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Chris Or,1 Sherin Lajevardi,1 Hashem Ghoraba,1 Jung Hyun Park,1 Neil Onghanseng,1,2 Muhammad Sohail Halim,1 Murat Hasanreisoglu,3 Muhammad Hassan,1 Gunay Uludag,1 Amir Akhavanrezayat,1 Quan Dong Nguyen1 1Department of Ophthalmology, Stanford University, Palo Alto, CA, USA; 2Department of Ophthalmology, Makati Medical Center, Manila, Philippines; 3Department of Ophthalmology, Koç University, School of Medicine, Istanbul, TurkeyCorrespondence: Quan Dong Nguyen, Spencer Center for Vision Research, Byers Eye Institute at Stanford University, 2370 Watson Court, Suite 200, Palo Alto, CA, 94303, USA, Tel +1 650 725 7245, Email ndquan@stanford.eduPurpose: To describe the prevalence and characteristics of posterior segment manifestations in patients with HLA-B27-associated uveitis using wide field imaging.Methods: Medical records of patients diagnosed with HLA-B27-associated uveitis from a tertiary uveitis clinic were reviewed. Posterior segment involvements including but not limited to peripheral vasculitis, optic disc inflammation, and macula edema documented based on medical records and various imaging modalities including wide field fluorescein angiography and optical coherence tomography, were noted. Demographic characteristics, accompanied with systemic diseases as well as duration and chronicity of uveitis, were also evaluated. Patients with significant systemic and ocular comorbidities were excluded. Statistical analyses including chi-squared tests and paired t-tests were employed.Results: Of the 44 patients with HLA-B27 associated uveitis, 22 patients (50%) were noted to demonstrate posterior segment involvement. Disc leakage and peripheral vasculitis were the most common findings of posterior involvement. Those with anterior chamber inflammation were found to have a significantly increased risk of posterior involvement. Those with posterior involvement were also noted to have a statistically significant decreased visual acuity. No significant association was found between documented duration of disease and posterior segment involvement.Conclusion: The prevalence of posterior segment involvement in HLA-B27 associated uveitis is higher compared to previous reports when evaluated with wide angle imaging modalities. Careful examination of the posterior segment is required in patients with HLA-B27 associated uveitis.Keywords: HLA-B27, uveitis, retinal vasculitis, vitreous haze, vitreous cells, macular edema, anterior chamber cells, anterior chamber flare

Azadeh Mobasserian,1,&ast; Moosa Zaidi,1,&ast; Sohail Halim,1,2 Jaclyn Joyce Hwang,1 Jonathan Regenold,1 Amir Akhavanrezayat,1 Irmak Karaca,1,3 Hassan Khojasteh Jafari,1 Negin Yavari,1 Wataru Matsumiya,1,4 Cigdem Yasar,1,5 Ngoc Tuong Trong Than,1 Gunay Uludag,1 Diana Do,1 Hashem Ghoraba,1 Quan Dong Nguyen1 1Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA; 2Ocular Imaging Research and Reading Center, Sunnyvale, CA, USA; 3Department of Ophthalmology, Ege University Faculty of Medicine, Izmir, Turkey; 4Division of Ophthalmology, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan; 5Department of Ophthalmology, Suleyman Demirel University, Faculty of Medicine, Isparta, Turkey&ast;These authors contributed equally to this workCorrespondence: Quan Dong Nguyen, Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, 2370 Watson Court, Suite 200, Palo Alto, CA, 94303, USA, Tel +1 650 725-7245, Fax +1 650 736-8232, Email ndquan@stanford.eduPurpose: Diopsys® NOVA fixed-luminance flicker full-field electroretinogram (ffERG) device is a potential adjunct to conventional flicker ffERG testing for assessing cone cell function. Magnitude of measured electrical response is known to vary with pupil size in conventional ffERG testing. The index study characterizes the relationship between magnitude of measured electrical activity and pupil size, both pupil diameter and pupil area, for this device.Methods: Seventeen patients (34 eyes) with no known ocular diseases were enrolled in the study. Electrophysiologic function of cone cells was evaluated using fixed-luminance flicker ffERG before and after dilation. Linear regression models, with inter-eye correlations controlled as fixed-effects, were used to characterize the effect of pupil dilation on the magnitude of the measured responses.Results: Mean age of study patients was 33.5 (standard deviation 7.4 years), and 35.3% of the subjects were female. Mean value of electrical response magnitude was 10.07± 2.79μV before dilation and 15.30± 4.08μV after dilation. The correlations of ERG magnitude with pupil diameter and with pupil area were not significant for either dilated or undilated eyes considered separately but were highly significant (p< 0.001) for dilated and undilated eyes considered in aggregate. ERG magnitude tended to increase by 1.08 μV for every 1 mm increase in pupillary diameter.Conclusion: An increase in pupil size, both pupil diameter and pupil area, is significantly associated with an increase in flicker ffERG magnitude recorded by the Diopsys device, suggesting that pupil size should be measured and considered when making clinical judgments based on the flicker ffERGs recorded by the device, and that pupil size-specific reference ranges could improve the clinical utility of the device.Keywords: electroretinogram, ERG, flicker ERG, pupil, magnitude, Diopsys

