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Background It was important to develop a non-invasive imaging technique for early evaluation of spinal cord integrity after injury; MRI was the method of choice for evaluation of any cord abnormalities. However, some patients have symptoms with no detectable abnormalities by MRI. The purpose of our study was to assess the role of diffusion tensor MRI in evaluating the integrity of spinal cord fibers in case of spinal trauma. Results Out of the studied 30 patients, conventional MRI revealed abnormalities in the spinal cord in 23 patients (76.67%), diffusion tensor tractography revealed abnormalities in the spinal cord in 27 patients (90%), the mean FA value at the level of injury (0.326±0.135) was less than the mean FA value (0.532 ± 0.074) in control group (p value < 0.001), and the mean ADC value at the level of injury (1.319 ± 0.378) was less than the mean ADC value (1.734 ± 0.768) in the control group. FA was sensitive than ADC in the detection of the spinal cord abnormalities with a sensitivity of 93.33% versus 67.66% respectively. Conclusion DTI can be used to detect structural changes of spinal cord white matter fibers in acute spinal cord injury. A significant decrease of fractional anisotropy and apparent diffusion coefficient has been found at the site of spinal cord injury.

Purpose Our aim is to study ocular diseases in symptomless and symptomatic newly admitted medical students in the Faculty of Medicine, Ain Shams University Patients and Methods This cross-sectional clinical study was conducted in Faculty of Medicine Ain Shams University. The study included 304 new medical students of class 2015 and 2016 who were randomly selected upon admission to college on October 2015 and October 2016 and who agreed to participate in this study. All participants underwent a complete ophthalmologic evaluation including detailed history and unaided visual acuity, best corrected visual acuity, anterior and posterior segment examination and assessment of binocular vision by titmus test. Results 301 students (99.0%) have normal gross stereopsis and (1.0%) have no gross stereopsis using Titmus fly test. Fine stereopsis among studied group ranged from 0-9 (800-40 sec of arc) which was the ability to define the circles in titmus test but with mean of 7.29 ± 2.33(i.e. mean stereopsis was 60 sec of arc). Anisometropia was found in 32/304 (10.5%) of total population and 32/169 (18.9%) of total number students with refractive errors, 10 students were males and 22 students were females. Myopia was the commonest refractive error (51.90%). Conclusion Normal vision is integral to an individual understanding of his visual world, and those with visual defects can experience difficulties in everyday life. From these visual impairment problems are refractive errors, and abnormal binocular vision which if left uncorrected can affect performance of medical students.

Background: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy. It is a combination of symptoms and signs caused by the compression of the median nerve as it passes in the carpal tunnel at the wrist. It is an important cause of functional disability, and is the commonest cause of referral to the Electro diagnostic laboratory. CTS is studied extensively. However, its pathophysiology still unclear and most of the cases still idiopathic especially in middle aged women. Objective: To correlate between severity of CTS and abnormality of lipid profile, and to establish the relationship between severity of CTS and age, Body mass index (BMI), in Egyptian middle aged women. Patients and Methods: This study included 155 female cases and controls recruited from the Neurology outpatient clinics of Al-Hussein University Hospital and Al Sahel Teaching Hospital during the period from November 2018 to September 2019, 103 cases with the clinical and neurophysiological diagnosis of idiopathic carpal tunnel syndrome. The study demonstrated the relation between age, lipid profile, BMI and severity of carpal tunnel syndrome in this group of females in comparison to the 52 females as a controls. Results: Age, high BMI, higher cholesterol and LDL levels, were correlated with severity of CTS, while Cholesterol and LDL were much higher among the cases compared to controls. HDL was less in the patients. Conclusion: Abnormal lipid profile, higher BMI, obesity and poor living circumstances could influence the incidence and severity of CTS among middle aged Egyptian women.

