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), 2022. 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.

Abdelzaher, H. A., M. K. Sidky, A. Awadein, and M. Hosny, "Aniseikonia and visual functions with optical correction and after refractive surgery in axial anisometropia.", International ophthalmology, vol. 42, issue 6, pp. 1669-1677, 2022. Abstract

PURPOSE: To evaluate differences in the subjective aniseikonia and stereoacuity in patients with axial anisometropia after full correction of the refractive error with spectacles, contact lenses, and refractive surgery.

METHODS: A prospective study was performed in Cairo University Hospitals on 20 patients with axial anisometropia caused by unilateral myopia > 5 D with > 4 D inter-ocular difference in spherical equivalent who were suitable candidates for excimer laser ablation (LASIK) or implantable collamer lens implantation (ICL). All patients had measurement of best-corrected visual acuity (BCVA), fusion, stereoacuity, and magnitude of aniseikonia with spectacles, contact lenses, and after surgery.

RESULTS: The mean age at time of surgery was 25.7 ± 3.1 years. There were no statistically significant differences in the BCVA or stereoacuity with spectacles, contact lenses, or after refractive surgery. Microkonia < 5%) was perceived with spectacles in 8 patients (40%) and remained unchanged in 7 of these 8 patients with contact lenses. Following LASIK (n = 11), there was an induced macrokonia < 2% in 4 patients (36%), persistent microkonia of 3% in 1 patient (9%), and no change in image size in 6 (55%) patients. Following ICL implantation (n = 9), there was a perceived macrokonia of 2% in 4 patients (44%), disappearance of microkonia in 1 patient (11%) and no change in 4 patients (44%).

CONCLUSIONS: Differences in BCVA, stereoacuity, and aniseikonia after correction of anisometropia by glasses, contact lens and surgery are both clinically and statistically insignificant. Retinal or neural adaptation might have a role in correction for differences in image size.

Arfeen, S., M. Azzab, Z. Saad, A. Awadein, M. Kasem, and A. Elkamshoushy, "Comparison between Hummelsheim and Jensen procedures in the management of chronic sixth nerve palsy.", Graefe's archive for clinical and experimental ophthalmology = Albrecht von Graefes Archiv fur klinische und experimentelle Ophthalmologie, vol. 260, issue 1, pp. 363-369, 2022. Abstract

PURPOSE: To compare the postoperative alignment, degree of improvement of abduction, and complications of the Hummelsheim procedure to the Jensen procedure in chronic sixth nerve palsy, and to calculate the dose-response of both procedures.

METHODS: A retrospective study was done on patients who either had Hummelsheim or Jensen procedure for chronic sixth nerve palsy. Demographic characteristics, details of surgical procedure, ductions, versions, and angles of misalignment before and after surgery were analyzed.

RESULTS: A total of 79 patients were identified: 38 Jensen and 41 Hummelsheim. There were no statistically significant differences in baseline characteristics of both groups. Medial rectus recession was performed in 35 patients in the Jensen group and in 30 patients in the Hummelsheim group. Success defined as orthotropia within 8 PD was achieved in 25 (66%) patients in the Jensen group and in 24 (59%) patients in the Hummelsheim group (P = 0.51). The mean improvement in the angle of deviation in the primary position was 42 ± 12 PD in the Jensen group and 42 ± 16 PD in the Hummelsheim group (P = 0.89). The mean improvement in abduction was slightly better in the Hummelsheim group (1.8 vs 1.5, P = 0.32). A new vertical deviation occurred in three patients in the Jensen group and in 4 patients in the Hummelsheim group. Anterior segment ischemia occurred in one patient in the Jensen group.

CONCLUSIONS: There was no difference in the success rate between the Hummelsheim and Jensen procedures in cases of chronic sixth nerve palsy. Strabismus surgeons can choose between the two procedures according to their preference.

Aly, A., J. Gouda, A. Awadein, H. M. Soliman, and D. El-Fayoumi, "Serum cortisol and adrenocorticotrophic hormone (ACTH) in infants receiving topical and subconjunctival corticosteroids following cataract surgery.", Graefe's archive for clinical and experimental ophthalmology = Albrecht von Graefes Archiv fur klinische und experimentelle Ophthalmologie, vol. 259, issue 10, pp. 3159-3165, 2021. Abstract

PURPOSE: Cushingoid features are occasionally encountered in infants after pediatric cataract surgery. The aim of this study is to evaluate whether the use of topical glucocorticoids (GCs) following congenital cataract surgery can result in endogenous adrenal suppression and/or systemic side effects similar to those seen with systemic steroids.