Hammouda Hamdy Ghoraba,1 Mahmoud Leila,2 Hashem Ghoraba,3 Mohamed Amin Heikal,4 Hosam Othman Mansour5 1Faculty of Medicine, Tanta University, Tanta, Egypt and Medical Director, Magrabi Eye Hospital, Tanta, Egypt; 2Retina Department, Research Institute of Ophthalmology, Giza, Egypt; 3Magrabi Eye Hospital, Tanta, Egypt; 4Faculty of Medicine, Benha University, Benha, Egypt; 5Faculty of Medicine, Al Azhar University, New Damietta City, EgyptCorrespondence: Mahmoud LeilaRetina Department, Research Institute of Ophthalmology, 2, Al-Ahram Street, Giza, EgyptTel +201286644025Email mahmoudleila@yahoo.comObjective: To describe the optical coherence tomography (OCT) findings in terms of macular hole closure and ellipsoid zone (EZ) recovery following modified internal limiting membrane (ILM) surgical technique in traumatic macular holes (TMH).Methods: The study was a retrospective case series that recruited 16 consecutive patients with TMH. Following vitrectomy (PPV), we performed modified ILM surgical technique (IFT) in which ILM peel was stopped at the edges of the hole forming a floating ILM flap. Primary outcome measures were pattern of TMH closure and recovery of EZ. Student’s T-test and Pearson’s correlation coefficient were used for statistical analysis.Results: The study had 16 eyes of 16 patients. Mean baseline minimum linear diameter (MLD) was 562μ. Mean baseline best-corrected visual acuity (BCVA) was 1.4 logMAR. U-pattern closure occurred in 50% of eyes, V-pattern closure occurred in 31.2% of eyes, whereas W-pattern closure occurred in 18.7% of eyes. Mean BCVA improvement was 5 lines (p 0.02). Failure of recovery of EZ was detected in 75% of eyes. In the present series, neither pre-operative MLD nor time lapse prior to surgery were significant factors in determining the closure pattern of TMH, the grade of EZ recovery or final BCVA.Conclusion: Modified IFT is effective in promoting macular hole closure and improving visual acuity in patients with TMH. The technique does not promote recovery of EZ.Keywords: modified ILM surgical technique, traumatic FTMH, ILM peel adjuvants, ILM blue-assisted ILM peel, ellipsoid zone recovery

Amir Akhavanrezayat,1 Wataru Matsumiya,1,2 Prapatsorn Ongpalakorn,1 Hashem H Ghoraba,1 Chris Or,1 Hassan Khojasteh Jafari,1 Gunay Uludag Kirimli,1 Cigdem Yasar,1 Ngoc Trong Tuong Than,1 Irmak Karaca,1 Moosa Zaidi,1 Azadeh Mobasserian,1 Negin Yavari,1 Vahid Bazojoo,1 Yong Un Shin,1 Albert John Bromeo,1 Quan Dong Nguyen1 1Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA; 2Department of Surgery, Division of Ophthalmology, Kobe University Graduate School of Medicine, Kobe, JapanCorrespondence: Quan Dong Nguyen, Spencer Center for Vision Research, Byers Eye Institute at Stanford University, 2452 Watson Court, Suite 200, Palo Alto, CA, 94303, USA, Tel +1 650 723 9386, Email ndquan@stanford.eduPurpose: To report a case of neurosarcoidosis (NS) who was initially diagnosed as Coccidioidomycosis immitis (CI) infection.Observations: A 57-year-old diabetic man presented with sudden painless diminution of vision, metamorphopsia, and color vision deficits in the left eye (OS) for one month. His vision was 20/20 in the right eye (OD) and 20/40 OS. Ophthalmic examination revealed left relative afferent pupillary defect, blurred optic nerve margin, creamy chorioretinal infiltration around the optic disc, and mild macular edema. OD examination was non-revealing. Chest CT scan with contrast showed calcified mediastinal lymph nodes, but biopsy of the lymph nodes was normal. Brain and orbit MRI demonstrated soft tissue abnormality with enhancement in left orbital apex with involvement of the extraocular muscles. CSF culture was negative, but complement fixation had positive titer of 1:2 for CI. The patient was diagnosed with CI meningitis, and antifungal therapy was initiated. Slight visual and symptomatic improvement was observed, which was not completely satisfactory. Biopsy of extraocular orbital muscle five months later revealed non-caseating granulomatous inflammation, leading to initiation of prednisone trial therapy. Nine months later, the patient was referred to a tertiary center owing to persistence of optic disc edema OS. PET CT was consistent with a diagnosis of sarcoidosis. Antifungal treatment was discontinued, and oral prednisone with methotrexate was initiated. Subsequently, methotrexate was replaced by infliximab to further manage ocular inflammation and neurologic symptoms which was effective. Vision was 20/20 OD and 20/30 OS at the most recent visit.Conclusion and Importance: Signs and symptoms of neurosarcoidosis and coccidioidomycosis can be similar and deceiving. The index case underscores importance of considering appropriate differential diagnoses in patients with similar symptoms and signs who may respond to preliminary designated treatment but not to the optimal extent. Considering such possibility could assist clinicians in managing the patients timely and efficiently.Keywords: neurosarcoidosis, coccidioidomycosis, sarcoidosis, ocular involvement

