c:\work\Jor\vol756_1 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (6), Page 2952-2957

Bimanual Pars Plana Vitrectomy for Diabetic Tractional Retinal Detachment
Ali A Ghali
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University, Damietta, Egypt
Corresponding author: Ali A Ghali, Email: ghalyegy@gmail.com, Phone: +20)1152028335

Diabetic retinopathy (DR) is considered the commonest cause of diabetic epiretinal membrane
(ERM) worldwide. DR remains one of the leading causes of legal blindness in the working- age population.
Aim of the work: was to evaluate the efficacy, safety and complications of bimanual pars plana vitrectomy (PPV)
for management of ERM associated with tractional retinal detachment (TRD).
Patients and methods: 27 eyes in 23 patients presented with diabetic ERM associated with TRD. After full
ophthalmic examination all patients underwent bimanual PPV with silicone oil injection or gas tamponade without
or with phacoemulsification and posterior chamber intraocular lens (IOL) implantation.
Results: Complete removal of ERM was achieved in 23 cases (85.18 %) while has incompletely removed in four
cases (14.81%). Residual tractional RD was observed in one cases (3.7%). Iatrogenic breaks were occurred in five
cases (18.51%). Endo-laser photocoagulation was done in 19 cases (70.73%). There was improvement of BCVA
in 23 (85.18%) cases, while remained the same in two cases (7.4%) and deteriorated in two eyes (7.4%) due to re-
proliferation and development of neovascular glaucoma.
It could be concluded that bimanual PPV is an effective, safe and an attainable technique for
management of diabetic ERM associated with TRD, learning curve with this technique and coast benefit ratio may
be considered.
Keywords: bimanual vitrectomy, tractional, retinal detachment.


duration of macular detachment. Older age, anterior
Diabetic retinopathy (DR) is considered the
segment neovascularization, longstanding macular
commonest cause of ERM worldwide. Despite all the
detachment have been associated with poor visual
important progress in the understanding and
outcome (10). However, early vitrectomy and ERM
management of diabetes over the recent years, DR
peeling is a controversial issue in patients with good
remains one of the leading causes of legal blindness
visual acuity, because it may increase the risk of
in the working- age population (1). The prevalence of
postoperative visual loss and development of cataract
DR in diabetic patients was reported as high as 54%
(11). Precise sectioning and removal of fibro-vascular
after 10­19 years of diabetes but TRD is the severest
membranes is essential step which considered the
stage of proliferative DR (PDR) (2).
most critical and challenging event that may be
Epi-retinal membrane (ERM) is a retinal, fine,
associated with severe complications (12). These
semi-translucent, fibro-cellular membrane on the
complicated situations encountered intraoperatively
inner retinal surface along the internal limiting
can be better mastered using bimanual techniques
membrane (ILM) resulting in visual impairment of
than with conventional single-handed methods (13).
variable degrees (3). The origin of this proliferation
The use of the chandelier illumination system
may be attributed to retinal glial cells, fibrous
as the source of endo-illumination for bimanual
astrocytes, and Muller cells migrating from
vitrectomy is an essential part of modern minimal
neurosensory retina, and composed of macrophages
incision vitreoretinal surgery, as it can provide
and retinal pigment epithelial (RPE) cells (4) .The
reliable fundus view including peripheral vitreous for
clinical importance of ERM is the tendency to
bimanual surgery (14) .The general concept of
contract, and pulls the underlying retina due to
bimanual surgery is to decrease the unwanted pull and
vitreoretinal adhesions which often results in
push-out forces of scissors and pics that are produced
distortion or TRD (5) .The tangential contractile force
on the retina during dissection of the ERMs. It is used
of ERM is the main factor influencing early vision
in difficult cases of diabetic TRD for the complete
loss (6) .
and safe removal of ERM as the surgeon can operate
PPV with membrane peeling is the standard
with two active hands and apply counteraction (15).
treatment, Surgical outcomes are better in patients
The surgeon can apply laser photocoagulation more
with recently reduced vision and poorer in patients
easily with the use of chandelier and up to the ora
with longstanding macular detachment (7,8,9). The
serrata with the help of self- indentation, and
results have improved following the advent of better
compatible with the use of wide-angle viewing
surgical techniques and tools. However, visual
systems during vitreous surgery (13,16) . Another use of
prognosis is influenced by many factors including the
chandelier in diabetic retinal surgery, in providing
patient age, location and extent of the TRD, and the


Full Paper (vol.756 paper# 1)

Effect of Sildenafil Citrate on Uterine Artery Blood Flow in Patients with Unexplained Recurrent Miscarriages: A Randomized Clinical Trial The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (6), Page 2958-2964
Effect of Sildenafil Citrate on Uterine Artery Blood Flow in Patients with
Unexplained Recurrent Miscarriages: A Randomized Clinical Trial
Mohamed A. Mohamed, Assem A. Moussa, Hazem M. El-Taybe
Department of Obstetrics and Gynecology Faculty of Medicine - Al-Azhar University
Corresponding author: Hazem M. El-Tayb; Email: hazemeltaib20@yahoo.com; Mobile: 01111842709

Unexplained recurrent miscarriage can be a challenging and frustrating condition for both
patients and clinicians. Sildenafil citrate is one of the currently available lines of treatment according to
simplicity of use, reliability and degree of invasiveness but up to now there are no prospective randomized
studies, powerful enough. Aim of this Work: To evaluate the efficacy of oral sildenafil citrate 20 mg on
uterine arteries Doppler flow studies in patients with unexplained recurrent miscarriages.
Patients and Methods:
This prospective case control study was conducted at Sayed Galal Maternity Hospital
outpatient clinics on 180 women who' were divided into 2 groups: (group 1) which included 91 patients who
took sildenafil citrate 20 mg orally, 4 times per day for 21 days and (group 2) which included 89 patients who
took placebo orally, 4 times per day for 21 days in the period starting from (August 2017 to June 2018).
Results: The statistical comparison between group I (sildenafil citrate) and group II (placebo) before and after
administration of drug regarding endometrial thickness showed non-significant difference before and
significant difference after 3 weeks of administration of sildenafil citrate in group I and placebo in group II. The
statistical comparison in patients in group I (sildenafil citrate) before and after 1 week, 2 weeks and 3 weeks
administration of drug regarding pulsatility index, resistance index and systolic/diastolic ratio showed
significant difference. Conclusion: Sildenafil citrate has an effective role in increasing the uterine arteries
blood flow in patients with recurrent miscarriage.
Keywords: Sildenafil Citrate, uterine artery blood flow, unexplained recurrent miscarriages.


necrosis factor-, have a detrimental effect on
Repeated abortion is the loss of three or more
pregnancy (7).
consecutive pregnancies before the 24th week of
Sildenafil citrate is a type 5-specific
pregnancy. Either primary (women without a pre-
phosphodiesterase inhibitor, augments the vasodilator
existing baby) or secondary (women with at least one
effect of nitric oxide by preventing the degradation of
pre-existing infant)(1). It affects about 0.5-1% of
cyclic guanosine monophosphate. It has been used
pregnant women. Allover for most women who
with great success in the treatment of male erectile
experience miscarriage, the recurrence rate is below
dysfunction (4). The effect of sildenafil was
30% and the chance of live birth after three
evaluated on endometrial development in women
consecutive losses is only 35%-45% (2).
who had thin endometrium; improved endometrial
The causes of repeated miscarriage are still
development was achieved among 70% of cases.
unclear. The causes in the majority of cases,
Among these women, a 29% ongoing pregnancy
excluding the anatomical, genetic, microbiological
rate was achieved (8).
and hormonal causes of abortion and full medical,
The use of sildenafil citrate in women with
surgical and social history, remain unknown (3).
unexplained recurrent abortions showed that the
Endometrial growth seems to be dependent on
drug helped to improve the uterine artery blood
uterine artery blood flow and the importance of
flow and endometrial thickness (4).
endometrial development on pregnancy outcome
Aim of the Work
has been reported (4).
The aim of this study is to evaluate the efficacy
The quality of the endometrium is an
of oral sildenafil citrate 20 mg on uterine arteries
Doppler flow studies (including endometrial
implantation. A typical trilaminar appearance with
thickness, pulsatility index, resistance index and
a minimum thickness of 7 mm and a uterine artery
systolic/ diastolic ratio) in patients with unexplained
pulsatility index of <3.0 are regarded as sound
recurrent miscarriages.
markers of endometrial receptivity (5).

