done on two stage technique, the first stage (reserve) is combined with a trabeculectomy plus mitomycin C as a model for treatment of refractory glaucomas

Methods: The procedure was applied to 28 eyes of refractory glaucomas (10 neovascular, 8 congenital, 6 aphakic, 2 juvenile and 2 post-uveitic).

In all the cases this was the first surgical procedure. Follow up ranged from 3-12 months.

Results: Intraocular pressure (I.O.P.) equal to or less than 21 min Hg with and without medication was achieved in 13 eyes (46.4%) after the first stage and in 12 eyes out of the remaining 15 eyes after the second stage (80%). Overall success rate was 89.28%.

Conclusion: Two stage modified Schocket operation is a valuable procedure in refractory glaucomas.

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Automated Field of Vision and Pattern Electroretinogram in Glaucoma and Ocular Hypertension

Mohamed Salah Bader, and Mostafa Debies

Purpose: To evaluate the sensetivity of P.E.R.G as objective test for detection of glaucoma and or ocular hypertension in comparison to automated field of vision.

Methods: 3 groups entered the study (1)15 patients with evident glaucoma (2)10 patients with ocular hypertension (3)10 Normal subjects both automated field of vision and pattemElectroretinogram were done

Results: P.E.R.G amplitude (P50 N95) was affected severly in glaucoma group patients and decreased more in the more advanced eye as releation to field defect and not related to I.O.P. it was also affected to less extent in ocular hypertensive group in comparison to normal control.

Conclusion: P.E.R.G is rapid objective test for ganglion cell layer with reproducable results and have the capability of differentiating glaucome patients from normals.

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Insight on Argon Laser Trabeculoplasty from the Statpac m 2 Point of View

Purpose: The development of new perimetric programs such as statpac-2 software makes it possible to precise evaluation of the field in glaucoma patients in respoi~e to different lines of treatment. We present the statpac value in evaluation of Argon Laser Traheculoplasty when it is applied to primary open angle glaucoma patients ujicontrolled by medical treatment.

Patients and Methods : A pre and post-laser perimetry was done for 6 months for 20 eyes of 10 patients suffering from primary open angle glaucoma using the statpac 2 program of the Humphery Automated Field Analyser 750. A standardized treatment technique for Argon Laser Traheculoplasty was carried out, and the lOP was measured by applanation tonometer currently.

Results: 80% (16 eyes) responded favorably to ALT where the field of vision and the lOP were much improved along the period of follow up (6months), while the rest (4 eyes) showed improvement in the lOP (less than 6 mmHg reduction) but the field remained stationary.

Conclusion : Argon Laser Traheculoplasty can he used as a safe and effective treatment for primary open angle glaucoma where effective management with medicine is impractical and the statpac software is a useful tool in the follow up of the field of glaucoma patients.

Diurnal Intraocular Pressure Variation in Normal Tension Glaucoma Patients

Purpose: In a trial to find a diagnostic value for the diurnal intraocular pressure ('OP) curves of normal tension glaucoma (NTG) patients, and studying their peak and trough values, compared to normal population and primary open angle (POAG) patients, this study was designed.

Methods: Diumal lOP curves of twelve NTG patients, thirteen POAG patients and ten normal people, were retrospectively evaluated, five readings representing the 24 hours were chosen and the values subjected to statistical analysis.

Results: The results showed that there is a statistical difference hetween the mean lOP of NTG and POAG patients but not with normal controls. It was also found that the peak and trough values of lOP occurred during moriiing office hours for both glaucoma groups and not in the evening hours.

Conclusion: These results point to the fact that we have to rely on other findings namely the optic disc and field changes for early detection of normal tension glaucoma.

Keywords: Diurnal Intraocular pressure - Normal tension glaucoma

Assessment of the Early Prognostic Value of Disappearance of the Neural Tissue Between Blood Vessel Walls and the Edge of the Optic Cup (Nabil's Sign) in Cases of Rise in IntraOcular Pressure

Purpose: To evaluate the prognostic value of Nabil's sign in sixty (60) eyes with ocular hypertension, sixty (60) eyes with open angle glaucoma and sixty (60) controls.

Methods: Partial or total loss of neural tissue hetween the nearest blood vessel wall and the edge of the optic cup was identified and recorded, together with changes in the field of vision and nerve fiber layer (NFL), follow up was done for 18 months.

Results: 23.3% of glaucomatous eyes showed Nabil's sign, but not in ocular hypertensives or the control group (Z-1 54*) NFL changes proceeded Nabil's sign in 75.6% of eyes. Field defects developed together with the development of the neural tissue loss or 6-12 months later but not hefore.