Hammouda Hamdy Ghoraba,1 Mahmoud Leila,2 Hashem H Ghoraba,1 Haithem Maamoun Abdelfattah,3 Emad Eldin Mohamed Elgemai4 1Retina Department, Magrabi Eye Hospital, Tanta, Egypt; 2Retina Department, Research Institute of Ophthalmology, Giza, Egypt; 3Ophthalmology Department, Benha Teaching Hospital, Benha, Egypt; 4Ophthalmology Department, Damanhour Teaching Hospital, Damanhour, EgyptCorrespondence: Mahmoud Leila, Retina Department, Research Institute of Ophthalmology, 2 Al-Ahram Street, Giza, Egypt, Email mahmoudleila@yahoo.comPurpose: This is a retrospective case report in which we describe our findings in two cases of endophthalmitis associated with perforating gunshot injury, in which we documented intraocular intrusion of multiple eyelashes as a plausible source of infection.Patients and Methods: Two male patients, 22 and 29 years old, respectively, presented with endophthalmitis following primary repair of rupture globe secondary to gunshot injury. Both patients had vitrectomy and silicone oil injection. Preoperative imaging and intraoperative findings confirmed the perforating nature of the projectile.Results: In both patients, we detected eyelashes that were concealed either in the pars plana region or within vitreous exudates. Silicone oil was not removed in both patients to prevent phthisis bulbi and because there was no potential for visual improvement. The postoperative course in both cases was uneventful.Conclusion: Gunshot injuries can inoculate eyelashes impregnated with infectious microorganisms into the eye. In cases presenting with endophthalmitis associated with a gunshot injury, we recommend meticulous examination of the posterior segment and the pars plana region during vitrectomy to exclude the presence of occult lashes.Keywords: gunshot injury, endophthalmitis associated with perforating IOFB, post-traumatic endophthalmitis, case report

Hashem H Ghoraba, Amir Akhavanrezayat, Irmak Karaca, Negin Yavari, Sherin Lajevardi, Jaclyn Hwang, Jonathan Regenold, Wataru Matsumiya, Brandon Pham, Moosa Zaidi, Azadeh Mobasserian, Anthony Toan DongChau, Christopher Or, Cigdem Yasar, Kapil Mishra, Diana Do, Quan Dong Nguyen Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USACorrespondence: Quan Dong Nguyen, Spencer Center for Vision Research, Byers Eye Institute, Stanford University, 2370 Watson Court, Suite 200, Palo Alto, CA, USA, Tel +1 6507257245, Fax +1 6507368232, Email ndquan@stanford.eduAbstract: Gene therapy has emerged as a research topic of choice in recent years. The eye in particular is one of few organs of the body for which gene therapy has received Food and Drug Administration approval, and it remains a field of great interest for gene therapy development. However, its associated immune and inflammatory reactions may render the treatment ineffective or harmful, which are of particular concern for the eyes due to their susceptibility to inflammation. The severity of immune and inflammatory reactions depends on the choice of vector and its route of administration. Furthermore, most preclinical and clinical studies have shown that the dose of vectors is correlated with the degree of humoral response and ocular inflammation. The route of administration directly impacts the degree of immune and inflammatory reaction. Subretinal delivery produces a weaker humoral response than the intravitreal route. However, some studies have demonstrated that the subretinal delivery induces a stronger inflammatory reaction. On the other hand, several instances of vision loss due to severe late onset intraocular inflammation were reported in a clinical trial involving intravitreal delivery of viral vectors. When compared with the intravitreal route, suprachoroidal gene delivery has been shown to produce weaker humoral response. However, unlike the subretinal space, the suprachoroidal space is not known to have immune privilege status. Inflammatory reactions following ocular gene therapy are typically mild and most clinical and preclinical studies have shown that they can be controlled with topical, local or systemic steroids. However, severe inflammatory responses may occur and require aggressive management to avoid permanent vision loss. Further investigations are required to elucidate and expand our knowledge of inflammatory reactions, and their optimal management, following ocular gene therapy.Keywords: ocular gene therapy, gene therapy, viral vectors, ocular inflammation, review

