El-Fayoumi, D., N. Bahgat, M. Khafagy, R. hatata, D. Sabry, G. Allam, M. A. Kasem, and S. Sadek, "Horizontal Extraocular Muscle Insertion Site in Relation to Axial Length Using Swept-Source Anterior Segment OCT.", Clinical ophthalmology (Auckland, N.Z.), vol. 14, pp. 3583-3589, 2020. Abstract

Purpose: The purpose of this study was to correlate between the axial length of the globe and the insertion site of horizontal extraocular muscles using swept-source anterior segment optical coherence tomography (SS-ASOCT), with posing an equation to calculate the muscle insertion site from the axial length.

Methods: The study design was observational and cross-sectional. It was performed on 157 eyes of 157 healthy subjects. The distance of the medial rectus (MR) and the lateral rectus (LR) insertion sites from the limbus were measured using SS-ASOCT. The insertion sites' distances were correlated to the axial length (hypermetropes < 22.5 mm, myopes > 24.5). Correlation between numerical variables was done by Pearson's correlation coefficient and confirmed by linear regression analysis and scatter diagrams.

Results: The mean MR insertion site was 5.47 ± 0.19 mm in hypermetropes versus 5.68 ± 0.23 mm in myopes, whereas the mean LR insertion site was 6.81± 0.23 mm in hyperopes versus 7.08 ± 0.16 mm in myopes. The axial length showed a moderate positive, but significant, correlation to the insertional position for the medial and lateral rectus muscles (MR: =0.417, p<0.001; LR: =0.410, p<0.001).

Conclusion: Comparing the horizontal extraocular muscle insertion site to axial length using SS-ASOCT showed a significant positive correlation. The model equation for MR insertion: MR (mm) = 4.522 + 0.045 (AXL in mm) with an R = 0.437, R= 0.191, F=12.071, P<0.001. The model equation for LR insertion: LR (mm) = 5.72 + 0.048 (AXL in mm) with an R = 0.438, R= 0.192, F=12.116, P<0.001.

Shaimaa A Arfeen, N. Bahgat, N. Adel, M. Eissa, and M. M. Khafagy, "Assessment of superficial and deep retinal vessel density in systemic lupus erythematosus patients using optical coherence tomography angiography.", Graefe's archive for clinical and experimental ophthalmology = Albrecht von Graefes Archiv fur klinische und experimentelle Ophthalmologie, vol. 258, issue 6, pp. 1261-1268, 2020. Abstract

PURPOSE: The aim of this study is to evaluate the retinal microvascular density in SLE patients using optical coherence tomography angiography (OCTA) and to correlate vascular density with the disease activity and damage risk.

METHODS: Twenty eyes of 20 SLE patients were compared with 20 eyes of normal subjects. The retinal capillary plexuses were examined by OCTA. The disease activity and damage risk were evaluated by the SLEDAI-2 K and SLICC/ACR SDI scoring systems.

RESULTS: No difference was found between SLE patients' central foveal thickness (CFT) and foveal avascular zone (FAZ) area and the normal (P > 0.05). SLE patients had slightly lower superficial vessel densities than normal in the upper and lower macular regions (P < 0.05), sparing the middle sectors (P > 0.05). In the deep plexus, vessel density loss was detected in all sectors (P < 0.001). The vessel density in 300-μm-wide region around the FAZ (FD-300) and the acircularity index (AI) were affected in the SLE in comparison to the normal group (P < 0.05). No significant correlation was found between the SLEDAI-2 k and the retinal vessel density in either layer, while the SLICC/SDI had moderate inverse correlation with vessel density in some sectors (P < 0.05). Receiver operating characteristic (ROC) curve analysis showed that the deep capillary plexus had high sensitivity and specificity for detecting vascular damage in SLE patients.

CONCLUSIONS: OCTA permits noninvasive quantitative assessment of retinal vessel density in SLE, allowing early detection of altered retinal circulation. Vessel density could be included in future assessment of SLE activity and damage scores.

Elzarga, A. A. A., A. A. Osman, M. Gamal, M. M. Khafagy, and I. S. Osman, "Vector Analysis of Femtosecond Laser-Assisted Arcuate Keratotomy for Post-Keratoplasty Astigmatic Correction.", Ophthalmic research, pp. 1-7, 2019. Abstract

PURPOSE: To study the astigmatic correction of high post-keratoplasty astigmatism using Femtosecond laser (FSL)-assisted Arcuate Keratotomy (FS-AK).

METHODS: A prospective interventional cohort study. We enrolled 17 eyes with high degree of irregular astigmatism, scheduled for FS-AK. FSL was used to perform paired arcuate incisions 1.00 mm inside the graft. Patients' uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), and astigmatic change were recorded and followed up to 1 year after surgery. Vector analysis using Alpins' method was done to analyze the astigmatic correction.