Background Static MRI was used as an effective tool for diagnosis of temporomandibular joint dysfunction instead of invasive techniques such as arthroscopy and arthrography. The purpose of this study was to detect whether dynamic MRI can be used instead of static MRI in diagnosis of TMJ dysfunction or not. Results According to disc displacement, anterior disc displacement was detected in 29 joints (36.25%) by both static and dynamic MRIs, and medial and lateral disc displacements were detected only by static MRI. Regarding disc mobility, dynamic MRI detects stuck disc in 4 joints versus 2 joints detected by static MRI (p value 0.008). Condylar translation was abnormal in 18 joints (22.5%) by static MRI and in 26 joints (32.5%) by dynamic MRI (p value < 0.001). The detection rate of articular disc for dynamic MRI was 87.5% versus static MRI 92.5% (p value 0.038), and the detection rate of condylar head for dynamic MRI was 97.5% versus static MRI 100% (p value 0.012). Conclusion Dynamic MRI cannot replace static MRI in evaluation of TMJ dysfunction; both of them support each other for accurate diagnosis and better image quality.

Purpose. Investigating the efficacy of intravitreal injection of erythropoietin (EPO) in managing indirect traumatic optic neuropathy (ITON) of different durations.Methods. A case series that included two groups of ITON patients: recent ITON group (Results. Significant improvement was found in BCVA, VER amplitude, and latency (P<0.0001, 0.0154, and 0.0291, respectively). Initial values of BCVA, VER amplitude, and latency correlated significantly to the final values. Differences between recent and old trauma groups were insignificant in the three parameters. In patients who received second injection, further clinical but statistically insignificant improvement was noted in BCVA in 60% of patients, VER amplitude in 50% of patients, and in VER latency in 100% of patients. No complications were recorded.Conclusion. Intravitreal injection of EPO may be effective and safe in treatment of recent and old indirect traumatic optic neuropathy.

Introduction Intermittent exotropia ‘X(T)’ is a disorder of binocular eye movement control, in which one eye intermittently moves outward. It is the commonest type of exodeviation and is usually detected by the parents in early childhood. Patients with X(T) tend to manifest their deviation when they are tired, stressed, or have cold. Purpose To manifest the prevalence of different types of X(T) in exotropic children aged 6–12 years attending Ain Shams University ophthalmology outpatient clinic. Patients and methods This is a cross-sectional study including 139 exotropic children aged 6–12 years attending Ain Shams University ophthalmology outpatient clinic. All patients underwent full medical and ophthalmic history. The ophthalmic examinations included visual acuity, ocular movements, and the angles of deviation. Further ocular examinations included slit-lamp examination for anterior segment, fundus examination, and Worth 4-dot test. Results A total of 139 exotropic children (6–12 years old) attending the ophthalmology outpatient clinic of Ain Shams University were included. We found that X(T) is the commonest type of exodeviation, in 86.3%. The ‘basic type’ was the commonest subtype of X(T), in 84.2%. The true divergence excess was the second most common type, in 7.5%, pseudodivergence was seen in 5.8%, and the convergence insufficiency was the least common type seen in 2.5%. Conclusions Intermittent exotropia was the commonest type of exodeviation among children aged 6–12 years. The basic type was the commonest subtype of X(T).

Objective. To measure the prevalence of amblyopia and amblyogenic factors among primary school children and to evaluate distance visual acuity (VA) as a screening test to detect amblyopia and define its cutoff value. Subjects and Methods. A cross-sectional study was conducted on primary school children in two schools in Central Cairo. Children underwent assessment of visual acuity using Landolt broken ring. Comprehensive ophthalmologic examination was performed for amblyopia suspects at the Ophthalmology Department of Ain Shams University Hospitals, including reassessment of best-corrected visual acuity (BCVA) using the same chart. Results. A total of 352 children were examined. Reduced screening VA (amblyopia suspect) was detected in 47 subjects (13.35%) proved amblyopia after comprehensive examination was 1.98% (7 cases). Refractive errors (REs) were present in all suspected and proved amblyopia cases (100%) but was only present in 11.6% of nonamblyopic students (P<0.05). The prevalence of hyperopia in the whole sample was 3.6%, and was 27.6% in subjects with RE. Thirty percent of hyperopic eyes were amblyopic. The prevalence of myopia was 9.3% of the whole sample and 70% of students with RE. Only 9% of myopic eyes were amblyopic. Mild to moderate amblyopia (VA better than 0.2log MAR) was 42.9%, while severe amblyopia represented 57.1%. Conclusion. This study emphasizes the importance of school-based eye care system targeting the detection of amblyopia by application of a fast screening distance VA test with a cutoff value of high sensitivity at log MAR 0.539 (Snellen′s VA equivalent 6/18).