Hashem H Ghoraba,1 Wataru Matsumiya,1,2 Hassan Khojasteh,1 Amir Akhavanrezayat,1 Irmak Karaca,1 Christopher Or,1 Negin Yavari,1 Sherin Lajevardi,1 Jaclyn Hwang,1 Cigdem Yasar,1 Diana Do,1 Quan Dong Nguyen1 1Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA; 2Department of Surgery, Division of Ophthalmology, Kobe University Graduate School of Medicine, Kobe, JapanCorrespondence: Quan Dong Nguyen, Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, 2370 Watson Court, Suite 200, Palo Alto, CA, USA, Tel +16507257245, Fax +1 6507368232, Email ndquan@stanford.eduPurpose: To evaluate the safety of intravenous high-dose pulse methylprednisolone succinate (IVHDM) in the management of severe or refractory non-infectious pediatric uveitis.Methods: We reviewed all uveitis patients who were ≤ 16 years of age and who received IVHDM with a dose of ≥ 500 mg per day (1– 3 days a month) for at least 3 months during their management at a tertiary care eye hospital.Results: Twenty pediatric patients with severe or refractory uveitis who received IVHDM were identified. Six patients received IVHDM either once, as a preoperative medication, or at a lower dose than 500 mg, and were excluded. The remaining 14 patients received IVHDM for at least 4 months. Age (mean±SD) was 11.9± 2.4 years and 50% were female. Duration of treatment was 14.2± 7.5 months. Thirteen patients received IVHDM in combination with other immunomodulatory therapy (IMT). Except for two outliers, IVHDM was given at a dose of 8– 25 mg/kg per infusion. Three major adverse events (AEs) occurred in two patients: a single episode of bradycardia, compression fracture following minor trauma and adrenal insufficiency. The number of AEs (major and minor) strongly correlated with duration of treatment (p=0.004) and moderately correlated with the cumulative dose/weight (p=0.051). Weight gain was associated with the use of concomitant oral steroids and not with duration of treatment or cumulative dose.Conclusion: IVHDM may be a valid therapeutic option for aggressive/refractory pediatric uveitis. The reported AEs in this series can also be attributed to the concurrent IMT or the underlying disease itself.Keywords: pediatric uveitis, intravenous methylprednisolone, adverse events

Hammouda Hamdy Ghoraba,1,2 Mahmoud Leila,3 Adel Galal Zaky,4 Sameh Mohamed Elgouhary,4 Amin Faisal Ellakwa,4 Hosam Othman Mansour,5 Mohamed Amin Heikal2,6,7 1Faculty of Medicine, Tanta University, Tanta, Egypt; 2Magrabi Eye Hospital, Tanta, Egypt; 3Retina Department, Research Institute of Ophthalmology, Giza, Egypt; 4Ophthalmology Department, Faculty of Medicine, Menoufia University, Shebin ElKom, Menoufia, Egypt; 5Ophthalmology Department, Faculty of Medicine, Al Azhar University - Damietta Branch, New Damietta, Egypt; 6Ophthalmology Department, Faculty of Medicine, Benha University, Benha, Egypt; 7Vitreoretinal Department, Magrabi Eye Hospital, Eastern province, Khober, KSACorrespondence: Mahmoud Leila 146 Street 3, 2nd Floor, Flat#8, Hadabet Al-Ahram, Giza, 12572, EgyptTel +201286644025Email mahmoudleila@yahoo.comPurpose: To report the long-term outcome of pars plana vitrectomy (PPV) for management of retained posterior segment intraocular foreign body (IOFB) secondary to gunshot injury.Methods: This is a retrospective interventional case series including consecutive patients who had PPV for retained posterior segment IOFB secondary to gunshot injury. Main outcome measures were final best-corrected visual acuity (BCVA), long-term globe survival and detection of complications. Spearman correlation analyzed relationships between numerical data. Kruskal–Wallis test compared differences in initial BCVA and final BCVA across variables. Categorical variables were tested using Chi square or Fisher’s exact test. P value is significant at 0.05.Results: The study included 103 eyes of 103 patients. Mean baseline BCVA was 0.01 decimal unit (2 logMAR). Mean duration from primary repair to PPV was 3 weeks. Mean duration of post-operative follow-up was 60 months. Mean final BCVA was 0.04 decimal unit (1.3 logMAR), p 0.001. Post-operatively, BCVA improved in 58.2% of patients. Nineteen patients (18%) gained ≥ 2 lines of vision, and 15 patients (14.5%) achieved final BCVA of 0.4 decimal unit (logMAR 0.4). All complications were related to the original injury. These included macular scar (19%), macular pucker (6%), recurrent retinal detachment (4%), subretinal fibrosis (3%), consecutive optic atrophy (3%), and PVR (3%). Phthisis bulbi or sympathetic ophthalmia did not develop in any case.Conclusion: PPV for removal of IOFB caused by gunshot injury yielded long-term favorable functional outcome with excellent globe survival. Poor initial BCVA, location of IOFB in the posterior pole, associated lens injury and retinal detachment are significant adverse prognostic factors for final BCVA but not for globe survival.Keywords: Intraocular foreign body; IOFB, ocular gunshot injury, penetrating ocular trauma, IOFB-associated endophthalmitis, pars plana vitrectomy for intraocular foreign body, PPV for IOFB