RESULTS: FS-AK reduced the refractive astigmatism at final follow-up visit at 12 months (p = 0.0008, repeated-measures analysis of variance [ANOVA]). The procedure improved the UCVA over the follow-up period (p = 0.007, repeated-measures ANOVA), with a similar effect on the BCVA (p = 0.046, repeated-measures ANOVA). There was a mild correlation between the target-induced astigmatism and the surgically induced astigmatism (R2 = 0.245) with a tendency to overcorrect more than under correct the astigmatism. A constant rotational error in the counterclockwise direction was also detected.

CONCLUSIONS: FS-AK improves the visual outcome and reduces the refractive cylinder in post-penetrating keratoplasty astigmatism. The predictability of astigmatism correction was variable in reducing post-keratoplasty astigmatism. Refinement of the treatment nomogram for such cases is highly recommended.

Nourleldine, A. M., P. H. Fouad, H. M. Ahmed, and M. M. Khafagy, "Early Diagnostic Parameters of Glaucoma in High Myopes Paramètres Diagnostiques Précoces du Glaucome chez les Myopes Forts", Journal Français d'Ophtalmologie, 2019. AbstractWebsite

Purpose
The goal of this study is to evaluate the changes in OCTs in high-grade glaucoma patients, and to enable early diagnosis and progressive glaucomatous damage. It was performed at the Department of Ophthalmology , Kasr Alainy Hospital, Cairo University, over a twenty-month period.

Methods
This study was a cross-sectional randomized single blinded study. It included 62 eyes of highly myopic individuals. Patients were divided into 2 groups: Group A included myopic non-glaucomatous individuals, and Group B included the myopic glaucoma patients. All patients had a full ophthalmological examination, as well as OCT assessment of the RNFL, GCC and ONH parameters. The VF has been tested as well as AXL and CCT. Correlation of the data was performed.

results
Regarding the GLV, its mean in group was 11.88 ± 6.71% versus 19.69 ± 9.69% in group B; the difference between both groups was statistically significant ( P = 0.001). Regarding the cup area, the mean in group was 0.51 ± 0.41 mm 2 , while that in group B was 1.25 ± 0.72 mm 2 ; the difference between both groups was statistically significant ( P < 0.001).

Conclusion
The parameter ONH, cup area, and GCC parameter, GLV, are key parameters in the diagnosis of glaucoma in myopic patients. Other parameters measured by OCT, such as inferior RNFL thickness, FLV, and C / D ratio, could be used in diagnosis as well.

Khafagy, M. M., N. El-Guendy, M. A. Tantawy, M. A. Eldaly, H. M. Elhilali, and A. H. A. A. Wahab, "Novel CYP1B1 mutations and a possible prognostic use for surgical management of congenital glaucoma", International Journal of Ophthalmology, vol. 12, issue 4, pp. 607-614, 2019. Abstract20190414.pdfWebsite

AIM: To identify CYP1B1 gene mutations and evaluate their possible role as a prognostic factor for success rates in the surgical management of Egyptian congenital glaucoma patients.

METHODS: Totally 42 eyes of 29 primary congenital glaucoma patients were operated on with combined trabeculotomy/trabeculectomy with mitomycin-C and followed up at 1d, 1wk, 1, 6 and 12mo postoperatively. Genomic DNA was extracted from peripheral blood leukocytes. Coding regions of CYP1B1 gene were amplified using 13 pairs of primers, screened for mutations using single-strand conformation polymorphism followed by sequencing of both strands. Efficacy of the operation was graded as either a success [maintaining intraocular pressure (IOP) less than 21 mm Hg with or without anti-glaucoma medication], or a failure (IOP more than 21 mm Hg with topical antiglaucoma medications).

RESULTS: Seven novel mutations out of a total of 15 different mutations were found in the CYP1B1 genes of 14 patients (48.2%). The presence of CYP1B1 gene mutations did not correlate with the failure of the surgery (P=0.156, odds ratio=3.611, 95%CI, 0.56 to 22.89); while the positive consanguinity strongly correlated with failure of the initial procedure (P=0.016, odds ratio=11.25, 95%CI, 1.57 to 80.30). However, the Kaplan-Meier survival analysis revealed a significantly lower time of IOP control in the subgroup with mutations in CYP1B1 versus the congenital primary glaucoma group without mutations (log rank test, P=0.015).

CONCLUSION: Seven new CYP1B1 mutations are identified in Egyptian patients. Patients harboring confirmed mutations suffered from early failure of the initial surgery. CYP1B1 mutations could be considered as a prognostic factor for surgery in primary congenital glaucoma.