Several regimens were proposed to improve a
poor endometrial response, including treatment
This prospective, randomized, double blinded
with estrogen and low dose aspirin, while in past
study was made at Sayed Galal Maternity Hospital,
few years much interest was focused on role of
starting from August 2017 to June 2018.
nitric oxide as a modulator of uterine blood flow (6).
It included 180 patients with three or more
It was demonstrated that oxidative stress (nitric
unexplained recurrent miscarriages who were
oxide and malondialdehyde), as well as tumor
randomly allocated (computer based randomization

Full Paper (vol.756 paper# 2)

c:\work\Jor\vol756_3 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (6), Page 2965-2970

The Role of Transdermal Testosterone Patch Over Pregnancy Rates in
Poor Ovarian Responders Undergoing ICSI Cycles
Hassan FI, Shehata M, El-Sheikh W.A., Mostafa M.M. Younis*
Department of Obstetrics and Gynecology, Faculty of Medicine - Al-Azhar University
*Corresponding author: Mostafa M.M. Younis, Mobile: (+20)0101872334, E-Mail: abomousa29@yahoo.com

poor responder management in IVF represents a critical dispute for fertility specialists. Meanwhile,
there is a lack of evidence to support the use of any particular intervention to improve treatment outcomes in poor
responders because of the small sample size and the heterogeneity between the trials on the definition of poor ovarian
responders (POR). Objective: the aim of this study was to evaluate the role of transdermal testosterone on the
probability of pregnancy achievement in poor responders undergoing ICSI trials. Thus, the number of oocytes,
pregnancy rates (clinical and live birth) and HMG dose and duration were compared between both trials.
Patients and Methods: This single-centre, randomized controlled trial was conducted from August 2016 to August
2017. A total of 61 poor responder patients with previous failed trial underwent their second ICSI trial. The patients
received ovarian stimulation using a short GnRH agonist protocol in both trials with transdermal testosterone patches
being used in the second trial starting five days prior to HMG.
Results: The oocytes recruitment and the pregnancy rates were higher after testosterone pretreatment in the second
trial, however, the difference between the previous and the second trial didn't reach the statistical significance.
Conclusion: Testosterone patches effect on oocyte number and pregnancy rates appears to be minimal for poor
responders. However, further trials are needed to prove the study's conclusion in the future.
Keywords: Transdermal Testosterone Patch, Over Pregnancy Rates, Ovarian Responders Undergoing ICSI Cycles.

poor responder patients undergoing ICSI trials versus
A woman is born with about 2 million
the traditional controlled ovarian stimulation protocols
primordial follicles, yet by the onset of menarche only
without any adjuvant therapy given. The secondary
about 400,000 follicles are left due to natural follicular
aim is to evaluate the safety profile (common side-
atresia (1). As a woman reaches her mid-30s the pace of
effects) of this drug when used prior to ICSI trials.
oocyte depletion begins to increase and by the time she

reaches her late 30s, the number of follicles declines to
approximately 25,000, concomitant with a significant
Sixty one poor responders fulfilling the
increase in miscarriage rate. The term "ovarian
Bologna criteria were enrolled in this prospective,
reserve" has traditionally been used to describe a
clinical trial. The study was conducted at The
woman's reproductive potential specifically, the
International Islamic Center for Population Studies
number and quality of oocytes she possesses.
and Research (IICPSR), Al-Azhar University from
However, commonly used ovarian reserve markers
August 2016 to August 2017.
serve as a proxy for oocyte quantity but are considered
Patients with previous failed trial due to poor
poor predictors of oocyte quality(1).
ovarian response were allocated and prescribed the
The treatment modalities for poor responders
transdermal testosterone patches and results were
have shown a diversity across the literature. The need
compared with the first trial for the same patients.
for an adjuvant therapy to solve the obstacle of poor
Patient's main criteria were menstruating females aged
ovarian response for maximal stimulation has gained
31-39 years at the time of their second IVF attempt
much interest recently; thus, the trials over growth
with a background of failed or cancelled IVF cycle at
hormone, androgens and aspirin have gained much
our fertility unit because of poor follicular response.
popularity. Androgen appears to be positive regulators
The main indications were: unexplained infertility,
of follicular development and also show some
tubal infertility and minimal to mild endometriosis.
synergistic effects with FSH on folliculogenesis.
Exclusion criteria included females over 39 years,
Remarkably, it has been reported that treatment of
male factor infertility, endocrinal disorders and
rhesus monkeys with dihydrotestosterone or
inverted FSH/LH ratio.
testosterone augments follicular FSH receptor
The study was approved by the Ethics
expression in granulosa cells (2), promotes initiation of
Committee of the international Islamic Center for
primordial follicle growth and increases the number of
Population Studies and Research, Al-Azhar
growing pre-antral and small antral follicles (3)
University. Written consents were obtained from
Aim of the work:
all patients.
The primary aim of this study is to evaluate
Ovarian stimulation:
the efficacy of testosterone when administered via
All patients underwent a short stimulation
transdermal route in improving the pregnancy rates in
protocol with GnRH agonist triptorelin 0.1mg starting


Full Paper (vol.756 paper# 3)

c:\work\Jor\vol756_4 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (6), Page 2971-2976
A Systematic Review of Ankle Reconstruction with
Limb Lengthening in Fibular Hemimelia
Yasser Ali Elbatrawy, Mahmoud Ali Ismail, *Abdel-Rahman Elsayed Abdel-Rahman
Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Corresponding author: Abdel-Rahman Elsayed Abdel-Rahman, Mobile: (+20) 01008889642,
E-Mail: dr.abdulrhman.ortho@gmail.com

fibular hemimelia (FH) is a congenital deficiency where part or all of the fibular bone is hypoplastic,
dysplastic or aplastic associated with hypoplasia and dysplasia of the tibia and hypoplasia, dysplasia and aplasia of parts
of the foot.
Objective: this systematic review was aimed to review the different method of ankle reconstruction with limb
lengthening in patients with Fibular Hemimelia to restore normal weight-bearing and normal limb length so that the
patient can walk with a normal gait as possible.
Material and Methods: online search was done using the Medline database on PUBMED, Google Scholar and
SCINCEDIRECT from 2001 to 2018; all the English language published studies were identified with the search
keywords of, ankle reconstruction with limb lengthening in fibular hemimelia, fibular hemimelia and treatment of fibular
hemimelia. Literature search database on PUBMED, Google Scholar and SCINCEDIRECT showed 193 studies.
Results: Our search revealed 6 studies accounting for total of 74 patients included in the final analysis. Numbers of
males were 24 patients and females were 30 patients. The mean age is 20.4 month, with average follow up time is 38.6
month. Each study was analyzed, and the following postoperative data were collected: outcomes, recurrence, dorsi-
flexion, planter-flexion, and complication.
Conclusion: SUPER ankle procedure is a widely used technique with or without lengthening showing good results in
correction of equinovalgus deformity of the ankle. Performing the reconstruction of the ankle at an earlier age plays a
significant role in preventing recurrent foot deformities.
Keywords: FH, Ankle.

Foot and ankle deformities have been the most
Fibular hemimelia (FH) is a congenital
challenging and disabling problems with FH. FH foot
deficiency where part or all of the fibular bone is
deformity has many components. At the ankle there is a
hypoplastic, dysplastic or aplastic associated with
dysplasia of the distal tibia and of the talus, which
hypoplasia and dysplasia of the tibia and hypoplasia,
ranges from mild valgus of the distal tibia to severe
dysplasia and aplasia of parts of the foot. The phenotype
dysplasia with flat malformed, maloriented joint
has a wide spectrum of pathology, ranging from mild to
surfaces. The talar neck may be very short and have
severe limb length discrepancy, ankle/foot deformities
little concave offset (6).
with or without subtalar coalition, midfoot coalitions
Successful management aims to restore normal
and absent rays. Knee ligament deficiencies and knee
weight bearing and normal limb length so that the
valgus deformity as well as associated femoral
patient can walk with as normal a gait as possible. In
hypoplasia, dysplasia and partial aplasia are common (1).
mild cases, treatment includes shoe-raises, prostheses,
The incidence of FH is about 1:50,000 in births.
epiphysiodeses or limb-lengthening procedures, and
Bilateral FH (fibular hemimelia affecting both legs)
correction of foot deformities. For more severe
occurs much less commonly (2).
deformities, the management is controversial. Many
The etiology of FH remains unknown, and in
authors recommend early amputation of the foot and
most cases it is usually not an inheritable condition,
prosthetic rehabilitation (7).
with the vast majority of children born with this
The introduction of the Ilizarov method of
condition having no family history of other birth defects
limb lengthening to the world has provided an
attractive alternative to amputation (8).
The most commonly used classification of FH
The SUPER ankle procedure was developed by
is that of Achterman and Kalamchi(4), which describes
Paley in 2016. The SUPER ankle procedure is
the amount of fibular deficiency.
performed in children between 18 and 24 months of
The Paley classification(6) is the first
age. It involves supramalleolar and/or subtalar
classification of FH to be designed with reconstructive
osteotomies combined with soft tissue release (1).
surgery options in mind. It is based on the patho-
The aim of the current systematic review was to
anatomy and deformities of the ankle and subtalar joint.
review the different method of ankle reconstruction
It classifies FH into 4 types; Type 1: Stable normal
with limb lengthening in patients with Fibular
ankle, Type 2: Dynamic valgus ankle, Type 3: Fixed
Hemimelia to restore normal weight-bearing and
equino-valgus ankle and Type 4: Fixed equino-varus
normal limb length so that the patient can walk with a
ankle (clubfoot type).
normal gait as possible.