Hammouda Hamdy Ghoraba,1,2 Mahmoud Leila,3 Mohamed Shebl,4 Mohamed Ahmed Abdelhafez,4 Haithem Maamoun Abdelfattah4,5 1Ophthalmology Department, Faculty of Medicine, Tanta University, Tanta, Egypt; 2Magrabi Eye Hospital, Tanta, Egypt; 3Retina Department, Research Institute of Ophthalmology, Giza, Egypt; 4Vitreoretinal Consultant, Magrabi Eye Hospital, Tanta, Egypt; 5Vitreoretinal Associate Consultant, Benha Teaching Hospital, Benha, EgyptCorrespondence: Mahmoud LeilaRetina Department, Research Institute of Ophthalmology, Giza, EgyptTel +201286644025Email mahmoudleila@yahoo.comPurpose: To assess the efficacy of pars plana vitrectomy (PPV) and silicone oil tamponade for management of myopic retinal detachment associated with macular hole (MRDMH) and to assess the anatomical and functional outcomes of this technique and its long-term validity after silicone oil removal.Methods: Retrospective interventional non-comparative case series including consecutive patients who had PPV and silicone oil tamponade for MRDMH. All patients had an axial length ≥ 26 mm. Main outcome measures were retinal re-attachment and macular hole closure after silicone oil removal, improvement of best-corrected visual acuity (BCVA), and complications secondary to surgery. Chi square/Fisher’s exact test was used to analyze categorical variables, while One-way ANOVA/Kruskal–Wallis test was used to compare variables across the closure type and complications. Correlations between numerical variables were tested using Spearman correlation. Kaplan–Meier method was used to estimate the event-free survival. P value is significant at 0.05.Results: The study included 26 eyes of 26 patients. Retinal re-attachment rate after primary and secondary surgeries was 88.4% and 100%, respectively. W-type macular hole closure occurred in 58% of eyes. Vision improved in 58% of eyes. Mean final BCVA was 0.05 decimal units, p = 0.004. Cataract and glaucoma developed in 42% and 15% of eyes, respectively. Initial BCVA, axial length and duration of silicone oil tamponade did not correlate significantly with either the type of macular hole closure or the final BCVA.Conclusion: PPV and silicone oil tamponade technique promotes successful anatomical and functional outcome in MRDMH. Long-term success is maintained after silicone oil removal. High incidence of silicone oil-induced complications mandate its removal from eyes with successful retinal re-attachment.Keywords: retinal detachment in high myopia, myopic macular hole, retinal detachment secondary to myopic macular hole, PPV for myopic retinal detachment associated with macular hole

Hammouda Hamdy Ghoraba,1,2 Mahmoud Leila,3 Adel Galal Zaky,4 Tamer Wasfy,1 Haithem Maamoun Abdelfattah,2,5 Emad Mohamed Elgemai,2,6 Sameh Mohamed El Gouhary,4 Hosam Osman Mansour,7 Hashem Hammouda Ghoraba,1,2 Mohamed Amin Heikal8,9 1Ophthalmology Department, Tanta University, Tanta City, Gharbia, Egypt; 2Ophthalmology Department, Magrabi Eye Hospital, Tanta City, Gharbia, Egypt; 3Retina Department, Research Institute of Ophthalmology, Cairo, Egypt; 4Ophthalmology Department, Menoufia University, Shebein Elkoom City, Menoufia, Egypt; 5Ophthalmology Department, Benha Teaching Hospital, Benha City, Qualuopia, Egypt; 6Ophthalmology Department, Damanhour Teaching Hospital, Dmanhour City, Albehaira, Egypt; 7Alazahr University, Damietta City, Damietta, Egypt; 8Ophthalmology Department, Benha University, Benha City, Qualuopia, Egypt; 9Vitreoretinal Department, Magrabi Eye Hospital, Khober City, Eastern Province, Kingdom of Saudi ArabiaCorrespondence: Mohamed Amin HeikalOphthalmology Department, Benha University, Benha City, Qualuopia, 13511, EgyptTel +00201007131431Email mohammedheikel@gmail.comPurpose: To compare different types of macular holes regarding the anatomic and functional success following pars plana vitrectomy (PPV) and internal limiting membrane (ILM) removal.Methods: A retrospective review of all patients with macular holes treated by PPV, ILM removal with gas tamponade from January 2014 to July 2017 in Magrabi Eye Hospital.Results: One hundred fifty-seven eyes of 153 patients were analyzed. The eyes were classified according to the etiology of macular hole into four groups: 79 eyes with idiopathic macular hole (IMH), 51 eyes with traumatic macular hole (TMH), 16 eyes with macular hole in diabetic patients (DMH) and 11 eyes with myopic macular hole (MMH). We classified the IMH group based on the International Vitreomacular Traction Study Classification according to size into 3 subgroups; subgroup 1: ≤ 250μ, subgroup 2: > 250 to 400μ and subgroup 3: ≥ 400 μ. All types of macular hole showed statistically significant postoperative improvement in BCVA compared to the baseline except cases with MMH. Anatomic postoperative hole closure was achieved in 86.1%, 60.7%, 43.65%, an 45.46% of eyes with IMH, TMH, DMH and MMH, respectively. In eyes with IMH, closure rate in subgroup 1 was significantly higher than in subgroups 2, and 3.Conclusion: PPV, ILM peel and C2F6 technique yielded variable anatomic and functional outcomes in different types of macular holes. Anatomic results were most favorable in IMH and least favorable in MMH. The smaller the diameter of the hole the better the results. The underlying pathogenetic mechanisms that lead to different types of macular holes are pivotal in determining the final outcome.Keywords: ILM peeling, macular holes, pars plana vitrectomy