Mohammad A RashadOphthalmology Department, Faculty of Medicine, Ain Shams University, Cairo, EgyptPurpose: This study aimed to evaluate the effectiveness of phototherapeutic keratectomy (PTK) as an alternative treatment to keratoplasty using the Pentacam to assess depth of dense opacities.Methodology: PTK was performed in eleven eyes of ten patients with superficial corneal opacities after assessment by Scheimpflug images of the Pentacam for central corneal thickness (CCT) and opacity level and depth.Results: The best-corrected spectacle visual acuity (BCSVA) significantly improved. The preoperative mean logMAR was 0.85 (0.14 decimal equivalent, 6/42 Snellen's equivalent), and the final postoperative mean logMAR was 0.58 (0.26 decimal equivalent, 6/23 Snellen's equivalent). The mean preoperative CCT was 465.64 ± 71.94 µm. The mean programmed ablation depth was 142.09 ± 47.58 µm. The programmed ablation depth was correlated to mean logMAR early (1 month) and not correlated later (6 months). None of the eyes lost lines of BCSVA or developed serious complications, such as keratectasia, delayed epithelialization, or corneal melting.Conclusion: Corneal scars extending beyond the anterior one-fifth of the cornea can be treated safely and effectively by PTK due to the smoothing effect, with reduction of the cylinder rather than complete opacity removal. This can decrease the need for keratoplasty.Keywords: phototherapeutic keratectomy, PTK, corneal opacities, Pentacam

Background— The impact of digoxin on outcomes of patients with advanced heart failure (HF) receiving optimal contemporary therapy is not known. Methods and Results— We retrospectively reviewed data of 455 advanced HF patients referred for transplant evaluation (age, 52�12 years; ejection fraction, 18.3�8%); 227 (49.9%) were on digoxin at baseline. Primary outcome was death (n=101), urgent transplantation (n=14), or ventricular assist device implantation (n=4); secondary outcomes included HF and all-cause hospitalizations. Digoxin use was evaluated (1) in the original cohort; (2) in a propensity score–matched subset (n=322); (3) as a time-dependent covariate; and (4) after adjustment for Seattle Heart Failure Score. Patients were on optimal therapy: angiotensin-II modulation, 92.5%; β-blockers, 91.2%; aldosterone antagonists, 45.6%; and devices, 71.0%. After a median of 27 months, 83 of 277 (36.6%) patients treated with digoxin versus 36 of 228 (15.8%) patients without digoxin met primary outcome (hazard ratio [HR], 2.28; 95% CI, 1.51 to 3.43; P P =0.021) and with time-varying digoxin use (HR, 2.05; 95% CI, 1.23 to 3.41; P =0.011). Digoxin was associated with higher risk among patients in sinus rhythm compared with atrial fibrillation. Digoxin was not associated with improvement in either all-cause or HF hospitalization rates. These results were similar across sex and race and when adjusted for Seattle Heart Failure Score and renal function. Conclusion— This study suggests that digoxin therapy may be of no benefit in patients with advanced HF referred for cardiac transplantation who received optimal medical therapy. Treatment with digoxin should be used cautiously in such patients because of risk for adverse outcomes.