METHODS: A prospective study was performed on 20 infants with bilateral congenital cataract. All infants received a single subconjunctival betamethasone injection of 1 mg at the end of surgery in addition to topical dexamethasone eye drops 1 mg/ml for 6 weeks. All infants had anthropometric measurements and blood pressure measurements, serum cortisol, and ACTH level measurements before surgery and 2 months after. In addition, the total administered glucocorticoid adjusted per weight was calculated.

RESULTS: The mean age of the infants was 4.93 ± 2.58 months. Thirteen were males (65%). The total administered glucocorticoid dose was 18.7 mg and the mean cumulative dexamethasone equivalent dose administered was 2.75 ± 1.31 mg/kg. There was a statistically significant increase in the adjusted weight percentile for age (P = 0.009). Both the systolic and diastolic blood pressure were significantly elevated (P = 0.005 and P = 0.025 respectively). There was a statistically significant reduction in both the morning and afternoon serum ACTH levels (P = 0.023 and P = 0.014). The reduction in serum cortisol levels was statistically non-significant.

CONCLUSIONS: Topical steroids following pediatric cataract surgery can result in both subclinical and clinical changes in the hypothalamic-pituitary-adrenal axis that can be easily overlooked and need careful attention and follow-up.

Awadein, A., Shaimaa A Arfeen, P. Chougule, and R. Kekunnaya, "Duane-minus (Duane sine retraction and Duane sine limitation): possible incomplete forms of Duane retraction syndrome.", Eye (London, England), vol. 35, issue 6, pp. 1673-1679, 2021. Abstract

PURPOSE: To report ocular motility patterns that mimic, but do not fulfil the full clinical picture of Duane retraction syndrome (DRS) and to describe their clinical features and surgical management.

METHODS: This is a retrospective case series study conducted on patients with DRS, mimicking non-comitant exotropia or esotropia and a face turn. Patients were included only if they lacked either globe retraction on adduction (sine retraction) or limitation of adduction or abduction on ductions (sine limitation not >0.5). Any overshoots or pattern strabismus was recorded. The ocular motility and alignment, details of surgery and their surgical outcomes were analysed.

RESULTS: Twenty-one patients were identified; 13 in the sine retraction and 8 in the sine limitation group. All patients presented with a compensatory face turn. Overshoots were present in 10 (77%) and 7 patients (88%) in the sine retraction and sine limitation groups, respectively. Forced duction test showed tightness of the ipsilateral medial and the ipsilateral lateral rectus muscle in esotropic (n = 3) and exotropic patients (n = 18), respectively. Orthotropia was achieved in 82% of patients following ipsilateral medial or lateral rectus muscle recession.

CONCLUSIONS: There is a subset of patients who present with motility pattern similar to DRS but lack its complete diagnostic criteria. The presence of a face turn, overshoots on adduction or an ipsilateral tightness of the affected muscle should make one consider DRS sine retraction/sine limitation. The patients in our study responded well to lines of management similar to those of DRS.

Samy, E., Y. Elsayed, A. Awadein, and M. Gamil, "Effect of general inhalational anesthesia on intraocular pressure measurements in normal and glaucomatous children.", International ophthalmology, vol. 41, issue 7, pp. 2455-2463, 2021. Abstract

PURPOSE: To investigate the agreement between the intraocular pressure (IOP) measurements in the awake condition and under different stages of general inhalational anesthesia using sevoflurane in both glaucomatous and normal children.

METHODS: A prospective study was performed on 43 glaucomatous children and 30 age-matched controls. Baseline IOP of one eye was measured immediately before general anesthesia using Perkins tonometer and then re-measured under light, intermediate, and deep anesthesia, and then after intubation. Depth of anesthesia was determined using bispectral index pediatric sensor. The agreement between the IOP measurements before and during different stages of anesthesia was analyzed using Bland-Altman plots. Systematic and proportionate deviations between the IOP measurements were analyzed.

RESULTS: The mean age was 58.6 ± 41.99 months. The mean IOP was significantly lower at all stages of anesthesia in both groups. The coefficient of variation was over 20% in all measurements under anesthesia. For all IOP measurements during anesthesia, the limits of agreement were > 7 mmHg difference in the control group and > 20 mmHg in the glaucomatous group. The best agreement was with the IOP measurement after intubation (mean limit of agreement of -1.4 mmHg, 1.96 s range, -8.8-6 mm Hg) in the control group and with the IOP measurement under intermediate anesthesia (mean limit of agreement of -4.2 mmHg, 1.96 s range, -15.1-6.8 mm Hg) in the glaucomatous group.

