Awadein, A., and S. Arfeen, "Muscle fenestration in vertical rectus muscle surgeries.", European journal of ophthalmology, pp. 11206721221129671, 2022. Abstract

PURPOSE: To evaluate the outcome of fenestration of the vertical rectus muscles in correcting vertical deviations.

MATERIAL AND METHODS: A retrospective chart review was conducted on patients who underwent fenestration surgery on the superior rectus (SR) or inferior rectus (IR) muscles. Ductions, versions, angle of deviations before and after surgery, and surgical details were analyzed Success was defined as vertical alignment within 4 PD of orthophoria.

RESULTS: Nineteen patients were identified. The mean age of the patients was 19.3 ± 13.1 (range; 4 to 48) years. The mean follow-up was 6.5 ± 2.7 (range, 3 to 12) months. Eleven patients presented with dissociated vertical deviation (DVD), 2 patients with sensory hypertropia, and 6 patients with sensory hypotropia. Fourteen patients had concomitant horizontal muscle surgery. The mean change of the angle of deviation was 13 ± 3 (range, 8 to 20) PD after SR fenestration. and 12 ± 2 (range; 10 to 15) PD after IR fenestration. There was a significant improvement in the post operative angle of deviation in both groups (P value <0.001). Success was achieved in 10 (77%) of patients who underwent SR fenestration and in all patients underwent ir fenestration. Only one patient in the IR group developed a 1-mm lower lid retraction.

CONCLUSION: Fenestration of the vertical rectus muscles is an effective and safe method for correcting vertical deviations. We recommend increasing the amount of fenstration in DVD to further improve the outcome.

Zedan, R., C. S. Farag, J. Gouda, A. Awadein, H. Elhilali, and D. H. Hassanein, "Outcome of intraocular lens exchange for the management of myopic shift in pseudophakic children.", European journal of ophthalmology, pp. 11206721231218299, 2023. Abstract

PURPOSE: To evaluate the visual outcome of intraocular lens (IOL) exchange for the management of myopic shift in pseudophakic children.

METHODS: The medical records of children who underwent IOL exchange for myopic shift were examined. The preoperative data, operative details and the postoperative outcome were analyzed.

RESULTS: Twenty-one eyes (16 patients) were identified. Mean age at cataract extraction was 20 ± 26 months (range, 2-84 months). Twelve patients (6 unilateral, 6 bilateral) had primary IOL implantation. Mean age at IOL exchange was 7.3 ± 3.2 years. Mean spherical equivalent (SE) at IOL exchange was -14 ± 5 D (range, -7 to -21 D): Mean SE at IOL exchange was -13.64± 4.99 D, -12 ± 1.53 D, and -15.5 ± 4.7 D in unilaterally pseudophakic cases (8 patients), in the eye that underwent unilateral IOL exchange (3 patients) in bilaterally pseudophakic cases, and in bilateral IOL exchange cases (5 patients), respectively. Mean axial length at IOL exchange was 24 ± 1.3 mm (range, 23 to 27 mm). Following IOL exchange, mean SE was reduced to -2 ± 1.8 D (range, -4 to +2.5 D). An average of three logMAR line improvement in the best-corrected visual acuity was observed in 12/16 eyes of patients for whom pre- and post-exchange visual acuity were available, while visual acuity remained unchanged in 4 eyes. Mean logMAR visual acuity improvement was 0.35 and 0.49 in unilateral and bilateral pseudophakic cases, respectively.

CONCLUSIONS: IOL exchange is a safe procedure that should be considered to improve visual rehabilitation in pseudophakic patients with myopic shift.

Ismail, M., and A. Awadein, "Palpebral Fissure Changes in the Contralateral Eye in Duane Retraction Syndrome.", Journal of pediatric ophthalmology and strabismus, vol. 60, issue 3, pp. e22-e25, 2023. Abstract

Duane retraction syndrome (DRS) is a congenital cranial dysinnervation disorder that is characterized by paradoxical lateral rectus muscle innervation of the affected eye by axons meant to innervate the ipsilateral medial rectus muscle, with resultant varying degrees of co-contraction. It is characterized by severe abduction deficiency, variable limitation of adduction, globe retraction with narrowing of the palpebral fissure, and oblique elevation or depression on adduction. A total of 16 patients with unilateral DRS were identified. The mean age was 13 ± 8 years (range: 6 to 28 years). There were 5 males and 11 females. The cohort included 8 patients with DRS type I, 3 patients with DRS type II, 4 patients with DRS type III, and 1 patient with synergistic divergence (DRS type IV). The mean width of the palpebral fissure in primary gaze was 9.95 ± 0.25 mm, increased in abduction to 11.11 ± 1.16 mm, and changed on adduction to 10.03 ± 1.19 mm. The mean reduction in the size of the palpebral fissure on adduction was 11.7 ± 10.2% (range: 0 to 30%). The difference in the palpebral fissure width between adduction and abduction was statistically significant ( = .0018). Of the 16 patients, 8 (50%) showed narrowing of the palpebral fissure of the contralateral eye on adduction compared to abduction of more than 10%. In this case series of unilateral Duane retraction syndrome, there was a common association between widening of the palpebral fissure of the unaffected eye and adduction of the eyes with DRS in DRS types II, III, and IV and DRS type I with upshoot or downshoot. .