El-Nabarawi, M. A., R. T. A. E. Rehem, M. teaima, M. Abary, H. M. El-Mofty, M. M. Khafagy, N. M. Lotfy, and M. Salah, "Natamycin niosomes as a promising ocular nanosized delivery system with ketorolac tromethamine for dual effects for treatment of candida rabbit keratitis; in vitro/in vivo and histopathological studies.", Drug development and industrial pharmacy, pp. 1-15, 2019. AbstractWebsite

OBJECTIVES: This study was aimed to develop dual-purpose natamycin (NAT)-loaded niosomes in ketorolac tromethamine (KT) gels topical ocular drug delivery system to improve the clinical efficacy of natamycin through enhancing its penetration through corneal tissue and reducing inflammation associated with Fungal keratitis (FK).

SIGNIFICANCE: Nanosized carrier systems, as niosomes would provide great potential for improving NAT ocular bioavailability.NAT niosomal dispersion formulae were prepared and then incorporated in 0.5%KT gels using different mucoadhesive viscosifying polymers.

METHODS: Niosomes were prepared using the reverse-phase evaporation technique. In vitro experimental, and in vivo clinical evaluations for these formulations were done for assessment of their safety and efficacy for treatment of Candida Keratitis in Rabbits. In vitro release study was carried out by the dialysis method. In vivo and histopathological studies were performed on albino rabbits.

RESULTS: NAT niosomes exhibited high entrapment efficiency percentage (E.E%) up to96.43% and particle size diameter ranging from 181.75 ± 0.64 to 498.95 ± 0.64 nm, with negatively charged zeta potential (ZP). NAT niosomal dispersion exhibited prolonged in vitro drug release (40.96-77.49% over 24h). NAT-loaded niosomes/0.5%KT gel formulae revealed retardation in vitro release, compared to marketed-product (NATACYN and NAT-loaded niosomes up to57.32% (F8). In vivo experimental studies showed the superiority for F8 in treatment of candida keratitis and better results on corneal infiltration and hypopyon level. These results were consistent with histopathological examination in comparison with F5 and combined marketed products (NATACYN and Ketoroline).

CONCLUSIONS: This study showed that F8 has the best results from all pharmaceutical in vitro evaluations and a better cure percent in experimental application and enhancing the prolonged delivery of NAT and penetrating the cornea tissues.

Elnahry, A. G., M. M. Khafagy, S. M. Esmat, and H. A. Mortada, "Prevalence and Associations of Posterior Segment Manifestations in a Cohort of Egyptian Patients with Pathological Myopia", Current Eye Research, no. ja: Taylor & Francis, pp. null, 2019. AbstractWebsite

ABSTRACTPurpose:To determine the prevalence of posterior segment manifestations among consecutive patients with pathological myopia attending our University Hospital general ophthalmology clinic and their association with age, refractive error, axial length and each other.Methods:Patients diagnosed with pathological myopia underwent full ophthalmological examination, optical coherence tomography, fluorescein angiography, and ocular ultrasonography. Manifestations detected were recorded for each eye and their prevalence and association with age, refractive error, axial length and each other was determined.Results:A total of 127 eyes of 77 patients with pathological myopia were examined. The most prevalent manifestation was peripheral retinal lesions, found in 63.8% of examined eyes, followed by tigroid fundus, found in 59.1%. Peripheral lesions were significantly associated with more myopia (P = 0.02) and longer axial length (P = 0.046). The commonest peripheral lesion was white without pressure, found in 37.8% of eyes. Lattice degeneration was found in 11.8% and snail track degeneration in 4.7% and were not associated with degree of myopia or axial length. Diffuse chorioretinal atrophy was present in 40.9% of eyes, while patchy atrophy was present in 18.9%. Macular holes were present in 4.7% of eyes and were significantly associated with foveoschisis (P = 0.035) and retinal detachment (P = 0.003), while foveoschisis was present in 5.5% and was significantly associated with older age (P = 0.012), longer axial length (P = 0.010) and patchy chorioretinal atrophy (P = 0.024). Retinal detachment was found in 6.3% of eyes and retinal breaks in 4.7%. Posterior staphyloma was detected in 33.1% and lacquer cracks and choroidal neovascular membranes in 6.3% of eyes.Conclusions:The prevalence of pathological myopia manifestations may differ between different populations. This may be due to the multiple genetic and environmental factors involved which may result in a variable natural history of the condition among different populations.