Full Paper (vol.756 paper# 4)

c:\work\Jor\vol756_5 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (6), Page 2977-2983
Diabetes as a Risk Factor Hepatic Encephalopathy among Egyptian Cirrhotic Patients
Mohammed Noshi El-Alfy1, Khaled Masoud Dousoky1, Ahmed Anwer Mohammed Shaheen2,
Mohammed Abdel-Hassib1and Abdullah Mahfouz Abd Elwahed1
1 Department of Internal Medicine, Faculty of Medicine, Al-Azhar University, 2
Clinical pathology and microbiology, Faculty of Medicine, Zagazig University.
Corresponding author: Abdullah Mahfouz Abd Elwahed,email: abdoomahfouz04@gmail.com

Background: Hepatic encephalopathy (HE) is one of the leading consequences among patients with cirrhotic liver,
which influence more than 35% of these patients. It was established that more than 95% of cirrhotic patients were
associated with glucose intolerance and approximately 33% of them had type 2 diabetes mellitus (DM). This
investigation was conducted to evaluate the possible association between DM and the development of HE.
this study was designed to examine the association of DM with the prevalence and severity of HE in
Egyptian patients with decompensated cirrhosis.
Patients and methods:
This study was carried out prospectively on 100 patients presented with HE. Those further had
been classified into diabetic (60 patients group 1) and non-diabetic (40 patients group 2). All patients in this study were
subjected to a thorough assessment of history taking, thorough physical examination, laboratory investigations
including complete blood picture, kidney and liver function tests, viral HBsAg and HCVAb, serum sodium, potassium,
calcium and magnesium, serum ammonia levels, fasting and glycosylated hemoglobin (HbA1C %) and abdominal
ultrasonography. Results: Diabetic patients showed a higher incidence of Grades, III, and IV of HE compared to the
non-diabetic group with p value < 0.0001 for each grade. Furthermore, there was a statistically significant difference
between both groups regarding the Child-Pough classification. A statistically significant positive correlations between
fasting blood sugar level, and glycosylated hemoglobin with HE grades (r = 0.430 and p =0.0006), (r = 0.314, p =
0.0145) respectively among diabetic patients group 1. Conclusions: Egyptian diabetic patients have a potential risk
of developing HE among cirrhotic liver patients relative to non-diabetic patients.
Keywords: diabetes mellitus, hepatic encephalopathy and liver cirrhosis.

Not only did diabetes have a significant role in liver
Egypt is one of the most prevalent nations which
cirrhosis, but it also played a considerable function in HE
suffered from the marvelous increase in the number of
evolving (9). The main etiopathology of HE is raising of
chronic liver diseases (1). Hepatic encephalopathy is one
serum ammonia owed to the reduction capacity of
of the leading consequences among patients with
ammonia metabolism as a resultant effect of impaired
cirrhotic liver, which influence more than 35% of these
liver function (10). On the one hand, diabetic patients
patients (2). Noteworthy, the underlying neurological
suffered from excess gastric transient and orocecal
sequences of HE varied from minimal behavioral
period along with overgrowth of the intestinal bacteria
aberration up to deep coma and even death (3).
and glutamase activity. Moreover, insulin resistance
Some cirrhotic patients are recognized to be at high
promotes the breakdown of the muscles and production
risk of HE relative to other candidates. For instance,
of ammonia. Additionally, these patients usually are
those with history of previous attacks, hyponatremia,
associated with diabetic gastropathy, which lead to
impaired liver function, and diabetic patients (4).
chronic constipation (5). The sequent impact of such
Hereafter, it was established that more than 95% of
mechanisms is the massive increase in the amount of
cirrhotic liver patients were associated with glucose
intolerance and approximately 33% had type 2 diabetes
reverberated dramatically in the development of HE (11,
mellitus (T2DM) (5, 6). Additionally, not only it did
macerate the prognosis of cirrhosis, but it also had a
major role in developing hepatocellular carcinoma (7).
Throughout literature search, there was a paucity
Consequently, hepatogenous diabetes may be evolved as
of studies discussed the association between diabetes
a sequel of cirrhosis. Besides, the cumulative deprivation
mellitus and distinct complications of decompensated
of beta-cell insulin secretion along with accretion of the
liver cirrhosis. However, neither of these studies
insulin resistance were the risk factors for non-alcoholic
evaluated this relationship among the Egyptian
fatty liver disease and T2DM (8).
population. Thereafter, this investigation was conducted


Full Paper (vol.756 paper# 5)

c:\work\Jor\vol756_6 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (6), Page 2984-2992

The Role of Pattern Visual Evoked Potential in Primary Open Angle Glaucoma
Al Araby Abd Elghany Nassar, Abd Elghany Ibrahim Abd Elghany and Ahmed Osama Mohamed*
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Corresponding author: Ahmed Osama Mohamed, Mobile: (+20)01061984263, E-Mail: tantawy_wael@yahoo.com

Primary open-angle glaucoma (POAG) is one of the leading causes of blindness worldwide.
The death of retinal ganglion cells in POAG is reflected by increased cupping of the optic disc, loss of nerve
fiber layer and functional visual field defect.
The aim of the work was to assess the role of Pattern Visual Evoked Potential (VEP) in diagnosis
of primary open angel glaucoma.
Patients and methods: We studied 40 eyes of 21 subjects, the eyes were classified into 2 groups: Group I
included 20 eyes of 11 patients with primary open angel glaucoma and Group II included 20 eyes of 10 normal
control (age and sex) matched group. All eyes underwent a full field ophthalmic, OCT and pattern VEP.
Results: OCT results showed significant reduction of retinal nerve fiber layer (RNFL) thickness in glaucoma
and glaucoma suspect eyes in the majority of quadrants as well as in the average RNFL thickness p < 0.001.
The pattern VEP of glaucomatous patient when compared to normal control group reported affection of the
VEP by causing both reductions in amplitude and increases in latency. And by statistically analysis of the
results that there were highly statistically significant differences between both groups of the VEP
measurements (p < 0.001).
Conclusion: The pattern visual evoked potential (VEP) has been shown to be sensitive to optic nerve lesions
caused by ischemia and glaucoma has also been reported to affect the VEP by causing both reductions in
amplitude and increases in latency.
Keywords: POAG, OCT, RNFL, VEP.


(OCT) which is a non-invasive interferometric
Glaucoma is a multi-factorial optic
technique that provides cross-sectional images and
neuropathy characterized by loss of the retinal
measurements of the retinal nerve fiber layer
ganglion cells axons, leading to progressive
thickness (RNFLT) with high resolution and good
irreversible loss of vision, manifests by cupping and
atrophy of the optic disc. Such loss develops retinal
Because glaucomatous damage can be
nerve fiber layer thinning and characteristic visual
controlled with medication and surgery , it is
field abnormalities (1).
important to detect early signs of inner retinal
Primary open angle glaucoma (POAG) is a
damage. The pattern visual evoked potential (VEP)
leading cause of irreversible world blindness. The
has been shown to be sensitive to optic nerve lesions
onset is without symptoms and progression occurs
silently until the advanced stages of the disease,
compression of the anterior visual pathway.
when it affects vision. Diagnostic instruments
Glaucoma has also been reported to affect the VEP
providing quantitative analyses in glaucoma assess
by causing both reductions in amplitude and
either structural or functional aspects of the disease
increases in latency. Increased pattern VEP latency
has been associated with optic disc cupping and the
A number of techniques have been developed
presence of visual field loss (7).
to diagnose and monitor POAG. The search for
Visual field testing results are often
ways of making an earlier diagnosis and hence
unreliable with poor repeatability. The Ocular
improving the prognosis of the disease continues
Hypertension Treatment Study (OHTS) found that
with varying degrees of success (3).
nearly 86% of diagnosed visual field defects seen on
Visual field testing remains the main stay as
standard visual field testing improve with
a subjective test currently available for diagnosis
subsequent testing. In the same vein as optical
and following patients with glaucoma (4).
coherence tomography, the VEP is an objective way
Reliance on IOP, optic disc cupping changes,
of evaluating functional vision loss versus
nerve fiber layer integrity and visual field changes
depending on only subjective standard automated
may delay the treatment of glaucoma since
perimetry (8).
irreversible changes may have already occurred at
The aim of the current work was to assess
the time of diagnosis (5).
the role of Pattern Visual Evoked Potential in
Imaging and quantitative analysis of retinal
diagnosis of primary open angel glaucoma.
nerve fiber layer (RNFL) measurement can be

accomplished with Optic Coherence Tomography


Full Paper (vol.756 paper# 6)

c:\work\Jor\vol756_7 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (6), Page 2993-2999

The Relationship between Ethmoid Roof, Cribriform Plate
Dimensions and Degree of Septal Deviation Angle
Mohammed Abd ElMon'em Yonis, Ahmed Seddiq Abd Elgalil, Mahmoud Ibrahim Elshamy and
Ibrahim Mohammed Mohammed Eldiehy*
* Department of Otorhinolaryngology, Faculty of Medicine - AL-Azhar University
Corresponding author: Ibrahim Mohammed Mohammed Eldiehy, Mobile: (+20)01117960311,
E-Mail: immhia6@gmail.com

endoscopic sinus surgery (ESS) is a common operation for the management of sinonasal pathologies,
the surgeons dealing with endoscopic sinus surgery should understand the crucial complex anatomy of the anterior
cranial base to avoid the intracranial violation during ESS.
Objective: the aim of this work is to investigate the relationship between degree of septal deviation angle and the
dimensions of cribriform plate and ethmoid roof by radiological paranasal CT evaluation.
Patients and methods: forty patients, 20 females and 20 males, were selectively collected according to inclusion
and exclusion criteria from the out-patient E.N.T clinics of El-Hussein and Bab-El-She'reya Hospitals from
November 2017 to January 2019 with their age ranged from 18 ­ 60 years old.
Results: the severity of deviation didn't have impact on the dimensions of the ethmoid roof and cribriform plate in
terms of depth and width except right ethmoid roof width (direct proportion) and the left cribriform width (inverse
proportion). There was a significant direct relationship between ipsilateral and contralateral ER width and between
ipsilateral and contralateral ER depth. This study showed no significant relation between ipsilateral and contralateral
CP width. High rate of asymmetry between CP and ethmoid roof in our study (100 %) was noted.
Conclusion: in cases of deviated nasal septum, this study suggests that the increase in the severity of septum
deviation rises the possibility of the increasing right ethmoid roof width and of decreasing the left cribriform width
and this possibility should be taken into consideration to avoid iatrogenic injury during ESS.
Keywords: Ethmoid Roof, Cribriform Plate Dimensions, Degree of Septal Deviation Angle.


contribution to the nasal septum which divides the
Radiological evaluation of the ethmoid roof is
nasal cavity into two separate chambers (2).
important in preventing the endoscopic sinus surgery
The septal deviation is defined as convexities
complications. Iatrogenic lesions of the anterior skull
of the nasal septum on one side with accompanying
base can occur in the ethmoid roof and the cribriform
deformities of midline structures (6).
plate (1).
The development and refinement of computerized
The relationship between cribriform plate (CP)
tomography (CT) imaging has allowed detailed
dimensions (height or width) and other paranasal
assessment of not only the sinonasal diseases, but also
structures such as frontal sinus pneumatization,
the characterization of the paranasal sinuses anatomy.
pneumatized middle turbinate, and nasal septum
It is important for the surgeon to look at the CT scan
deviation was investigated by several researchers in the
preoperatively to get an idea of the anatomy and to
relevant literature (2).
relate the changes revealed on the CT scan to the
However, the relationship between septal deviation
patient's clinical condition (7).
(SD) and CP dimensions has not been evaluated so far.