Meqdad, Y., M. El-Basty, A. Awadein, J. Gouda, and D. Hassanein, "Randomized Controlled Trial of Patching versus Dichoptic Stimulation Using Virtual Reality for Amblyopia Therapy.", Current eye research, vol. 49, issue 2, pp. 214-223, 2024. Abstract

To compare the outcomes of patching to dichoptic stimulation using virtual reality (VR) in moderate and severe amblyopia. This study was conducted on 86 subjects with unilateral anisometropic and mixed amblyopia. The subjects were randomized to the VR or patching group. The VR group received treatment using the Vivid Vision software (Vivid Vision Inc., San Francisco, USA) with each subject receiving weekly 2 h-sessions for 10 weeks. The patching group was prescribed patching for 10 weeks. Best-corrected visual acuity (BCVA) was measured using a single crowded letter in an ETDRS chart before, after 10 weeks of treatment, and after another 10 weeks of cessation of treatment. Near stereoacuity was measured using the TNO test. Forty-two patients were randomized to the patching group and 44 to the VR group. The median age of the subjects was 12.0 (range 6.0 to 37.0) years. In the VR group, mean amblyopic eye BCVA showed statistically significant improvement by 0.89 line (95% confidence interval {CI}, 0.73 to 1.35 lines;  < 0.001) after 10 weeks of therapy, and after another 10 weeks of follow-up by 1.32 lines from baseline (95% CI, 1.15 to 1.7 lines;  < 0.001). Regarding the patching group, mean BCVA showed statistically significant improvement after 10 weeks by 1.38 lines (95% CI, 0.82 to 1.8 lines;  < 0.001), and after another 10 weeks by 1 line from baseline (95% CI, 0.06-0.147; 0.6 to 1.47 lines;  < 0.001). There was no significant difference between both groups at any time-point ( values >0.05). No serious adverse events were noted. Adults and severe amblyopes in the VR group showed more significant VA improvement than their counterparts in the patching group. Amblyopes treated using VR dichoptic treatment demonstrated statistically significant VA improvement after 10 and 20 weeks of follow-up that is comparable to patching.

Awadein, A., C. S. Farag, and S. Maher, "Zip-up Loop Myopexy in Heavy Eye Syndrome.", Journal of pediatric ophthalmology and strabismus, pp. 1-8, 2024. Abstract

PURPOSE: To describe and report the results of a zip-up modification for loop myopexy for facilitating a muscle union procedure in heavy eye syndrome.

METHODS: A retrospective chart review was conducted on patients with heavy eye syndrome in whom the modified surgical technique was performed. Superior and lateral rectus muscle bellies were approximated using a suture 4 to 5 mm from the muscle insertion. Muscles were then zipped together by 5-0 polyester sutures placed in an anteroposterior direction using a hand-over-hand technique. Details of the surgical technique were reported. Ductions, versions, and angles of strabismus were evaluated before and after surgery. Complications were reported.

RESULTS: A total of 8 patients were identified (mean age: 60.8 ± 7 years). Mean axial length was 33.2 ± 1.2 mm. Mean preoperative horizontal and vertical angles of deviation were 78 ± 20 prism diopters (PD) (range: 50 to 120 PD) and 34 ± 4 PD (range: 30 to 40 PD), respectively. Preoperative limitation of abduction and elevation was -4 to -5 in all patients. An average of seven to eight sutures were used. No intraoperative complications were reported. In 7 patients, both vertical and horizontal angles of deviation were reduced to within 8 PD from orthophoria and limitation of ductions was reduced to null or -1 after surgery. Undercorrection occurred in 1 patient with bilateral heavy eye syndrome who had unilateral surgery. No recurrences developed over a median of 6 months of follow-up.

CONCLUSIONS: A zip-up modification for loop myopexy can facilitate the surgical procedure to achieve a satisfactory outcome in heavy eye syndrome. .