Conclusion: Nabil's sign is a simple sure sign of progression in glaucoma even in the absence of changes in field of vision and nerve fiber layer.

The Prevalence of Glaucoma after Surgery for Infantile Cataracts

Purpose: To evaluate the prevalence of glaucoma in young children undergoing surgery for infantile cataracts.

Method: 36 eyes of infantile cataracts who underwent lensectomyl vitrectomy were subjected to follow tip period for 12 months.

Results: 12 eyes (33%) of 36 eyes developed glaucoma as defined by any pressure of 23 mmHg or greater at two or more examinations

Conclusion: The prevalence of postoperative glaucoma after lensectomyl vitrectomy in those with infantile cataracts is high . Pediatric aphakic patients should be routinely monitored for glaucoma throughout their lives.

The Use of Topical Carbonic Anhydrase Inhibitor Dorzolamide Hydrochloride in the Management of Selected Cases of Open Angle Glaucoma

Purpose: This study was designed to evaluate the efficacy of the recently introduced topical carbonic anhydrase inhibitor Dorzolamide Hydrochloride 2% (Trusopt 2%: Merck) as an additional therapeutic agent in selected patients suffering from bilateral chronic open angle glaucoma receiving other forms of antiglaucoma topical drugs.

Methods: The patients were divided into two groups. Group I included 9 patients with bilateral open angle glaucoma under topical heta blockers. Group II included 11 patients with bilateral open angle glaucoma under topical beta blockers in addition to other topical medications. Dorzolamide Hydrochloride 2% was instilled three times daily in one eye only that was randomly selected if both eyes are of the same intraocular pressure or the eye with higher pressure was selected. The intraocular pressure was recorded in both eyes and the patients were followed up for 24 weeks.

Results: The intraocular pressure reduction, in both the study eye and the fellow eye were recorded and the results were tabulated.

Conclusion: Dorzolamide Hydrochloride 2% was found to he a useful adjunctive therapy in control of intraocular pressure elevation and in stabilizing otherwise inadequately controlled cases.

Apraclonidine Versus Timolol Eye Drops in Management of Open Angle Glaucoma

Purpose: To compare the intraocular pressure (lOP) lowering effect of Apraclonidine 1% eye drops with that of Timolol 0.5% eye drops in patients with primary open angle glaucoma.

Methods: 56 eyes of 28 patients (18 females and 10 males) with primary open angle glaucoma were enrolled in the study. Their lOP ranged between 22-30 mmHg.

14 patients (group 1) used Timolol maleate 0.5% eye drops twice daily for at least 4 weeks(~16 weeks). The other 14 patients (group 2) used Apraclonidine hydrochloride 1 % eye drops for the same period. lOP was measured twice weekly during the 3 months follow up period.

Results: Both groups showed significant lOP reduction. Mean lOP reduction in group 1 ranged from 3.8 to 5.1 inmHg. and in group 2 it ranged from 3.8 to 4.6 mmHg. which is statistically insignificant difference.

Conclusion: Twice daily 1 % apraclonidine provides a significant ocular hypotensive effect in patients with primary open angle glaucoma with no significant difference in lOP lowering effect of both Timolol 0.5% and Apracolinidine 1% eye drops. So, Apracolidine 1% eye drops can be used as an altcmative to Timolol 0.5% eye drops.

Keywords: Apraclonidine , Timolol , primary open angle glaucoma, lopidine.

The Intraocular Pressure Lowering Effect of Apraclonidine in Patients with Poorly Controlled Glaucoma

Purpose: This work investigates the intraocular pressure (lOP) lowering effect of apraclonidine hydrochloride when used in patients with poorly controlled glaucoma on maximum tolerated medical treatment.

Methods: 24 patients with elevated lOPs entered this study. Each used apraclonidine 1.0% twice daily for three weeks.

Results: Apraclonidine produced a significant additional lOP lowering. No significant change in pulse rate or blood pressure was seen during apraclonidine administration.

Conclusions: Apraclonidine proved to be a usefi~l agent in patients with poorly controlled glaucoma.

Evaluation of Functioning Trabeculectomy Following E.C.C.E.

Purpose: To evaluate the functional outcome of trabeculectomy surgery followed by ECCE with posterior chamber IOL implantation.

Methods: Thirty patients with previous successful trabeculectomy undergoing ECCE with P.C. IOL implantation were included in this retrospective study. The patients were followed up to 24 months following cataract extraction and P.C. IOL implantation either in the bag (13 cases) or in the sulcus (17 cases). Failure of the function was considered when lOP was above 21 mmHg.