Among studies, a study was done by Saylisoy et al. (3).
They observed that when septal deviation angle is
The aim of this work is to investigate the
increased, ipsilateral and contralateral CP width and
relationship between degree of septal deviation angle
depth is increased.
and the dimensions of cribriform plate and ethmoid
Understanding the complex anatomy of the
roof by radiological paranasal computed tomography
paranasal sinuses is crucial to surgeons to avoid the
(CT) evaluation.
intracranial violation during endoscopic sinus surgery

(ESS) (4).
Inadvertent violation of the cribriform plate
This prospective study was carried out at the
(CP) or the ethmoid roof may result in an intracranial
Otorhinolaryngology Department with assistance of
injury, cerebrospinal fluid rhinorrhea, and a
the Radiology Department of Al-Azhar University
consequent increased risk of developing meningitis (5).
Between the two CPs there are two central vertically
Forty patients, 20 females and 20 males, were
disposed midline processes of ethmoid bone the
selectively collected according to inclusion and
superior is the crista galli, and the inferior is the
exclusion criteria from the out-patient E.N.T Clinics of
perpendicular plate that makes a substantial
El-Hussein and Bab El-She'reya Hospitals from


Full Paper (vol.756 paper# 7)

c:\work\Jor\vol756_8 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (6), Page 3000-3005
Evaluation of Different Modalities of Tendon Transfer in Ulnar Nerve Palsy
Magdy A. Abd Elmoktader, Moustafa Mekky, Khallad Sholkamy, Mohamed Nageh
Department of Plastic and Burn Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Mohamed Nageh,email:nagih318@gmail.com

Tendon transfer surgery is a type of hand surgery that is performed in order to improve lost hand function.
A functioning tendon is shifted from its original attachment to a new one to restore the action that has been lost.
Aim of the study:
the present study was performed to evaluate the different modalities of tendon transfer in
management of clawing of little and ring fingers in ulnar nerve palsy.
Patients and Methods: Correction of clawing of ring and little fingers was done in 20 patients (with ulnar palsy whether
high or low; age range: 5-60 years). Different techniques of tendon transfer were used including Zancolli-lasso
procedure using flexor digitorum superficialis (FDS), Stiles Bunnel procedure using FDS and Brand procedure
Results: Anti-claw procedures were performed in 20 cases, 10 patients showed excellent results, 6 patients showed
good results, 3 patients showed fair results, while 1 patient showed poor result according to MRC grading system.
Conclusion: It could be concluded that among many techniques of tendon transfer procedures prescribed for treatment
of claw hand in ulnar nerve palsy, FDS transfer is the best reconstructive tendon transfer procedure for correction of
ulnar claw hand especially in low ulnar palsy. In case of high ulnar palsy when FDS isn't available ECRL transfer is
the next choice.
Keywords: tendon transfer, ulnar nerve palsy, claw hand.

IPJ extension. If the patient's flexed IPJ posture
Tendon transfers follow a basic concept that
improves, then Bouvier's test is positive, and clawing
nothing new is created but functional parts are
is defined as simple. If the IPJ's remain flexed, then
rearranged into the best possible working combination,
Bouvier's test is negative, and the clawing is defined
so it is the relocation of a tendon from a functioning
as complex (4).
muscle to replace an injured or nonfunctional muscle-

tendon unit (1).
Tendon transfer procedures used for correction of
Paralysis of the ulnar nerve can be classified as
clawing included:
either a high or low palsy. In the forearm, the ulnar
1-Zancolli lasso FDS transfer: It maintains the MP
nerve innervates the flexor carpi ulnaris (FCU), and the
joint in flexion passively, commonly indicated in simple
flexor digitorum profundus (FDP) of the little and ring
clawing with positive Bouvier's test. It isolates the FDS
fingers. Lesions at or proximal to this level are
tendon for transfer and to be looped around the A1 pulley
considered high ulnar nerve palsy. In the hand, the
creating a dynamic flexion of the MP joint. and it
ulnar nerve innervates the hypothenar muscles, the
corrects the clawing simply by preventing the MP joints
ulnar lumbricals, the interossei, the adductor pollicis,
hyperextension and allows simultaneous flexion of the
and the deep head of the flexor pollicis brevis. The
IP joints (5).
ulnar nerve also provides sensation to the little finger
2-Stiles-Bunnel FDS transfer: The FDS tendon is
and the ulnar half of the ring finger. Lesions involving
transected distal to the A2 pulley and split proximally.
these latter motor and sensory deficits only are
Each slip of the FDS tendon is tunneled along the
considered low ulnar nerve palsy (2).
lumbrical canal then looped around the lateral bands.
Ulnar nerve palsy alters both the form and
The transfer is tensioned and secured with the wrist
function of the hand. Claw hand deformity due to loss
neutral and the MCPJ flexed at 45 degrees of flexion
of active IPJ extension and MCPJ flexion, which
prevents the patient from cupping the hand around
3-Brand procedure (ECRL with 4-tail tendon transfer):
objects, grip strength is diminished and key pinch is
A transverse incision at the dorsal base of the index
lost in most cases, Froment's sign, loss of thumb
metacarpal is used to expose the insertion of the ECRL
adduction and Wartenberg's sign are also presented in
tendon. A palmaris longus tendon graft is harvested
ulnar palsy (3).
and secured to the ECRL tendon end, the two tendon
Bouvier's test involves passively correction of
graft ends are split to create four tendon ends,
the MCPJ hyperextension and checking for improved


Full Paper (vol.756 paper# 8)

c:\work\Jor\vol756_9 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (6), Page 3006-3012

Detection of Multi-Drug Resistant Klebsiella Pneumoniae in
Al-Zahraa University Hospital
Marwa Abd-Allah Abo Samra, Naeima Khodeir Ali, Asmaa Abd Elsalam El-Madboly
Department of Clinical Pathology, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
Corresponding author: Marwa Abd-Allah Abo Samra, Mobile: (+20)01141664211;
Email: sunny_skies_2008@yahoo.com
: the rate of multidrug resistant (MDR) klebsiella pneumonia is increasing worldwide, its detection by
available phenotypic methods represents a challenge. However, every lab should estimate its frequency for infection
control measures and antibiotic stewardship program. Objective: The aim of the study was to estimate the frequency of
MDR klebsiella pneumoniae in Al-Zahraa University Hospital, Cairo, Egypt, and to determine their different phenotypic
methods. Methods: frequency of MDR K. pneumoniae isolates from different clinical samples provided to the
microbiology laboratory, Al-Zahraa University Hospital, Cairo, Egypt during the period from May 2016 to
January 2017 was detected by different phenotypic methods including ESBL detection (ESBL combined disk
test, the double disk synergy test and the ESBL NDP test), AmpC production, carbapenemase production, the
temocillin disk diffusion test, the Carba NP test, the Blue carba test and the genotypic detection of OXA-48
gene). Results: out of 2058 samples provided to Al-Zahraa University Microbiology Lab, 143 isolates were K.
pneumoniae (6.94 %), 120 out of these 143 (83.9 %) were MDR. Their incidence rate (0.1) from the total and
(0.8) and from the K. pneumoniae isolates respectively.98.3% of these MDR were ESBL producers, 45.8%
were AmpC B lactamase, 39.16% were carbapenem resistant while quinolone and aminoglycoside resistance
were 63.6% and 68.3% respectively. Conclusion: continuous laboratory surveillance for different types of
resistance in all K. pneumoniae isolates is recommended. ESBL NDP test and blue carba test could be used as
routine tests in the microbiology lab for rapid detection of ESBL and carbapenem isolates.
MDR klebsiella pneumoniae, ESBL, Carbapenem resistance, AmpC B lactamase.