Galal, S., M. M. Khafagy, H. M. Ahmed, and S. M. Esmat, "Subfoveal Choroidal Thickness in Relation to Age and Refractive Error", Med. J. Cairo Univ., vol. 86, issue 3, pp. 1679-1681, 2018. Abstract020.pdfWebsite

Background: The choroid is a highly vascular structure and it undergoes structural and functional alterations with increasing age which may affect the visual function. In addition, choroidal thickness differs according to the state of refraction and axial length.
Aim of the Study: To correlate between the subfoveal choroidal thickness and various clinical data including age, error of refraction, and best corrected visual acuity.
Patients and Methods: This cross sectional, non-randomized, non-controlled study was conducted on 124 eyes. Measurement of the subfoveal choroidal thickness was done using spectral domain optical coherence tomography in the Investigative and Laser Unit of the Ophthalmology Department of Kasr Al-Ainy Hospital.
Results: Results showed that thinner choroid was associ-ated with older age (r=–0.264, p-value=0.003) and myopic refraction (r=0.243, p-value=0.007), while thicker choroid was related to a better visual acuity (r=0.199, p-value=0.026). Also, there was no significant difference in choroidal thickness measurements by the two obsevers (p-value=0.161).
Conclusion: Older persons and eyes with myopic refraction have a thinner choroid. A thicker choroid is related to a better visual acuity. No inter-observer variation was found regarding choroidal thickness measurements.

Galal, S., M. M. Khafagy, H. M. Ahmed, and S. M. Esmat, "Comparative Study between Subfoveal Choroidal Thickness in Glaucomatous Eyes Versus Normal Eyes Using Spectral Domain Optical Coherence Tomography", Med. J. Cairo Univ., vol. 86, issue 4, pp. 2051-2058, 2018. Abstracta20.pdfWebsite

Background: There has been increasing interest in inves-tigating the role of the choroid in the pathogenesis of glauco-matous optic neuropathy. While measurement of choroidal thickness by spectral domain optical coherence tomography (SD-OCT) would be an attractive addition to the armamentar-ium of diagnostic and monitoring tools in glaucoma, the potential role of choroidal thickness as a risk factor requires further investigation.
Aim of the Study: To compare subfoveal choroidal thick-ness measurements in primary angle closure glaucoma (PACG), primary open angle glaucoma (POAG) patients, and normal control group, and to correlate between the subfoveal choroidal thickness with each of the average peripapillary retinal nerve fiber layer (RNFL) thickness, the average ganglion cell complex (GCC) thickness, as well as Humphrey field Analyzer parameters in these patients mainly the mean deviation (MD) and pattern standard deviation (PSD).
Patients and Methods: Cross sectional observational case-control study. The study included 124 eyes; 40 eyes of PACG patients, 42 eyes of POAG patients and 42 eyes of normal controls. Measurement of the subfoveal choroidal thickness was done using SD-OCT in The Investigative and Laser Unit of The Ophthalmology Department of Kasr Al-Ainy Hospital. Results: There was no significant difference in subfoveal choroidal thickness among normal eyes, eyes with POAG and eyes with PACG (All p-values >0.05). There was a significant positive correlation between choroidal thickness and average RNFL thickness (r=0.804, p-value <0.001).
Conclusion: Lack of a significant difference in subfoveal choroidal thickness among normal eyes, eyes with POAG and eyes with PACG. A significant positive correlation existed between choroidal thickness and average RNFL thickness.

Elnahry, A., M. M. Khafagy, S. M. Esmat, and H. A. Mortada, "Prevalence of pathological myopia among patients in a large tertiary care center in Egypt", New Front Ophthalmol, vol. 4, issue 4, 2018. Abstractnfo-4-216_1.pdfWebsite

Purpose: To determine the prevalence of Pathological Myopia at the general ophthalmology clinic of our University Hospital over a period of 3 months.

Methods: This is a cross sectional study to determine the prevalence of Pathological Myopia at the ophthalmology clinic of our University Hospital. Patients had full ophthalmological examination. Eyes were subjected to non-cycloplegic refraction using an autorefractometer. Eyes not liable for refracton (e.g. vitreous hemorrhage) underwent either A scan or B scan ultrasonography to determine their axial length. The prevalence of Pathological Myopia in this sample of eyes was then determined, where Pathological-Myopia was defined as refraction more than or equal to -6D spherical equivalent (SphEq) or an axial length more than or equal to 25.5 mm.

Results: A total of 1289 eyes of 668 consecutive patients were examined. One hundred and forty eyes (10.9%) were found to have Pathological-Myopia. The number of patients with at least one pathologically myopic eye was 84 patients (12.6% of examined patients). Of these patients, 19 (22.6%) had unilateral Pathological-Myopia, while 65 (77.4%) had bilateral Pathological-Myopia. The refractive error of pathologically myopic eyes ranged from -3.00D to -26.00D (mean -12.11 ± 5.05D) calculated as the SphEq of their refraction. Their axial lengths ranged from 25.50 mm to 36.00 mm (mean 28.65 ± 2.34 mm).

Conclusion: This study suggests a high prevalence of Pathological Myopia in Egypt compared to studies from other countries. A large community-based study in Egypt is required to determine the prevalence in the general population.

Keywords: Pathological Myopia, axial length, prevalence, refractive error, Egypt

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