Background Impaired renal function portends poor heart failure (HF) outcomes. The Seattle Heart Failure Score (SHFS), a multimarker risk assessment tool, however does not incorporate renal function. In this study, we assessed the incremental value of renal function over the SHFS in patients with advanced HF on contemporary optimal treatment. Methods Blood urea nitrogen (BUN), serum creatinine (sCr), BUN/sCr ratio, and estimated glomerular filtration rate were assessed in survival models with SHFS as the base model among 443 patients with HF (52 ± 12 years, male 68.5%, white 52.4%, ejection fraction 0.18 ± 0.08). Incremental value of renal function was assessed by changes in the likelihood ratio χ 2 and the area under the receiver operating characteristic curves for 1-, 2-, and 3-year event prediction. Results During a median follow-up of 21 months, 108 (24.5%) of 443 patients had an event (death [n = 92], urgent transplantation [n = 13], or ventricular assist device implantation [n = 3]). All renal parameters individually were associated with outcome (BUN, P P P = .006; and estimated glomerular filtration rate, P = .006); however, only BUN was an independent predictor of events in multivariable analyses. Addition of BUN improved the predictive ability of SHFS (Δlikelihood ratio χ 2 5.03, P = .025); however, the increase in the area under the receiver operating characteristic curve was marginal (year 1, 0.786 to 0.791; year 2, 0.732 to 0.741; year 3, 0.745 to 0.754; all P > .2). Conclusion Among the various renal function parameters, BUN had the strongest association with outcomes in patients with advanced HF. However, the incremental value of renal function over the SHFS for risk determination was marginal.

Mohammad Ahmad Rashad, Ahmed Abdel Aliem Mohamed, Asmaa Ismail Ahmed Department of Ophthalmology, Faculty of Medicine, Ain Shams University, Cairo, Egypt Purpose: To assess the pathological macular changes with optical coherence tomography (OCT) before the removal of silicone oil (SiO) in eyes that had undergone pars plana vitrectomy for complicated forms of retinal detachment (RD).Patients and methods: Subjects included 48 patients (51 eyes) with complicated RD including proliferative vitreoretinopathy, proliferative diabetic retinopathy, recurrent RD, penetrating trauma, uveitis, giant retinal tears, and macular holes. All the eyes had undergone SiO injection. Furthermore, all eyes had been planned for the removal of SiO 6–12months after the primary surgery. Finally, all eyes had a fundus examination and OCT examination before the silicone oil removal.Results: OCT findings indicated epiretinal membrane in 41% of the eyes, macular edema in 17%, macular detachment in 13.5%, macular thinning in 13.5%, macular holes in 10%, and subretinal membranes in 2%. Preoperative OCT was normal in only 12% of the eyes, while a clinical fundus examination was normal in 43% (P

Mohammad A RashadOphthalmology Department, Faculty of Medicine, Ain Shams University, Cairo, EgyptPurpose: To evaluate the success rate of a modified bleb needling technique in eyes with previous glaucoma surgery that had elevated intraocular pressure.Methods: A retrospective study of 24 eyes of 24 patients that underwent repeated bleb needling performed for failing and failed blebs on slit lamp with 5-fluorouracil (5-FU) injections on demand. This was performed after gonioscopic examination to define levels of filtration block.Results: There was significant reduction of mean IOP from 36.91 mmHg to 14.73 mmHg at the final follow-up (P < 0.001). The overall success rate was 92%.Conclusion: Repeated needling with adjunctive 5-FU proved a highly effective, safe alternative to revive filtration surgery rather than another medication or surgery.Keywords: bleb, failure, 5-FU, needling, gonioscopy

Hatem A Tawfik,1 Mohammad A Rashad21Oculoplastic Service, 2Pediatric Ophthalmology Service, Ophthalmology Department, Ain Shams University, Cairo, EgyptPurpose: To describe the demographics, characteristics, management pitfalls, and outcomes of pseudoptosis associated with congenital fibrosis of the extraocular muscles (CFEOM).Methods: A retrospective review was performed of eight patients presenting with ptosis and hypotropia to oculoplastic service. All patients underwent full ocular evaluation and magnetic resonance imaging of brain and orbit. Five of these patients underwent stepwise correction of hypotropia by single-stage adjustable strabismus surgery (SSASS), followed by a frontalis sling if needed.Results: Eight patients had congenital strabismus with severe ptosis and a positive forced duction test. There was a highly significant improvement from preoperative mean hypotropia angle of 30 prism diopters (PD) to 9 PD mean postoperative angle (P = 0.006). Surgery for ptosis was not needed in 80% of eyes.Conclusion: CFEOM involving both ptosis and hypotropia could be properly managed with the correct sequence of surgical steps. Proper vertical alignment by correction of hypotropia utilizing SSASS may alleviate the need for ptosis surgery.Keywords: congenital fibrosis of extraocular muscles, CFEOM, single-stage adjustable suture surgery, SSASS, pseudoptosis