CONCLUSIONS: Inhalational anesthesia has variable effects on IOP measurement at all stages of anesthesia. Caution should be taken when extrapolating the true IOP from these measurements.

Gouda, J., R. H. Tomairek, A. M. Elhusseiny, D. El-Fayoumi, A. Awadein, G. Gawdat, and H. Elhilali, "Changes in Intraocular Pressure and Anterior Chamber Angle After Congenital Cataract Extraction.", Journal of glaucoma, vol. 30, issue 1, pp. 61-64, 2021. Abstract

PRECIS: Anterior chamber angle (ACA) narrowing continues to occur for at least 2 years after congenital cataract surgery. Risk factors for intraocular pressure (IOP) elevation after congenital cataract surgery were higher central corneal thickness (CCT) and surgery at <2 months.

PURPOSE: The purpose of this study was to study the changes in IOP and in the ACA during the first 2 years after pediatric cataract surgery and to determine risk factors for such changes.

PATIENTS AND METHODS: A retrospective observational study was done on infants who underwent pediatric cataract surgery in Cairo University Hospitals and completed a 1-year follow-up. Demographic and clinical characteristics were recorded including age at surgery, sex, corneal diameter, CCT pupil diameter, IOP, gonioscopic findings, presence of persistent hyperplastic primary vitreous, surgical approach, primary intraocular lens implantation, and perioperative subconjunctival steroid injection. Changes in IOP and in the ACA were recorded, and the risk factors for such changes were analyzed.

RESULTS: Postoperative IOP elevation >18 mm Hg occurred in 23 eyes of 206 eyes (11%), who completed Year 1 and in 9 (13%) of 86 eyes who completed Year 2. Risk factors for IOP elevation were larger preoperative CCT (P=0.01) in Year 1, and younger age at surgery (P=0.01), and aphakia (P=0.05) in Year 2. In multivariate analysis only younger age at surgery was a risk factor for IOP elevation in Year 2. ACA narrowing occurred in 49% and in 21% of the examined eyes in Years 1 and 2, respectively. Aphakia was not a significant risk factor of angle narrowing in Years 1 and 2 (P=0.17 and 0.42, respectively).

CONCLUSIONS: Higher preoperative CCT was a risk factor for early-onset IOP elevation. Surgery at >2 months was associated with lower susceptibility to late-onset IOP elevation.

Fouad, H. M., A. M. Kamal, A. Awadein, and M. A. Del Monte, "Contralateral Surgery for the Treatment of Third Nerve Palsy with Aberrant Regeneration.", American journal of ophthalmology, vol. 222, pp. 166-173, 2021. Abstract

PURPOSE: To report the results of contralateral recession-resection of the horizontal muscles in oculomotor nerve palsy with aberrant regeneration to correct both the strabismus and the ptosis in one procedure.

DESIGN: Retrospective case series.

METHODS: This is an institutional study on patients with oculomotor nerve palsy with aberrant innervation who had contralateral eye muscle surgery in 2 different centers. Patients were included if they have both exotropia and aberrant regeneration with a ptosis that improved on adduction. All patients had contralateral lateral rectus recession and medial rectus resection. Ductions, versions, angle of misalignment, and degree of ptosis were evaluated before surgery and at last follow-up.

RESULTS: Eleven patients were identified. The mean age at surgery was 15.0 ± 9.2 years. Five patients were male (45%). Trauma was the cause in 8 (72%) cases. The mean angle of exotropia was 42 ± 14 prism diopters. The mean degree of ptosis was 3.9 ± 1.6 mm. The mean lateral rectus recession was 8.2 ± 1.1 mm, and the mean medial rectus muscle resection was 6.7 ± 0.9 mm. The mean follow-up was 6.4 ± 2.5 months. After surgery, none of the patients had residual exotropia >10 prism diopters. The mean degree of ptosis after surgery was 0.9 ± 0.8 mm. None of the patients required further surgery for ptosis or strabismus.

CONCLUSION: Contralateral eye muscle in third nerve palsy with aberrant innervation offers the advantage of simultaneous correction of both strabismus and ptosis through a single procedure.

Awadein, A., and M. A. Fakhry, "Evaluation of intralesional propranolol for periocular capillary hemangioma", Clinical ophthalmology (Auckland, NZ), vol. 5: Dove Press, pp. 1135, 2011. Abstract
Awadein, A., M. Sharma, M. G. Bazemore, H. A. Saeed, and D. L. Guyton, "Adjustable suture strabismus surgery in infants and children", Journal of American Association for Pediatric Ophthalmology and Strabismus, vol. 12, no. 6: Mosby, pp. 585–590, 2008. Abstract