Hammouda Hamdy Ghoraba,1,2 Hosam Othman Mansour,1,3 Mohamed Ahmed Abdelhafez,1 Sameh Mohamed El Gouhary,4 Adel Galal Zaky,4 Mohamed Amin Heikal,5 Ali Ahmed Ali Ghali3 1Magrabi Eye Hospital, Tanta, Egypt; 2Tanta University, Tanta, Egypt; 3Al Azhar University, Damietta Branch, New Damietta, Egypt; 4Meunofia University, Meunofia, Egypt; 5Benha University, Benha, EgyptCorrespondence: Hosam Othman MansourAl Azhar University, Damietta Branch, New Damietta, EgyptTel +201001559282Email drhmansor@yahoo.comBackground and Objectives: To compare anatomical and visual results of pars plana vitrectomy (PPV) with or without additional encircling band in the management of pediatric traumatic rhegmatogenous retinal detachment (RD) in a tertiary referral center.Methods: A retrospective review of children diagnosed with traumatic rhegmatogenous retinal detachment treated by pars plana vitrectomy with or without encircling band.Results: One hundred thirty-nine eyes of 139 children diagnosed with traumatic rhegmatogenous retinal detachment. Surgeries were performed between May 2011 and November 2016. Patients were followed up for at least 18 months after last intervention. The included eyes were categorized into two groups. Group A (vitrectomy with additional encircling band) included 72 eyes of 72 children; 58 boys and 14 girls. Group B (vitrectomy without encircling band) included 67 eyes of 67 children; 58 boys and 9 girls. In group A, the mean age was 9.21± 3.24. Attached retina was achieved in 61% (44 out of 72 eyes), of which 34 eyes remained attached after silicon oil removal, and 10 eyes remained attached under silicon oil tamponade. Recurrent RD under oil was present in 28 eyes (38.9%). In group B, the mean age was 11.06± 3.64. Attached retina was present in 61.2% (41 out of 67 eyes), of which 30 eyes remained attached after oil removal, and 11 eyes remained attached under silicon oil tamponade. Recurrent RD was present in 26 eyes (38.8%). In group A, the final visual acuity (VA) ranged from NLP to 0.5; 58.7% of patients achieved VA more than counting fingers at 1 meter, and 34.6% of patients achieved VA of 0.05 or more. In group B, the final postoperative VA ranged from NLP to 0.9; 16% of patients achieved VA from counting fingers at 1 meter to 0.05, and 29.2% achieved VA of 0.05 or more.Conclusion: Although no statistically significant difference between the two groups (combined vitrectomy and encircling band versus vitrectomy alone in pediatric traumatic retinal detachment), it is wise to consider adding encircling band in severe trauma cases.Keywords: trauma, pediatric retinal detachment, encircling band, pars plana vitrectomy, silicon oil