Mohammad A RashadOphthalmology Department, Ain Shams University, Cairo, EgyptPurpose: This paper evaluates the visual outcome and report complications and uveitis control of one-stage combined pars plana vitrectomy, phacoemulsification, and intraocular lens (IOL) implantation in eyes with resistant noninfective uveitis after preoperative control by oral cyclosporin A (CSA).Methods: This paper uses an interventional case-series study of ten eyes in nine patients with panuveitis, controlled by oral CSA with the least dose of topical and systemic steroids. All eyes underwent standard pars plana vitrectomy, microcoaxial phacoemulsification, and IOL implantation. The data recorded were visual acuity (VA), intraoperative and postoperative complications, and recurrences of activity through a minimum follow-up of 6 months.Results: The mean logarithm of the minimum angle of resolution (logMAR) significantly improved from 1.597 at baseline (3/60 Snellen's equivalent), to 0.819 at the 3-month follow-up meeting (6/45 Snellen's equivalent), to 0.663 at the 6-month postoperative visit). VA improved in 70% of eyes, worsened in 20%, and stabilized in 10%. There was improvement (.6 lines) in 30% of eyes. The rate of posterior synechia formation and uncontrollable glaucoma decreased from 60% preoperative to 10% postoperative (P = 0.01). There was significant decline in the number of eyes requiring topical steroids from 100% preoperative to 50% postoperative (P = 0.01). The same is true for oral CSA, which decreased from 100% preoperatively to 10% postoperatively.Conclusion: A single-stage combination of phacovitrectomy and IOL implantation is able to control noninfective panuveitis with less need for systemic treatment and topical steroids, and results in fewer incidence of glaucoma and posterior synechia. Furthermore, it restores useful postoperative vision.Keywords: phacovitrectomy, panuveitis, cyclosporin A

Mohammad A RashadOphthalmology Department, Faculty of Medicine, Ain Shams University, Cairo, EgyptBackground: The purpose of this study was to compare a weight-adjusted dose of carbidopa-levodopa as treatment adjunctive to occlusion therapy with occlusion therapy alone in children and adults with different types of amblyopia.Methods: This prospective study included 63 patients with amblyopia classified into two groups, ie, an occlusion group which included 35 patients who received occlusion therapy only and a pharmacological enhancement group which included 28 patients who received oral carbidopa-levodopa together with occlusion therapy for 6 weeks.Results: The mean logarithm of the minimal angle of resolution (logMAR) of the eyes with amblyopia was not significantly different in the occlusion group (0.52, 0.52, and 0.51) than in the pharmacological enhancement group (0.58, 0.49, and 0.56) at three follow-up visits (at months 1, 3, and 12, respectively). There was a highly significant improvement in mean logMAR of amblyopic eyes compared with baseline in both occlusion groups (from 0.68 to 0.52, from 0.68 to 0.52, and from 0.68 to 0.51) and in the pharmacological enhancement group (from 0.81 to 0.58, from 0.81 to 0.49, and from 0.81 to 0.56) at the month 1, 3, and 12 visits (P = 0.01, P = 0.01, and P = 0.001, respectively). The improvement of mean logMAR in the subgroup of patients older than 12 years was greater in the pharmacological enhancement group (42.5%) than in the occlusion group (30%). The improvement of mean logMAR in the subgroup of patients with severe amblyopia was greater in the pharmacological enhancement group (34.3%) than in the occlusion group (22%).Conclusion: Significant improvement was reported in both groups at all follow-up visits over 1 year. Regardless of the etiology of amblyopia, levodopa-carbidopa may be added to part-time occlusion in older patients as a means of increasing the plasticity of the visual cortex. Levodopa may add to the effect of occlusion in severe amblyopia and bilateral amblyopia.Keywords: amblyopia, levodopa, carbidopa, occlusion