Results: Postoperative gonioscopy shows pigmentation in 30 eyes, I.O.L malpositioning in 5 eyes, P.A.S. in 6 eyes and occluded intemal fistula in 4 eyes. Total failure of functioning trabeculectomy after ECCE & P.C. IOL implantation was 6 patients (2d) Five patients (1 6.6%) needed topical antiglaucoma therapy only (relative, while one patient (3.3%) required additional surgery (absolute).

Conclusion: Cataract extraction following trabeculectomy may be associated with failure in the functional outcome of filtering bleb. lntrabagal fixation of IOL significanly reduces the incidence of P.A.S. and decrease stress on already compromised out flow system of these eyes.

Gonioscopy in Pseudophakia

Purpose: Recording changes that occur in the anterior chamber angle in the cases of intraocular implant.

Subjects & Methods: Eighty five eyes with senile cataract and fifteen aphakic eyes (all 100 eyes) were classified into 3 groups:

*Group L ECCE with PC IOL implantation.

*Group II: ICCE with AC IOL implantation.

*Group III: Secondary implantation using scleral fixated IOL.

Gonioscopic study is performed preoperatively and postoperatively for 6 months.

Results: Gonioscopic findings included peripheral anterior synaechiae , increased angle pigmentation and patches of iris atrophy. No angle neovascularization could be detected. There was no significant increase of I.O.P.

Conclusion: Gonioscopy is recommended in cases of pseudophakia to record angle changes.

Primary Versus Secondary Implantation of Intraocular Lenses in Children - A Short Term Study

Purpose: To compare the results obtained after primary intraocular lens (I.O.L.) implantation with posterior capsulotomy and anterior vitrectomy versus the results obtained with the same technique done secondarily in aphakic eyes of children (2 mon15 y).

Methods: In the 1st. group (100 eyes) a routine extracapsular cataract extraction, peripheral iridectomy, posterior chamber (P.C.) I.O.L., pars plana (or pars plicta) posterior capsulotomy (central 5-6 mm) and anterior vitrectomy were done . In the second group (20 eyes) a pars plana Iplicata lensectomy and anterior vitrectomy were done, 1-2 month later a secondary I.O.L. implantation were done.

Results: The difficulties, the complications and the corrected visual outcome were discussed. The overall results ensured a clear papillary area, minimal postoperative complications and a favourable visual outcome in all cases . The difficulties were more considerable in secondary implanted cases thanthose with primary implantation. The postoperative reaction in primary implanted cases was a little more than those with secondary implantation.

Conclusion: primary posterior chamber lens implantation with primary posterior capsulotomy and anterior vitrectomy is the preffered technique in children, however, it needs more follow up.

Keywords: Cataract in children, Secondary LO.L., Pars plana Posterior capsulotomy.

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Secondary Anterior Chamber Flexible Open Loop Implants for Correction of Acapsular Aphakia A- Retrospective Study.

Purpose: Visual rehabilitation of monocular aphakes with no posterior lens capsule who are contact lens intolerant is achieved by secondary IOL implantation either in AC. or in PC with fixation sutures. The aim of this work is to evaluate the visual outcome and the complications of secondary implantation of flexible open loop AC. IOL.

Methods: A retrospective study is presented of a series of AC. IOL implantation in 50 eyes of 50 patients after an earlier cataract surgery.

Results: Best corrected visual acuity: improved in 10%, remain the same in 76% and deteriorated in 14%. The deterioration was due to persistent comeal oedema in 4%, persistent cystoid macular oedema in 6% and glaucoma in 4%.

Conclusion: Secondary AC.IOL. implantation is a simple & easy technique for correction of monocular acapsular aphakes that needs neither special surgical skill nor sophisticated instruments.

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Posterior Capsulorhexis for Opaque Posterior Capsule in Children

Purpose: Toevaluate the efficacy of posterior curvilinear - continuous capsulorhexis technique in providing a post operative clear visual axis in children with opaque posterior capsule found during cataract surgery.

Pacients and Methods: Twenty eyes of fourteen patients found to have opaque posterior capsule during surgery. The age of patients ranged from 5 to 12 years with average 8.5 years . Extra capsular cataract extraction (ECCE), posterior curvilinear continuous capsulorhexis (PCCC) and posterior chamber intra ocular lens implantation (PC IOL) was performed on all eyes. Anterior vitrectomy was done in four eyes with inadvertent vitreous loss. The patients were followed one week, four weeks, three months, six months and eight months after surgery for: unaided visual acuity, clarity of visual axis, intra-ocular lens centration, intra-ocular pressure, shape and reaction of the pupil. Our main concern was the clarity of the visual axis

Results: All the patients had a clear visual axis through the tollow up time. Unaided visual acuity ranged from 6/9 to 6/24. The posterior chamber intra-ocular lenses were centered. In all patients. The intra-ocular pressure ranged from 14 to 18 mmHg. The pupil was rounded in 17 eyes and oval in 3 eyes.