numerous multiple resistance determinants with very
Klebsiella pneumoniae is a member of the
limited treatment options (5).
Enterobacteriaceae family, a natural population of the
The aim of this study was to detect frequency of
nasal pharynx and the digestive tract of healthy humans
MDR K. pneumonia in Al-Zahraa University Hospital,
and animals. It is a common pathogen associated with the
Cairo, Egypt and to assess risk factors for acquiring
opportunity, accounting for about one-third of all negative
infections with these MDR K. pneumonia.
infections in grams. It is involved in a wide range of

infections acquired from hospitals and society (1).
The European Center for Disease Control
This study included a total of 143 K. pneumonia
(ECDC) and the Centers for Disease Control and
isolates recovered from all inpatient different clinical
Prevention MDR know that at least one factor is not
specimens provided to the Microbiology Laboratory, Al-
obtained in three or more antimicrobial groups (2).
Zahraa University Hospital, for culture and antimicrobial
Many risk factors can contribute to multi-drug
susceptibility testing. For patients from whom multiple
resistant K. pneumoniae. Including: age, previous
isolates were collected, only the initial isolate was
hospitalization, in particular ICU admission, long hospital
included. Approval of the ethical committee was
stay, and use of associated gaseous devices and associated
diseases (3). Antibiotic resistance in K. pneumoniae occurs
Isolates were identified as K. pneumoniae by the
by inhibiting the enzyme with antibiotics, modifying the
standard microbiological methods. These isolates were
target or decreasing the concentration of antibiotics by
subjected to:
reducing its permeability and increasing flow activity.
A. Antibiotic susceptibility tests: by modified Kirby
These are encoded either substantially or by acquired
bauer using antibiotic discs (Ceftazidime (30 g),
resistance genes, too, as a result of environmental stresses
Aztreonam (30 g), Cefotaxime (30 ug), Cefepime (30
through the formation of biofilm (4).
ug), Cefoxitin (30 ug), Cefuroxime (30 ug) ,
The prevalence and incidence rate of MDR
Gentamycin (10 ug), Amikacin (10 ug), Amoxicillin/
klebsiella pneumoniae is different according to
clavulanic acid (30/10 ug), Meropenem (10µg),
geographical area and even within the same country
Trimethoprim/Sulfamethoxazole ((1.25/23.75 ug),
according to strict adherence to infection control
Ciprofloxacin (5 ug), Pipracillin (100 ug), (Oxoid,
strategies and strict antibiotic policy.
UK). according to the recommendation of the Clinical
Detection of multidrug resistant K. pneumonia
and Laboratory Standard Institute (CLSI) (6).
becomes challenging as these strains co-carry diverse and


Full Paper (vol.756 paper# 9)

c:\work\Jor\vol756_10 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (6), Page 3013-3017
The Relation of Left Ventricular Diastolic Dysfunction and Increased Left
Ventricular Mass with Blood Pressure Variability in Non-Established
Hypertensive Patients
Mohsen Ali Mahmoud Salama1, Yasser El Sayed Mohammed Hasan1,
Moataz Abd Al Rahman Abd Al Salam Farag2*
1Department of Cardiology, Faculty of Medicine, Al-Azhar University, 2Department of Cardiology, Matrouh
Specialized Cardiothoracic and Interventional Catheterization Center, Egypt
*Corresponding author: Moataz Abd Al Rahman Abd Al Salam Farag,
Mobile: (+20)01007859945, E-mail: muataz.7farag@gmail.com
long term high blood pressure is a major risk factor for coronary artery disease, stroke, heart failure,
peripheral vascular disease, vision loss and chronic kidney disease.Objective: the aim of this study is to
demonstrate the relation between left ventricular diastolic dysfunction, increased left ventricular mass and
ambulatory blood pressure recording in subjects not known to be hypertensive.
Patients and Methods: this study is cross sectional study that was carried out on (100) normotensive patients in
Cardiology Department Clinic at Matrouh Specialized Cardiothoracic and Interventional Catheterization Center
from October, 2017 to January 2019. Results: significantly marked difference in left ventricular (LV) mass
between two groups (normal blood pressure and latent hypertension) and significantly marked difference in
diastolic dysfunction. According to (normal circadian and impaired circadian) there is significant difference
between the two major groups in sex where male >female and marked difference in LV mass between the two
groups (normal circadian and impaired circadian) and in smoking.
Conclusion: ambulatory blood pressure (AMBP) plays an important role as a predictor to estimate prevalence of
hypertension based on diastolic dysfunction and increased left ventricular mass in persons with normal blood
pressure measures at office specially masked hypertension in white coat hypertensive patients.
Keywords: Left ventricular diastolic, Blood pressure variability.


Hypertension determines an increased risk of
cardiovascular events which may be predicted by the
The aim of this study is to demonstrate the relation
occurrence of target-organ damage (TOD) (1). In
between left ventricular diastolic dysfunction,
addition to elevated mean levels of blood pressure
increased left ventricular mass and ambulatory blood
(BP), short-term daytime or 24-h BP variability (BPV)
pressure recording in subjects not known to be
was shown to carry an independent prognostic value in
hypertensive patients and is directly related to TOD (2).

Moreover, whenever present, left ventricular
dysfunction in hypertension, even if asymptomatic, is
This study is cross sectional study that was
a potent predictor of adverse cardiovascular events (3).
carried out on (100) normotensive patients in
With the growing acknowledgement of the
Cardiology Department Clinic at Matrouh Specialized
importance of BPV, in its different components, as a
Cardiothoracic and Interventional Catheterization
possible new cardiovascular risk factor in hypertensive
Center from October, 2017 to January 2019.
patients, BPV hypothesized its role in predicting
The ethics committee of Al AZHAR
subclinical left ventricular systolic dysfunction in
University of Medical Sciences approved the study,
newly diagnosed, never treated hypertensive patients,
and written informed consent was obtained from
by focusing in our study on short-term BP variations
each patient after thorough explanation of the study
occurring over a 24-h period or selectively only during
to patients before enrollment.
the daytime subperiod (4).

Ambulatory BP becomes important tools for
Inclusion criteria
diagnosis of hypertension in pre hypertensive stage and
1. Age: 18 years.
white-coat or isolated clinic hypertension, which
2. Sex: both sexes.
currently defines individuals whose blood pressure
3. High normal blood pressure and left ventricular
(BP) is elevated in the medical setting, but normal
diastolic dysfunction and increased left ventricular
when assessed away from the medical environment,
mass according to hypertension guidelines.
such as by 24-h ambulatory BP recording and/or home

BP measurement (5).
Exclusion criterions were:
High normal blood pressure is defined as systolic
1. Any patient with blood pressure >140/90 mm Hg.
blood pressure (SBP) 140 mm Hg or higher and/or
2. Patients on current antihypertensive medication.
diastolic blood pressure (DBP) 90 mm Hg or higher (6). 3. Patients with diabetes.

Full Paper (vol.756 paper# 10)

Full Paper (vol.756 paper# 11)

c:\work\Jor\vol756_12 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (6), Page 3027-3032

Kallistatin as a New and Reliable Biomarker for the Diagnosis of Liver Cirrhosis
Atef Abou El fotouh Ibrahim1, Tarek Abd El Kareim El Dahshan2,
Zakarya Mohamed Zakarya1 and Bahaa Najeeb Abd Elwahab Oadaa1*
1Department of Internal Medicine, 2Department of Clinical Pathology,
Faculty of Medicine, Al-Azhar University
*Corresponding author: Bahaa Najeeb Abd Elwahab Oadaa, E-mail:b.najib1989@gmail, Mob: (+20)01097931469

Cirrhosis represents the final common pathological outcome for the majority of chronic liver
diseases. Most patients with cirrhosis die from one or more clinical complications including ascites, hepatic
encephalopathy and variceal hemorrhage.
Objective: The aim of the study was to explore the relationship between serum kallistatin and clinical evidence
of cirrhosis and to determine if serum kallistatin levels could be used as a diagnostic indicator of hepatic health
status especially human liver cirrhosis.
Patients and methods:
The present study included 70 patients with liver cirrhosis and 25 healthy volunteers
served as controls. Cirrhotic patients were subdivided into groups A, B and C according to Child score.
Results: The results in the current study revealed that there was highly significant decrease of kallistatin level
in liver cirrhosis patients compared to control group. The level of kallistatin was significantly decreased in
decompensated patients more than compensated patients. These findings pointed to the value of kallistatin as
a new biomarker for diagnosis of liver cirrhosis.
Conclusion: Our findings support that kallistatin may be an efficient biomarker in early detection of liver
cirrhosis. Also combination of kallistatin with Fib4 score could improve the sensitivity and specificity for
chronic liver disease.
Keywords: Cirrhosis, Kallistatin, Encephalopathy.

liver cirrhosis as several studies have shown that
Liver cirrhosis (LC) is the final common
the liver represents the major site of synthesis and
pathological pathway of liver damage arising from
secretion of kallistatin (8).
a wide variety of chronic liver diseases (1).

Most patients with cirrhosis die from one
or more clinical complications including ascites,
The aim of the study was to explore the
hepatic encephalopathy and variceal hemorrhage
relationship between serum kallistatin and clinical
(2). Among the 1.4 million liver disease-related
evidence of cirrhosis and to determine if serum
deaths that occur each year worldwide, over 55%,
kallistatin levels could be used as a diagnostic
or 796,000, are directly attributable to cirrhosis (3).
indicator of hepatic health status especially human
Liver biopsy (LB) is the gold standard for
liver cirrhosis.
appraising hepatic fibrosis. However, this

procedure has several drawbacks including being
invasive test with the risk of omplications, high
The present study included 75 patients
cost, high rate of refusal by patients and sampling
with liver cirrhosis and 25 healthy volunteers
errors, which led to approximately 10­30% false
served as controls. Cirrhotic patients were
negative result in cirrhotic patients (4).
subdivided into groups A, B and C according to
It is important to identify reliable
Child score. The study was approved by the
biomarkers for the early detection of liver disease
Ethics Board of Al-Azhar University and
and subsequent evaluation of response to
an informed written consent was taken from
therapeutic intervention as there is evidence of
each participant in the study.
either fibrotic or cirrhotic regression has now been

reported in chronic liver diseases of different
Collection of blood samples:
etiologies, including viral hepatitis (5).
Blood samples were collected from
Kallistatin, an endogenous human serine
Damanhur Medical National Institute and serum
proteinase inhibitor, was originally known as a
was separated by centrifuging of clotted blood at
tissue kallikrein inhibitor (6). Kallistatin has
4000 rpm at 4 C for 10 minutes and then stored at
vasodilatory, anti-angiogenic, anti-inflammatory,
- 80 C until testing of biochemical parameters.
anti-tumor and anti-oxidant effects (7). The
Additional blood samples were collected in tubes
significantly reduced levels of serum kallistatin in
containing sodium citrate centrifuged at 4000 rpm
patients with LC hypothesized that serum
for 10 minutes and then plasma was collected
kallistatin levels could be a potential biomarker for
immediately for testing clotting parameters.