Awadein, A., J. Gouda, H. Elhilali, and K. Arnoldi, "Convergence Excess Esotropia: Review.", Journal of binocular vision and ocular motility, vol. 73, issue 4, pp. 131-159, 2023. Abstract

Convergence excess esotropia is a condition characterized by an esotropia which is greater for near fixation than for distance fixation after full hypermetropic correction with a single focus lens. Convergence excess esotropia may be classified according to the AC/A ratio into two subtypes: accommodative type and non-accommodative type. Bifocal glasses are a suitable option for the management of patients with a high AC/A ratio and for the hypoaccommodative type. However, the overall success rate with bifocals is still low even in selected patients. Surgery is often eventually needed for most patients with convergence excess esotropia. Surgical options that do not directly address the variability of the angle of deviation entail medial rectus recession with the target angle based on the distance deviation, the near deviation, an augmented formula based on an intermediate angle, or on a prism adaptation test. Surgical options that directly address the variability of the angle include partial myotomy, medial rectus muscle posterior scleral fixation with or without recession, pulley fixation, slanting recession, Y-splitting, or combined recession-resection of the medial rectus muscle. The review article summarizes the surgical outcome of these strategies and suggests an algorithm for the management of patients with convergence excess esotropia.

Elkamshoushy, A., A. Awadein, H. Elhilali, and D. H. Hassanein, "Overcorrection after vertical muscle transposition with augmentation sutures in sixth nerve palsy.", Eye (London, England), vol. 37, issue 127, pp. 131, 2023. Abstract

PURPOSE: To report a series of cases, who developed consecutive exodeviation after vertical muscle transposition (VRT) performed for sixth nerve palsy, describe their management and analyse their outcome.

DESIGN: Retrospective case series.

METHODS: This is an institutional study on patients who developed consecutive exotropia following VRT for sixth nerve palsy in two different centres. The age, gender, cause, and time to surgery were reviewed. Ductions, versions and angles of misalignment were analysed. In those who developed an exotropia >10 PD after surgery, a second surgery was performed. The time to the second surgery, intra-operative findings, surgical procedure and outcome were studied.

RESULTS: A total of 164 cases of VRT for sixth nerve palsy were identified. Nine patients developed consecutive exotropia >10 PD (5.5%). There were no significant differences in the characteristics of those who developed overcorrection compared to those who did not. Five patients had full-tendon muscle transposition, three patients had Hummelsheim procedure and one patient had Jensen procedure. The average angle of consecutive exotropia was 26 ± 9 Δ (range 10-40 Δ). After the second surgery, angle of exotropia decreased to 21 ± 15 PD. Seven patients still had residual exotropia ≥10Δ and the exotropia was corrected in the remaining two patients. The time to second surgery in those two patients was much shorter than the other seven patients.

CONCLUSIONS: Patients who undergo VRT should be followed up in the early post-operative period and revisiting the transposition should be done immediately in case of consecutive exotropia to avoid permanent overcorrection.

Gouda, J., A. Awadein, H. Elhilali, and F. Heba M, "Relationship between Age at Surgery and Surgical Outcome of Bilateral Lateral Rectus Recession in Intermittent Exotropia", Neuroquantology, vol. 20, issue 3309, pp. 3319, 2022.
Monem, A. A. A., A. Awadein, M. M. Genaidy, A. Shawkat, and S. Torky, "Adjustable Sutures in Strabismus Surgery", Neuroquantology, vol. 20, issue 908, pp. 910, 2022.
Awadein, A., A. A. Youssef, and J. Gouda, "Nasal insertion of the superior oblique tendon presenting as Brown syndrome.", Strabismus, vol. 30, issue 3, pp. 144-149, 2022. Abstract

BACKGROUND: Anomalous ocular muscle insertions are a rare cause of ocular motility disturbances.

METHODS: We report the clinical presentation and the intraoperative findings of two cases with an abnormally nasally inserted superior oblique tendons presenting with a Brown syndrome-like clinical picture.

RESULTS: Case no 1 was a 5-year-old girl presenting with a chin up position. There was bilateral limitation of elevation in adduction, -4 on the right side and -3 on the left side with +1 downshoot on adduction on either side Patient was orthotropic in down-gaze with small V-pattern exotropia. Case no 2 was a 4-year-old boy presenting with an esotropia of 35Δ that was partially corrected with his spectacles to 20Δ. Ductions showed -4 defective elevation in adduction of the right eye. Surgical exploration in both cases revealed abnormal nasal insertion of the superior oblique tendons. The line of insertion had a convexity facing superonasally. The posterior fibers were inserted 7-8 mm posterior and just nasal to the nasal border of the superior rectus insertion, while the anterior fibers were shorter and inserted 5 mm nasal and 4 mm posterior to the nasal edge of superior rectus insertion. In both cases, there was an improvement in the elevation on adduction after superior oblique lengthening.

CONCLUSIONS: Abnormal nasal insertion of the superior oblique muscle enhances the depressor effect of the muscle and can create a Brown-like picture.

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