Ahmed Kotb

Effect of brimonidine tartrate ophthalmic solution 0.2% on pupil size in normal eyes under different luminance conditions

Purpose: To evaluate the effect of brimonidine tartrate ophthalmic solution 0.2% (Alphagan®) on pupil size in normal eyes. Three luminance conditions were used to assess the potential use of brimonidine in postoperative refractive patients who experience nighttime vision problems related to large pupil size. Setting: McDonald Eye Associates, Fayetteville, Arkansas, USA. Methods: Pupil size was measured in 16 eyes of 16 participants with the Colvard pupillometer under 3 luminance conditions. One drop of brimonidine 0.2% was administered to each patient. Pupil size was then measured using the same technique 30 minutes and 4 and 6 hours after drop administration. Results: Under scotopic conditions, 100% of the pupils showed significant miosis at 30 minutes (P < .05). The effect continued in all eyes for 4 hours. At 6 hours, a miotic effect was still present in 81.3%. However, under photopic luminance, there was no significant effect on pupil size in all 16 eyes (P gt; .05). The pupil size in 5 eyes (31.2%) was not affected at 30 minutes or 4 or 6 hours. At 6 hours, 15 eyes (93.8%) had returned to their preinstillation size. Conclusion: Brimonidine tartrate 0.2% had a significant effect in decreasing pupil size under scotopic conditions. The results indicate that the drug can decrease night‐vision difficulties such as halos, star bursts, glare, and monocular diplopia in postoperative refractive patients.

Ocular aberrations and visual performance with an aspheric single-piece intraocular lens: Contralateral comparative study

PURPOSE: To study spherical aberration, coma, and trefoil after implantation of a single‐piece aspheric Tecnis intraocular lens (IOL) in cataract patients and the influence on photopic and mesopic contrast sensitivity. SETTING: Ophthalmology Department, Ain‐Shams University Hospitals, Cairo, Egypt. METHODS: In this randomized prospective contralateral comparative study, patients had bilateral senile cataract. Eyes with a pathological condition other than cataract that might influence postoperative visual function were excluded. The aspheric IOL was compared with the Sensar AR40e spherical IOL. The IOL selection was randomized. Study criteria included corrected distance visual acuity (CDVA), wavefront aberrometry, and contrast visual acuity. RESULTS: Fifty‐six eyes of 28 patients were enrolled. All patients completed the 2‐month postoperative visit. There was no significant difference between the IOLs in CDVA (P>.05). Ocular spherical aberration was significantly lower with aspheric IOLs than spherical IOLs (P<.001). Two months after surgery, eyes with the aspheric IOL had better photopic contrast sensitivity and better mesopic contrast sensitivity at all cycles per degree. There was no significant difference in 3rd‐order aberrations (coma and trefoil) between IOLs. CONCLUSIONS: After cataract surgery, the single‐piece aspheric IOL resulted in significantly lower ocular spherical aberration and significantly better mesopic contrast sensitivity. No significant difference in 3rd‐order aberrations indicates that both IOLs had satisfactory centration in the capsular bag. Financial Disclosure: Neither author has a financial or proprietary interest in any material or method mentioned.

Efficacy and safety of intacs SK in moderate to severe keratoconus

Purpose: To examine the safety and efficacy of Intacs SK for moderate to severe keratoconus (KC) using femtosecond technology. Materials and Methods: This prospective, non-comparative study included 37 contact lens intolerant keratoconic eyes (stage II-III) of 24 patients who underwent femtosecond-assisted Intacs SK implantation. Inclusion criteria were mean K readings <56.00 D, corneal thickness >400 μm at the incision site, mesopic pupil <6.50 mm. Evaluation included manifest refraction, slitlamp examination, corneal topography, uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA). P < 0.05 was statistically significant. Results: Thirty-one (83.8%) eyes were classified as Amsler-Krumeich′s stage II and 6 (16.2%) were stage III. Mean central pachymetry was 490.3 ± 37.4 μm. UDVA at 6 months post-operatively was significantly better than pre-operatively (0.90 log MAR ± 0.52 standard deviation [SD] versus 0.32 ± 0.27 logMAR; respectively, P < 0.0001), as was the spherical equivalent (SEq) (−3.64 ± 2.52 D vs. −1.84 ± 2.2 D; P < 0.0001). The mean CDVA and manifest cylinder improved compared with pre-operatively (P = 0.319 and P = 0.078, respectively). Average keratometry decreased significantly from 48.50 ± 3.08 D to 44.40 ± 3.03 D (P < 0.0001). Conclusion: Implantation of Intacs SK using femtosecond laser in moderate to severe KC is safe and effective.