Full Paper (vol.756 paper# 12)

c:\work\Jor\vol756_13 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (6), Page 3033-3038

Role of Retrograde Transpopliteal Angioplasty for Superficial
Femoral Artery Occlusion
Omar Mokhtar Ibrahim Elhaieg, Ahmed Said Ahmed Daha and Sameh Attia Ali Abd-Elhamid*
Department of Vascular Surgery, Faculty of Medicine, Al-Azhar University
*Corresponding author: Sameh Attia Ali Abd-Elhamid, Mobile: (+20)01011208030,
E-Mail: vascularsurgeon.82@gmail.com
surgical interventions are indicated for patients with peripheral arterial disease (PAD) who
developed CLI or debilitating IC that is refractory to conservative management; while bypass, with an
autologous vein or prosthetic conduit, is the mainstay of open surgical management of PAD. On the other
hand, the percutaneous endovascular interventions has emerged as an alternative effective, and safe, treatment
option in patients with PAD. Objective: the aim of the study was to evaluate the effectiveness and safety of
the retrograde popliteal approach for recanalization of long segment occlusion of superficial femoral artery in
cases with chronic lower limb ischemia.
Patients and Methods: this is a prospective study conducted on 30 patients presenting to Al-Azhar University
Hospitals and Mataria Teaching Hospital; all of them have chronic lower limb ischemia due to proximal long
segment occlusion of superficial femoral artery (SFA) after failure to pass through the antegrade access either
by the ipsilateral or by the contralateral femoral approach.
Results: ankle brachial index (ABI) is a commonly used surrogate marker of atherosclerosis. In the present
study, the rate of complications was relatively low (16.7%) in which pseudoaneurysms were encountered in
10% and arteriovenous fistulae were encountered in 6.7% of the patients.
Conclusion: retrograde popliteal approach is feasible, safe, and effective technique for the management of
CTO of superficial femoral artery in patients with failure of pass through the antegrade access either by the
ipsilateral or by the contralateral femoral approach.
Keywords: PAD, SAF, CTO.

the ostial location, present the greatest operator
Patients with lower extremity peripheral
challenge (3).
artery disease (PAD) experience substantial
The principle reasons for procedural
functional disability due to claudication, rest pain,
failure are the inability to remain intraluminal
and the loss of tissue integrity in the distal limbs.
during crossing the CTO segment, and re-entering
The number of patients requiring lower limb
the true lumen. There is also an associated risk of
revascularization for limb ischemia is likely to
increase significantly worldwide as a result of
arteriovenous fistulas (4).
aging populations, the increasing prevalence of
In about 20 to 30% of the cases standard
diabetes, and the failure so far to significantly
techniques including the cross-over and the
reduce global tobacco consumption (1).
antegrade approach fail to cross total superficial
Lower extremity occlusive disease may
femoral artery occlusions. In these cases, the
range from exhibiting no symptoms to limb-
transpopliteal technique can be used as secondary
threatening gangrene. There are two major
approach after failed cross-over recanalization.
classifications developed based on the clinical
Furthermore, long superficial femoral artery
presentations, the Fountain classification and the
occlusions without visible patent proximal stump
can be recanalized using this technique (3).
classification uses four stages: Fontaine I, II, III,
The primary success rate of EVT for SFA
and IV. The Rutherford classification has four
CTO has improved from 75% in 2001) to 81%­
grades (0-III) and seven categories (0-6). These
94% in 2014) EVTs for SFA are generally
clinical classifications help to establish uniform
managed by the antegrade approach, which uses a
standards in evaluating and reporting the results of
contralateral retrograde puncture or ipsilateral
antegrade puncture of the common femoral artery.
interventions (2).
Alternatively, the popliteal approach is less
Endovascular specialists who treat patients
frequently utilized (5).
with advanced symptomatic peripheral arterial
disease are commonly faced with long segments of
occlusions require persistent innovation regarding
complex TASC D or chronically occluded lesions,
access, options, and equipment. Understanding the
especially in the superficial femoral artery (SFA).
available techniques of subintimal angioplasty
SFA chronic total occlusions (CTOs), especially in
along with familiarity with reentry devices allow


Full Paper (vol.756 paper# 13)

c:\work\Jor\vol756_14 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (6), Page 3039-3045

Horizontal Recti Muscle Plication Versus Resection in Squint Surgery
Madeha Abdelfatah Kamel, Zeinab Sayed Hasan, El Sayed Mohammed El Toukhi,
Amani Mohammed Ali*
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University
*Corresponding author: Amani Mohammed Ali, Tel: (+20)01155050833, E-mail: dramenna@hotmail.com

Strabismus surgery serves to align the visual axes to provide binocular single vision, or improve
cosmesis, or restore normal eye contact, or enhance the quality of life.
Objective: this study aims at evaluating muscle scleral plication technique as regards efficacy, stability,
predictability and possible complications and comparing it to the standard resection technique.
Patients and Methods: this study was carried out in the Ophthalmology Department in Al-Zahraa University
Hospital and Research Institute of Ophthalmology between 2015 and 2018 on 40 patients. Their ages ranged
from 1 to 40 years. 28 patients were males and 22 were females. 23 patients were exotropia and 17 patients were
Results: from this study it was found that the effect of plication is more or less the same as that of resection. But
it can be noted that muscle scleral plication offers a safe, predictable, alternative to resection with no especially
alarming complications that differ from those of ordinary strabismus surgery. This technique can be used instead
of resection whenever there is fear of anterior segment ischaemia (ASI), such as when there is a possibility of
operating on more than two rectus muscles or when the patient suffers from blood diseases or dysthyroid
Conclusion: from the results of this study, it can be concluded that the muscle-scleral plication technique is an
easy alternative to resection that can be used on horizontal muscles especially when anterior ciliary vessels
sparing is needed.
Keywords: Horizontal Recti Muscle Plication, Squint Surgery

circulation in muscle scleral attachment, thus
Resection of an extraocular muscle is
decreasing any potential anterior segment problems
generally classified as a strengthening procedure. A
muscle resection consists of tightening a muscle by
Plication is a quick, simple surgery whose
removing part of the muscle and reattaching the
effect is quantitatively similar to resection, and has
shortened muscle to its original insertion site. A
the advantage of causing lesser surgical trauma and
resection produces incomitance as the tightened
preserving anterior ciliary circulation. This is of
muscle restricts rotation away from the restricted
specific value where anterior segment ischemia is a
muscle (1).
consideration as in patients of atherosclerosis and
Resection procedure is easy to learn and
carotid artery disease (5).
perform. Resection procedure produce more
Plication with minimal dissection through a
redness and lumpiness of the conjunctivae
small incision technique may have further
particularly in the area of medial rectus. Natural
advantages (6). Another possible advantage of
barriers to orbital fat are also brought more
plication is that it can be readily performed under
anteriorly around the medial rectus, promoting the
topical anesthesia as it does not entail relatively
possibility of unsightly fullness after resection.
painful crushing of extraocular muscles (EOMs) as
Inferior oblique is often included inadvertently
in resection (7).
during resection of the lateral rectus leading to
limited elevation in the involved eye (2).
This work aims at comparing muscle
Muscle scleral plication can be performed
scleral plication technique to the standard resection
on patients at risk of developing anterior segment
in patients suffering from horizontal deviations.
ischemia e.g., atherosclerosis, carotid artery disease

and dysthyroid ophthalmopathy (3).
A typical tuck procedure is performed
This study was carried out in the
through a fornix based incision producing a
conjunctivo-tenons flap and thereby exposing the
University Hospital and Research Institute of
muscle tendon. The tendon is seized in a tucker and
Ophthalmology between 2015 and 2018 on 40
tucked. The muscle in the tuck is folded over on
patients, their ages ranged from 1 to 40 years. 28
itself and sutured with 6/0 suture. Tucking
patients were males and 22 were females. 23 patients
procedure is a saving time technique with
were exotropia and 17 patients were esotropia.
avoidance of muscle loss and preservation of


Full Paper (vol.756 paper# 14)

c:\work\Jor\vol756_15 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (6), Page 3046-3051

Results of Treatment of Distal Radius Fracture in Geriatrics Patients Using
Closed Reduction and Percutaneous K-Wires Fixation
Hesham Hamed Refai, Morsy Mohammed Basiony, Moataz Bellah Yousef Salh Ahmed*
Department of Orthopedic Surgery, Aswan University, Egypt
*Corresponding Author: Moataz Bellah Yousef Salh Ahmed, Phone: 01114423341, Email: motaz.yousef@gmail.com

distal radius fractures are a common fracture among geriatric population. Requiring comprehensive
understanding of fracture anatomy and comprehensive selection of method of treatment.
aim of this study is to observe treatment of unstable distal radius fracture by closed reduction and percutaneous
pinning among old age. Patients and Methods: prospective study for analysis of 30 patients above age of 50 suffering
from distal radius fracture and managed by closed reduction and percutaneous pinning in Aswan university hospital.
After acceptable reduction of the fracture was achieved, two or more percutaneous K-wires were inserted through the
distal radius with the wrist in traction to maintain the reduction. All cases were assessed by Gartaland and Werely score
and by radiological assessment. Patients were followed up for a period of about 6 months.
Results: the majority of cases were women (70%). Majority of the patients (76.6%) sustained the injury due to fall. The
side of involvement was predominantly the right side (60%). According to scoring system of cases; NO excellent results
(36.7%), scored Good (50%), scored Fair (13.3%), and scored Poor at the end of 6 months follow up.
Conclusion: closed reduction and percutaneous pinning of distal radius fracture can considered as a satisfactory
treatment in old age group and doesn't give an excellent results after short period of follow up.
Keywords: Distal radius fracture, Closed reduction, Percutaneous Kirschner wire fixation, geriatrics.