Hammouda Hamdy Ghoraba,1,2 Mahmoud Leila,3 Sameh Mohamed Elgouhary,4 Emad Eldin Mohamed Elgemai,2,5 Haithem Mamon Abdelfattah,2,6 Hashem Hammouda Ghoraba,2 Mohamed Amin Heikal7 1Department of Ophthalmology, Faculty of Medicine, Tanta University, Tanta, Egypt; 2Department of Retina, Magrabi Eye Hospital, Tanta, Egypt; 3Retina Department, Research Institute of Ophthalmology, Giza, Egypt; 4Department of Ophthalmology, Faculty of Medicine, Menoufia University, Menoufia, Egypt; 5Department of Ophthalmology, Damanhour Teaching Hospital, Damanhour, Egypt; 6Department of Ophthalmology, Banha Teaching Hospital, Banha, Egypt; 7Department of Ophthalmology, Faculty of Medicine, Benha University, Benha, Egypt Purpose: The purpose of this study was to evaluate the safety of high-dose intravitreal triamcinolone acetonide (IVTA) as affordable low-cost alternative to anti-vascular endothelial growth factor (anti-vascular endothelial growth factor [anti-VEGF] agents) in lower-middle-income countries.Patients and methods: This was a retrospective interventional non-comparative case series. The study recruited patients who received 20 mg IVTA for treating various retinal and optic nerve diseases over the past 5 years. Main outcome measure was assessment of complications secondary to high-dose IVTA. The crosstabs procedure was used to display the interaction between the variables tested. The ANOVA test was used to analyze the differences among group means.Results: The study included 207 eyes of 168 patients. The main indication for high-dose IVTA were diabetic macular edema 64%, and macular edema secondary to retinal vein occlusion 19%. The mean follow-up period post-injection was 22 months. Mean number of injections was 1.3. Cataract developed in 54% of eyes. Glaucoma developed in 18.5% of eyes. Glaucoma surgery for intractable glaucoma attributed to high-dose IVTA was needed in 1% of eyes. Endophthalmitis and retinal detachment developed in one patient each.Conclusion: High-dose IVTA is a safe and cost-effective alternative to anti-VEGF agents. Cataract formation and intraocular pressure rise do not pose major adverse effects when weighed against the risk of vision loss due to inability to afford anti-VEGF treatment. Keywords: high-dose IVTA, cost-effectiveness of anti-VEGF, ICER of anti-VEGF per QALY

Hamouda Hamdy Ghoraba,1,2 Adel Galal Zaky,3 Amin Faisal Ellakwa31Ophthalmology Department, Faculty of Medicine, Tanta University, Tanta, 2Opthalmology Department, El Magrabi Eye Hospital, Tanta, 3Ophthalmology Department, Faculty of Medicine, Menoufia University, Cairo, EgyptObjective: The aim of this study was to report and compare the anatomic and functional results of primary vitrectomy with and without 360° encircling scleral buckle (SB) for the treatment of rhegmatogenous retinal detachment (RRD) due to inferior retinal break(s).Background: A variety of options, including SB, pars plana vitrectomy (PPV) with or without SB, and pneumatic retinopexy have been described as methods to repair RRDs. The use of additional SB with vitrectomy for RRD associated with inferior breaks has been a recent controversy after the introduction of transconjunctival cannula systems.Patients and methods: A retrospective, interventional, comparative case study was performed. In this study, we reviewed 105 consecutive patients who underwent vitrectomy for primary RRD with inferior retinal break(s) at the vitreoretinal center, performed by a single surgeon. Ninety four patients (94 eyes) were followed up for at least 4 months after silicon oil removal (SOR), and were analyzed. They were divided into two groups: group I included 50 patients who underwent PPV alone + silicon oil (SO); and group II included 44 patients who underwent PPV with 360° SB + SO. The essential parameters were single-operation success rate (SOSR) before SOR, incidence of retinal redetachment after SOR, and final visual acuity.Results: SOSR was obtained in 89 eyes (47 [94%] in group I and 42 [95.5%] in group II). From overall 59 phakic retinal detachments (RDs), SOSR was obtained in 56 eyes (30 in group I [93.8%] and 26 in group II [96.3%]) while from overall 35 aphakic or pseudophakic RDs, SOSR was obtained in 33 eyes (17 in group I [94.4%] and 16 in group II [94.1%]). Retinal redetachments after SOR occurred in three patients in group I and two patients in group II. Visual acuity improvement was greater in group I than in group II before SOR.Conclusion: Both surgical procedures had similar reattachment rates. The addition of 360° SB to PPV + SO might not have additional benefits in patients with RD due to inferior retinal break.Keywords: pars plana vitrectomy, scleral buckle, rhegmatogenous retinal detachment

Hammouda H Ghoraba,1,2 Ali Ahmed Ghali,3 Hosam Othman Mansour2,3 1Tanta University, Tanta, Egypt; 2Magrabi Eye Hospital, Cairo, Egypt; 3Al-Azhar University, Cairo, Egypt Purpose: To report a retrospective series of seven phakic eyes of seven patients suffering from a malignant glaucoma-like syndrome following pars plana vitrectomy and silicone oil (SO) injection.Materials and methods: Seven eyes with retinal detachment treated with pars plana vitrectomy with or without scleral buckling with SO tamponade. This was followed by cataract extraction to manage the elevated intraocular pressure (IOP).Results: This was a retrospective review of seven cases that received pars plana vitrectomy and SO with or without scleral buckling for different causes of retinal detachment (three were rhegmatogenous and four were tractional). After a period ranging from 1 week to 1 month, they presented with malignant glaucoma-like manifestations; high IOP, shallow axial anterior chamber, and remarkable decrease of visual acuity. Atropine eye drops and anti-glaucoma medical treatment (topical and systemic) had been tried but failed to improve the condition. Dramatic decrease of IOP and deepening of the axial anterior chamber was observed in all cases in the first postoperative day after phacoemulsification and posterior chamber foldable intraocular lens implantation with posterior capsulotomy.Conclusion: Aqueous misdirection syndrome may be observed following pars plana vitrectomy and SO tamponade. This must be differentiated from other causes of post vitrectomy glaucoma. Cataract extraction with posterior capsulotomy controls the condition. Keywords: malignant glaucoma, pars plana vitrectomy, silicone oil