Torsional mode phacoemulsification: effective, safe cataract surgery technique of the future.

Purpose: To compare various outcome measures using torsional mode and longitudinal mode in the phacoemulsification of cataract with different nuclear densities. Setting: Magrabi Eye Hospitals, Kingdom of Saudi Arabia. Design: A randomized comparative clinical study. Materials and Methods: This study includes 200 eyes of 156 patients (100 in the ultrasound longitudinal “US” group and 100 in the torsional group). All eyes received AcrySof® single piece intraocular lens (Alcon Surgical, Fort Worth, TX). The primary outcome measures were ultrasound time (UST), cumulative dissipated energy (CDE), and surgical complications. Postoperative outcome measures were the degree of corneal edema on the first postoperative day and final best corrected visual acuity (BCVA) and CCT (central corneal thickness). Results: The differences in UST and CDE between subgroups of nucleus hardness were statistically significant (P < 0.01). The UST and CDE consistently increased in eyes with higher grades of nucleus density. On day one, the mean BCVA was 0.61 ± 0.13 decimals in the ultrasound (US) group and 0.67 ± 0.11 decimals in the torsional group (significant P < 0.05). Corneal edema was significantly less in the torsional group (P < 0.05). At 30 days, the mean BCVA was 0.94 ± 0.22 decimals in the US group and 1.0 ± 0.12 decimals in the torsional group but this difference was not statistically different (P > 0.05). Conclusions: The torsional mode provides an effective and safe method for cataract removal with lower energy usage as compared to longitudinal traditional phacoemulsification. However, the final visual outcome was similar for both study groups.

Bony reconstruction of hip in cerebral palsy children Gross Motor Function Classification System levels Iii to V: a systematic review

Hip dislocation is a common source of disability in cerebral palsy children. It has been remedied by various reconstructive procedures. This review aims at providing the best evidence for bony reconstructive procedures in cerebral palsy hip migration. The literature extraction process yielded 36 articles for inclusion in this review. There is fair evidence to indicate that the comparative effectiveness of femoral versus combined pelvifemoral reconstruction favours pelvifemoral reconstruction. All except one were retrospective articles with a significant degree of selection and performance bias and confounding variables that limited the validity and generalizability of the conclusions. The findings of this systematic review provide fair evidence for the use of adequate soft tissue and combined pelvifemoral reconstruction in the management of hip migration in none and minimally ambulatory cerebral palsy children in the short and long term. This has been shown in studies with a summed sizable patient population. There is limited evidence available that would support the use of soft-tissue and isolated femoral reconstruction. In the context of these retrospective and biased studies, it is extremely difficult to identify, with great precision, predictors of surgical success. Future studies should consider prospective designs that allow for bias control, strict patient selection criteria and incorporation of validated quality-of-life scales.

A Posteriorly Displaced Distal Metaphyseal Clavicular Fracture (Type IV AC Joint Dislocation-Like) in Children: A Case Report and Literature Review Study

Fractures of the lateral end of the clavicle are common in pediatric patients; most of these fractures occur at the physeal level representing Salter Harris injuries. The vast majority of fractures of the lateral end of the clavicle are managed nonoperatively. In this report, we describe a unique type of fracture of the distal end of the clavicle in the pediatric patients in which the fracture occurs in the metaphyseal lateral clavicle with the proximal edge of the fracture displaced posteriorly through the trapezius muscle causing obvious deformity. It is similar in pathology to type IV AC joint dislocation. In this study we report this injury in eleven-year-old boy. Literature review showed that similar injuries were described before three times (two of them in pediatric patients). Due to the significant clinical deformity of this category with entrapment of the bone through the trapezius muscle, reduction (open or closed) of the fracture is the recommended treatment.