Conclusion: Posterior curvilinear continuous capsulorhexis is a safe technique for the management of opaque posterior capsule found during Surgery in children. It ensure a long term clear visual axis, rapid visual rehabilitation and decrease the need for secondary surgery to clear the visual axis in this group of patients.

Motorized Pump Irrigation Aspiration Versus Manual Technique in Cataract Surgery with Posterior Chamber I.O.L. Implantation

Purpose: Evaluation of the results in extracapsular cataract extraction by motorized pump irrigation aspiration and manual technique.

Methods: 50 eyes of senile cataract were managed by ECCE with I.O.L. implantation.

Group A: 25 eyes were irrigated and aspirated by Mentor Surg-E-Trol system II,

Group B: The other 25 eyes were irrigated and aspirated by manual double way canula. Advantages and benefits for each technique were discussed.

Results: All cases run smoothly without complications except 2 cases in group A (8%), 1 case in group B (4%) suffer vitreous loss residual lens matter in 2 cases of group B (8%), comeal haze in 6 cases of group A (24%) & 8 cases in group B (32%).

Conclusion: No differences in both techniques, except the motorized pump is more beneficial than the manual technique in management of vitreous loss.

Minimal Dose of YAG Laser Posterior Capsulotomy

Purpose: To evaluate the efficacy of YAG laser posterior capsulotomy with minimal complications.

Methods: 200 Patients with opacified posterior capsule in the period from July, 1993 to July 1995, were treated with HGM YAG laserS-is shots 2-4 mj was the dose used in 95% of cases and up to 150 shots, l2mj used in 5% of cases with dense fibrous capsule.

Results: Transient rise of lOP were detected in 8 cases (4%) which return to normal after treatment, no injury of the anterior vitreous face, no R.D, no other complications detected.

Conclusion: Treatment with YAG laser for posterior capsular opacification using minimal dose must be used to guard against incidence of complications.

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Purpose: This work is a part of continuous effort to find the proper solution for cases of unilateral developmental cataract.

Subjects & Methods: 15 patients with unilateral developmental cataract less than 6 years were included in the study from Jan 1995 to Dec.1996. Aspiration with PCIOL implantation were done all cases were done by the same technique. Occlusion of the sound eye is started one week after surgery. YAG laser posterior capsulotomy is needed in 8 cases.

Results: Visual acuity was improved in 8 patients to 6118 or more where as, in 4 cases, it ranges from 6/60 - 6/24 and in the remaining 3 cases, visual acuity cannot be tested. The most common complications are opacification of the posterior capsule (8 cases), transient iritis (6 cases), posterior synchiae (2 cases) and iris capture (one case).

Conclusion: The earlier the surgical intervention, the more favourable is the prognosis. IOL implantation in children more than 3 years, inspite of some complications, is the best solution for unilateral developmental cataract.

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Purpose: Small incision cataract surgery has several advantages over conventional ECCE surgery, including earlier visual recovery and less induced astigmatism..

Methods: To report upon 60 consecutive cataract surgeries using the scieral tunnef mulsificaton technique and implantation of a 5 mm PCL. Resub: Scleral tunne phacoemulsification technique and implantation of a 5 mmPCL.

Results: Scleral tunnel phacoemulsification provided more control during surgery; refraction and K-readings stabilized within the first postoperative week. Complication were tolerable and insignificant.

Conclusion: The surgical outcome and safety of the procedure justify standardization of this technique.

BULL. OPHTHALMOL SOC. EGYPT, 1997; VOL.90, NUMBER 2, 293-296

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Purpose: To present the Banha University (BU) formula, and the methods used to derive it.

Methods: Fifty-three patients were operated upon by extracapsular cataract extraction and posterior chamber intraocular lens (IOL) implantation. Cases with more than three diopters (D) of post operative astigmatism or with post operative visual acuity of worse than 6/12 were excluded. K- readings were obtained in diopters. The axial lengths were measured along the visual axis with applanation A-scan unit. Retrograde study and regres~ion analysis has been accomplished on an IBM compatible computer using the Microsoft Excel program version 5.0 designed for use under windows. After developing the formula, the prediction accuracy was compared with that of the SRK II, the SR~T, the Binkhorst H, and the Holladay formulas.

Results: The new BU formula performed slightly better than the SRK II, the SRK\T, the Binkhorst II, and the Holladay formulas, which was expected result as any formula performs superiorly with the data from which it was derived.

Conclusion: BU formula is a new formula for IOL power calculation, which needs further assessment.

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