One of popular surgical options for unstable
All patients were treated by closed reduction and
distal radius fractures is closed reduction and
percutaneous pinning with k-wires in Aswan University
percutaneous k-wires with or without external fixation (1).
hospital in the period between April 2017 and May 2018.
Also open reduction and internal fixation (ORIF) with

dorsal, volar and fragment specific approaches (2).
Inclusion criteria
Comminuted fractures of the distal end of the
Inclusion criteria were sustained a fracture of the
radius are usually caused by high-energy trauma in young
distal radius (extra-articular and intra-articular), they
patients and by low-energy trauma in the elderly, and
were over the age of fifty years, the patients presented
presents as shear and impacted fractures of the articular
within 2 weeks of injury.
surface of the distal radius with displacement of the
Exclusion criteria
fragments (3). An articular step of > 2 mm will result in
Exclusion criteria were open fracture with a
painful radiocarpal arthrosis (4). A persistent dorsal tilt
Gustillo-Anderson (9) grading greater than 1, fractures
results in incongruity in the distal radioulnar joint
which require open reduction / ligamentotaxis (external
(DRUJ), and changes in the transfer of force with dorsal
overload and secondary carpal bone disease(5). Non-

operative treatment was producing too many A. Preoperative:
unsatisfactory results, up to 30% in large surveys (6). In 1. History:
elderly VLP, but not k-wires fixation, can maintain
Personal history: Name, Age, Sex, Occupation,
surgically corrected ulnar variance in distal radius
Dominant side.
fractures, independent of the degrees of initial ulnar
Past history: Details of previous disease or injury to the
variance. VLP enhances earlier recovery in range of
affected wrist and history of present symptoms:
motion and grip strength than k-wirs(7). This technique
1. Complain: Pain, swelling, finger anesthesia
minimize morbidity in the elderly population by
Mechanism of injury:
successfully handling osteopenic bone, allowed early
1. Fall outstretched on hand, Road traffic accident, others.
return to function, provided good final results, and was 2. Clinical examination:
associated with a low complication rate(8).
Throughout examination of ipsilateral elbow and

shoulder was done.
Wrist examination:
This is a prospective study for thirty patients above
Neurological examination: median-ulnar nerves.
age of fifty suffering from distal radius fracture.
Vascular examination: capillary refill.


Full Paper (vol.756 paper# 15)

c:\work\Jor\vol756_16 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (6), Page 3052-3059

The Diagnostic Value of Tzanck Test in Vesiculobullous, Pustular, and
Oral Lesions in The Dermatology Clinic
Amira Ahmed Adel Abdel Azim1, Gamal El-Din Abd El-Hamid El-Sayed2,
Marwa Said Mahmoud1, Heba Ibrahim Mostafa Ibrahim1*
1Department of Dermatology and Venereology, 2Department of Pathology,
Faculty of Medicine - Al-Azhar University
*Corresponding author: Heba Ibrahim Mostafa Ibrahim, Mobile: (+20)01019899044, E-Mail: drhebaibrahim2015@gmail.com

Vesiculobullous disorders represent a heterogeneous group of dermatoses with protean manifestations.
The accurate diagnosis of bullous disorders of the skin and mucous membrane requires evaluation of clinical,
histological, and immunofluorescence findings.
Objective: The aim of this study was to investigate Tzanck smear findings and to determine the diagnostic value of
this test in moist (erosive, vesicular, bullous, and pustular) skin and oral lesions.
Patients and Methods: This cross sectional study was conducted on one hundred patients presented with vesicular,
bullous, and pustular skin lesions and/or oral lesions. All patients were included from Dermatology Outpatient Clinic
at Al-Zahraa University Hospital over the period from March 2018 to March 2019.
Results: Positivity of multinucleated giant cells in herpetic infection, acantholytic cells in pemphigus, dyskeratotic
acantholytic cells and cocci in bullous impetigo were useful landmarks in Tzanck smear. A decrease in viral shedding
from herpetic lesions of longer duration may correlate with the lower sensitivity of the Tzanck smear. Therefore, in
this study we excluded the lesions older than 3 days. The percentage of positivity in vesicles was much higher than
that of pustules.
Conclusion: According to this study, Tzanck smear was an inexpensive, simple, and rapid test and did not require
any specialized laboratory equipment for evaluation of various vesiculobullous and pustular lesions either skin or
mucosal one.
Keywords: Tzanck test, Vesiculobullous, Pustular, Oral lesions, Dermatology.

and to distinguish it from metastasis from another
site (2). As a method for the diagnosis of
heterogeneous group of dermatoses with protean
cutaneous disorders, cytology was first used by
manifestations. The accurate diagnosis of bullous
Arnault Tzanck in 1947. Although it was
disorders of the skin and mucous membrane
suggested as a simple, rapid, and reliable
requires evaluation of clinical, histological, and
technique to be used in the diagnosis of many
immunofluorescence findings (1). Cytology may
diseases during the following 6 decades, the
be used as a diagnostic tool in a wide range of
practice of cytodiagnosis has been limited to a
few diseases (3).
diagnosis at low cost and swift referral of the
To date, only a few studies have
patient for appropriate treatment. The procedures
examined the dermatological use and diagnostic
value of this method. The majority of these
complications are rare. In addition to its role in
studies have related to herpetic infections,
the diagnosis of disease, cytology is useful in
monitoring disease progress and detecting relapse
(2). In developing countries, clinical information
carcinoma (4).
supported by cytodiagnosis is valuable in the

Furthermore, cytology can provide highly reliable
The aim of this study is to investigate Tzanck
information concerning a variety of skin tumours
smear findings and to determine the diagnostic value of
in situations where biopsy is to be avoided (2).
this test in moist (erosive, vesicular, bullous, and
pustular) skin and oral lesions.
minimal tissue injury compared with biopsy.

With the increasing use of new, non-invasive
topical treatment modalities for non-melanoma
Patients: This cross sectional study was conducted on
skin, cancer cytology may become the diagnostic
one hundred patients presented with vesicular, bullous,
method of choice. A comprehensive knowledge
and pustular skin lesions and/or oral lesions. All patients
of the cytological features of primary skin
were included from Dermatology Outpatient Clinic at
Al-Zahraa University Hospital over the period from
establishing the precise origin of a skin tumour
March 2018 to March 2019.


Full Paper (vol.756 paper# 16)

ABSTRACT The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (6), Page 3060-3069

Comparative Study between Dexmedetomidine and Dexamethasone as an
Adjuvant to Bupivacaine in Ultrasound Guided Supraclavicular
Brachial Plexus Block in Upper Limb Surgeries
Mohamed Hussien Hamada, Wael Mohamed Elmahdy Ibrahim, Mohamed Adel Ashiry
Department of Anesthesia and ICU, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Mohamed Adel Ashiry, Mobile: 01004814878, email: ashirybeng@gmail.com

Brachial plexus block is frequently used for ambulatory upper limb surgery. It can significantly
reduce pain and nausea, allowing for faster discharge from hospital when compared with general anesthesia (GA).
Doing this block through ultrasound has higher index of safety, allowing providers to identify the appropriate point
of injection and performing this block with greater accuracy under direct visualization.
the aim of the study was to compare the efficacy of bupivacaine plus dexamethasone versus bupivacaine
plus dexmedetomidine as adjuvants on block characteristics including onset and duration of sensory and motor
blockade, duration of postoperative analgesia, post-operative pain score and sedation score.
Patients and Methods: This prospective double ­ blinded, randomized controlled trial included a total of 60
patients divided to two groups, each group contained 30 patients. Group 1 (dexmedetomidine group) had received
1g/kg of dexmedetomidine + 20 ml bupivacaine 5%. Group 2 (dexamethasone group) had received dexamethasone
+ 20 ml of bupivacaine5%.
Results: In this study the onset and duration of sensory and motor blockade was statistically shorter in
dexamethasone group when compared to dexmedetomidine group.
Conclusion: It could be concluded that addition of dexmedetomidine to bupivacaine prolongs the time of block and
analgesia duration longer than dexamethasone, but the onset of block was shorter when dexamethasone was added
to bupivacaine.
dexmedetomidine, supraclavicular block, bupivacaine,upper limb surgery.