Hammouda H Ghoraba,1,2 Sameh M Elgouhary,3 Amin F Ellakwa3 1Department of Ophthalmology, Tanta University, Tanta, Egypt; 2Vitreoretinal Unit, Magrabi Eye Hospital, Tanta, Egypt; 3Department of Ophthalmology, Menoufiya University, Menufia, Egypt Purpose: To evaluate the safety and efficacy of different methods of transconjunctival cannulated vitrectomy versus conventional non-cannulated vitrectomy in various vitreoretinal disorders. Methods: A prospective randomized study was done from August 2009 to February 2011. The study included 129 eyes of 122 patients, randomly divided into four groups. Group 1 comprised 34 eyes operated on using transconjunctival 20-gauge cannula Claes system. Group 2 comprised 32 eyes operated on using transconjunctival cannulated 23 gauge system. Group 3 comprised 27 eyes operated on using combined 20-gauge non-cannulated and 23-gauge transconjunctival cannulated system. Group 4 comprised 36 eyes operated on using conventional non-cannulated 20-gauge system. Results: The four groups were demographically similar. Anatomical outcome was achieved in all cases. Vision was improved in 29 eyes (85.3%) in group 1, 23 eyes (71.9%) in group 2, 19 eyes (70.4%) in group 3, and 26 eyes (72.2%) in group 4. There was no statistical difference between the four groups 1-day postoperative (P=0.405) and 1-week postoperative intraocular pressure (P=0.254). The number of sutureless sclerotomies was 68 (66.6%) in group 1, 78 (81.3%) in group 2, 50 (61.8%) in group 3, and 0 in group 4. Hypotony occurred in one eye (2.9%) in group 1, three eyes (9.4%) in group 2, two eyes (7.4%) in group 3, and no eyes in group 4. Operative endophthalmitis did not occur in any one of the four groups. Conclusion: Final anatomical and functional outcomes were not related to the type of sclerotomy used (cannulated or non-cannulated), the gauge used (20 or 23), the route (transconjunctival or transscleral), or type of suture used. The advantages of small-gauge transconjunctival vitrectomy were patient comfort, early ambulation, and preservation of the conjunctiva. This should be weighed against the cost of this cannula system. Keywords: 20 gauge, 23 gauge, PPV, sutureless vitrectomy

Hammouda H Ghoraba1, Amin F Ellakwa2, Ali A Ghali31Tanta University, Magrabi Eye Hospital, Tanta, Egypt; 2Menoufiya University, Shebin Elkom, Menoufiya, Egypt; 3Alazhar University, Damitta, EgyptPurpose: To compare the effectiveness of pars plana vitrectomy (PPV) with either silicone oil or gas tamponade for the treatment of traumatic macular holes.Methods: A retrospective comparative study included 22 patients who were operated on by PPV for repair of traumatic macular holes with either silicone oil tamponade (nine patients) or perfluoropropane (C3F8) gas tamponade (13 patients).Results: Twenty-two cases were reviewed to assess the anatomical and visual outcomes of surgery with silicone oil tamponade in nine cases (40.9%) vs 14% C3F8 gas tamponade in 13 cases (59.1%). The age of the silicone oil-treated patients ranged from 10 to 40 years (mean 27.4 ± 11.3 years), while that of the gas-treated patients ranged from 19 to 35 years (mean 26.54 ± 5.68 years). Female patients accounted for 33.3% of the silicone oil group and 30.77% of the gas-treated group. The minimal follow-up time for the silicone oil-treated group was 13 months, with a maximum of 18 months after silicone oil removal. The minimal follow-up time for the gas-treated group was 12 months and the maximum was 24 months. The rate of hole closure after the primary operation with oil tamponade was significantly lower than that with gas tamponade (66.67% vs 92.3%; P = 0.022). With re-operations, the final rate of hole closure was higher in the gas group (100%) than in the silicone oil group (77.8%). The final postoperative decimal visual acuity for the gas group was significantly better than for the oil group (0.433 vs 0.245; P = 0.047).Conclusions: C3F8 gas was a more effective tamponade than silicone oil in achieving initial closure of traumatic macular holes. Eyes receiving an oil tamponade required significantly more re-operations to achieve hole closure than did eyes undergoing a gas tamponade. Final visual acuity was better for gas-treated eyes than for silicone oil-treated eyes.Keywords: C3F8 gas, macular hole, silicone oil, trauma, vitrectomy