Open reduction internal fixation versus external fixation with limited internal fixation for displaced comminuted closed pilon fractures: A randomised prospective study

Background Pilon fractures involve the dome of the distal tibial articular surface. The optimal treatment for high-energy pilon fractures remains controversial. Some authors advocate the use of open reduction and internal fixation (ORIF) to avoid articular incongruence. Others advocate the use of bridging external fixation with limited internal fixation (EFLIF) to reduce soft tissue complications. Literature reports of prospective studies comparing the radioclinical outcomes of ORIF and EFLIF in high-energy fractures are scarce. Retrospective studies have their limitations because of insufficient randomisation. The objective of this randomised prospective study is to compare the clinical, radiologic and functional outcomes of displaced and comminuted closed pilon fractures, Rüedi and Allgöwer type II and III, treated by either ORIF or EFLIF. Materials and Methods Forty-two patients were selected for the study. Twenty-two patients were subjected to ORIF and 20 patients were subjected to EFLIF. We used the American Orthopaedic Foot and Ankle Society score as a standard method of reporting clinical status of the ankle. Patients were followed-up clinically and radiologically for over 2 years after the surgical treatment. Results The results of ORIF and EFLIF in treatment of high-energy pilon fractures are equally effective in terms of functional outcomes and complication rates on the short term. Conclusion Soft tissue integrity and fracture comminution seem to have a significant influence on outcomes of intervention. A prospective multicentre study with a larger sample size that controls for other associated variables and comorbidities is warranted. Level of evidence Level II.

Coccygectomy for posttraumatic coccygodynia: a long-term prospective study

Background: Coccygodynia is pain around the coccyx; its most common etiology is trauma. About 20% of patients do not respond to conservative measures in the form of medical treatment, local injection, or physical therapy. Our prospective clinical study aims at highlighting the results of coccygectomy for coccygodynia caused by trauma that could not be treated conservatively. Methods: Thirty eight patients were included in the study with 28 women (73.7%) and 10 men (26.3%). After failure of conservative treatment measures, coccygectomy was done in all patients. The duration of symptoms before the surgical procedure varied between 9 and 48 mo with a mean of 19.6 mo. Clinical presentation of the local pain was quantified according to a visual analog scale (VAS) on deep manual palpation at the tip of coccyx preoperatively and at 4 mo, 12 mo, then at 2-year and 4-year follow-up. Results: The mean preoperative VAS was 9.2, at 4 mo it was 2.7, and at 12 mo it was 1.8. At 2 and 4-year postoperative follow-up, VAS was 1.5 and 1.3, respectively (P=0.0001). Conclusion: Coccygectomy for coccygodynia caused by a traumatic event affords significant pain relief postoperatively. Coccygectomy is recommended as a last resort treatment for coccygodynia after failed conservative treatment. Level of Evidence: Level IV (prospective study).

Management of bicondylar tibial plateau fractures with severe articular comminution by ligamentotaxis with biplanar spanning external fixation

Background: Bicondylar tibial plateau fractures are serious injuries with a high incidence of complications. The fracture treatment protocol has to take into consideration soft-tissue complications that might develop with severe articular comminution. This prospective study aims at highlighting the role of ligamentotaxis and spanning external fixation as an effective method in treatment of such injuries. Methods: Twenty-three patients were admitted with bicondylar tibial plateau fractures. Seventeen men and six women with severe intraarticular comminution were treated with ligamentotaxis and fixation with two spanning external fixators. Patients were followed for 2 yr. Functional outcome was assessed using the Knee Society Scoring System directly after removal of the fixators then at 1 and 2 yr. Results: The scores of the patients ranged from 94-72, with an average of 82.4. Seven of the patients had an excellent score (80-100), and five had a good score (70-79). Conclusions: Ligamentotaxis and spanning external fixation is a safe and successful method for treatment of severely comminuted bicondylar tibial plateau fractures. This technique allows achievement of an acceptable reduction with avoidance of skin and soft-tissue complications. Level of Evidence: Level IV therapeutic study.