efficacy of 2-adrenoceptor agonists has been
Regional nerve block offer alternative choice
established in a variety of regional anesthesia
of anesthesia using minimal anesthetic drugs and high
techniques. Clonidine, when added to lidocaine,
safety profile. Brachial plexus block is a popular and
prolonged the duration of anesthesia and analgesia
widely employed regional nerve block technique for
after brachial plexus block(4).
perioperative anesthesia and analgesia for surgery of
the upper extremity and supraclavicular approach is the
adrenoceptor agonist and is approximately 8 times
easiest and most consistent method for surgery below
more potent than clonidine(5). Dexmedetomidine is also
the shoulder joint (1) .
reportedly safe and effective when administered with
Supraclavicular nerve block is good alternative
long-acting local anesthetics in peripheral nerve
to general anesthesia for upper limb surgery. This avoids
blocks(6). No significant histopathologic abnormalities
the complication of general anesthetic drugs and upper
were reported after intrathecal or perineural
airway intubation and its complication. It achieves
administration of dexmedetomidine (7).
complete muscle relaxation, intraoperative hemodynamic
Various clinical trials have found that
stability, and postoperative analgesia(2).
administration of dexmedetomidine with local
anesthetics in neuraxial and peripheral nerve blocks
supraclavicular nerve block as it has long duration of
prolonged the duration of sensory and motor
action from 6 to 9 h. Adjuvant to local anesthetics for
brachial plexus block may enhance the quality and
Steroids have powerful anti-inflammatory as
duration of analgesia(3).
Brachial plexus blockade reduces pain, but still
inflammation through inhibition of phospholipase A2.
with short duration and the challenge remains to
Local application of methylprednisolone has been
increase the duration of analgesia with decreasing side-
found to block transmission in nociceptive C-fibers but
effects (4).
not in myelinated A-beta fibers(9). The effect was
Different adjuvants have been used to prolong
reversible, suggesting a direct membrane action of
regional Blockade, shorten the onset times of blocks
steroids. Corticosteroids also suppress ectopic neuronal
and prolonge duration of post operative analgesia.
discharge. Perineural injection of glucocorticoid along
Various adjuvants, including opioids, midazolam,
with local anesthetics is reported to influence the onset
magnesium sulfate, dexamethasone, and neostigmine,
and duration of sensory and motor block(10).
have been added to local anesthetics in an attempt to
Dexamethasone is a very potent and highly selective
increase the duration of block and postoperative
glucocorticoid. Various studies have been done using
analgesia with the risk of various adverse effects. The
dexamethasone 4 mg as an adjuvant to local


Full Paper (vol.756 paper# 17)

c:\work\Jor\vol756_18 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (6), Page 3070-3078

Evaluation of the Results of Management of Humeral Shaft Fractures Using
Flexible Intramedullary Nails
Gad Ragheb Abdel Baki, Abd El Alim Mohamed Mohamed, Kareem Mohamed Naguib Yousef Elsharkawy
Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University
Corresponding author: Kareem Mohamed Naguib Yousef Elsharkawy, Tel: (+20)01002387158, E-mail:

the humerus is the most mobile long bone of the upper limb. Humeral shaft fractures comprise about
3 to 5% of all body fractures.
Objective: the aim of the work was to assess the results of using the flexible intramedullary nails in the treatment
of humeral shaft fractures.
Patients and Methods:
the study included 20 patients presented to Alexandria Police Hospital and El-Zahra
Hospital, suffering from humeral shaft fracture. A full workup including history taking, clinical examination and
radiological evaluation as well as laboratory investigations was performed for every patient on admission.
Results: the results obtained after a mean follow up time of 32 weeks, were excellent in twelve patients (60%), good
in six patients (30%), fair in one patient (5%), and poor in another one patient (5%). The difference between excellent
and good groups was statistically significant, that the younger the patient the more rapid the fracture healing occurred.
Conclusion: flexible intramedullary nailing is a simple, easy semi rigid and quick technique for stabilization of
humeral diaphyseal fractures in selected cases of humeral shaft fractures in different ages.
Keywords: Management of Humeral Shaft Fractures, Flexible Intramedullary Nails

be achieved with absolute fixation, but has the
Trauma has been the leading cause of mortality
disadvantage of excessive periosteal stripping, large
and morbidity since the beginning of mankind and is
incision and increased chances of infection and
on the rise in the present age. Fractures of the shaft of
iatrogenic radial nerve palsy, less secured fixation in
humerus are commonly encountered by orthopedic
an osteopenic bone, there may be stress raiser in
surgeons, representing 3 to 5% of all fractures(1).
primary healing in absolute fixation compared to the

There is a bimodal distribution of humeral
callus healing seen in relative fixation with an
shaft fractures, with a peak in young male patients due
intramedullary nailing(5, 6).
to high energy trauma (road traffic accidents, falling

The elastic nail method was developed by
from a height, blow to the arm and gunshot wounds),
Küntscher and the principle was 3 point fixation when
and another large peak in older females usually by
introduced in the medullary canal of long bones and
simple falls(1, 2).
was first used in the fracture of long bones of lower
Diaphyseal fractures of the humerus could be
extremities and soon became very popular method for
managed by both conservative methods as well as
fracture fixation of long bone and later used for
surgically also. The goals of treatment are to achieve
diaphyseal fracture of humerus(7).
union with acceptable humeral alignment. So, patients

can resume their prior level of function(2,3).
Conservative treatment has its demerits such
The aim of the work was to assess the results
as prolonged limb immobilization, the need for
of using the flexible intramedullary nails in the
constant cooperation, compliance and follow ups. The
treatment of humeral shaft fractures.
conservative methods of treatment include U-shaped

slab, hanging plaster cast, prefabricated functional
braces, and simple sling(3, 4).

The study included 20 patients presented to
Surgical fixation of humeral shaft fractures
Alexandria Police Hospital and El-Zahra Hospital,
could be: surface fixation using plate and screws,
suffering from humeral shaft fracture.
intramedullary fixation either antegrade or retrograde

using interlocking nails, rush pins, flexible
A full workup including history taking,
intramedullary nails, Marchetti-Vicenzi retrograde
clinical examination and radiological evaluation as
nails, and Halder humeral nail, as well as external
well as laboratory investigations was performed for
fixation either by uniplanar, biplanar or Illizarov
every patient on admission.
fixators(2, 4).
Written informed consent:
Plate osteosynthesis has always been a gold
An approval of the study was obtained
standard and always given a good result for union of
from Al-Azhar University Academic and Ethical
the bone if properly done according to principle of
Committee. Every patient signed an informed
Open Reduction Internal Fixation but the complete
written consent for acceptance of the operation.
compression is achieved as the primary union should


Full Paper (vol.756 paper# 18)

ABSTRACT The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (6), Page 3079-3082

Optical Coherence Tomography Angiography of Acute Non-Arteritic
Anterior Ischemic Optic Neuropathy
Abd El-Mongy El Sayed Ali, Nour El Din Abd Al-Hamid Abd Al-Halim,
Moaaz Mohamed Sayed Hussein
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Moaaz Mohamed Sayed Hussein, Mobile: 01066345730; Email: m_smoaaz@yahoo.com

Non-arteritic anterior ischemic optic neuropathy (NAION) is an ischemic change involves the 1 mm
thickness of the optic nerve head (optic disc). We depend on fundus fluorescein angiography (invasive investigation)
and visual field for diagnosis of NAION. Optical coherence tomography angiography (OCT A) is a new modality
(non-invasive) for assessment of vascular tissue at multiple retinal levels. We are seeking for a role of OCT A in
diagnosis of NAION. Objective: The aim of the current study was to assess the optical coherence tomography
angiography peripapillary perfusion density in diagnosed non-arteritic acute ischemic optic neuropathy patients within
a period from one week to 3 weeks during (acute stage while the disc is still edematous) of acute painless diminution
of vision. Patients and Methods: This study included a total of ten patients diagnosed with non-arteritic anterior
ischemic optic neuropathy and 10 age-matched normal control individuals with normal RNFL thickness, attending at
ophthalmology outpatient clinic of Al-Azhar University Hospitals. OCT A 6x6 on the disc is done for all subjects and
control group with Zeiss angioplex (cirrus 5000).
Results: showed a decreased perfusion density in a ring from 3 to 6 mm around the center of the disc in all quadrants
except the lower one. Central to this ring, the perfusion density is higher in NAION cases, which may be due to
superficial displacement of the deeper capillary plexa with edema.
We can depend on the perfusion density in ring 3- 6 mm in diameter when assessing a case of acute
NAION not the central circle.
Keywords: Optical coherence tomography angiography, non-arteritic anterior ischemic optic neuropathy, superficial
peripapillary plexus perfusion density


specificity of 91.2% by presence of 3 of these 5 criteria.
Anterior ischemic optic neuropathy (AION) is divided
These criteria are age more than 50 years, new onset of
into arteritic anterior ischemic optic neuropathy
localized headache, temporal artery tenderness or lost
(AAION) which accounts for 15% and Non-arteritic
anterior ischemic optic neuropathy (NAION) which
sedimentation ratio more than 50 mm/hour and biopsy
accounts for 85% of cases (1).
sample including the artery shows necrotizing
Non-arteritic anterior ischemic optic neuropathy
vasculitis. At that time, patient should be given an
(NAION) is an ischemic change involves the 1 mm
intravenous steroid followed by course of oral steroids
thickness of the optic nerve head (optic disc). It affects
(5). Optical coherence tomography (OCT) is a non-
around 10 cases per 100,000 per year in the age group
invasive and interferometric imaging modality
over 50 (2). Crowded disc (disc at risk) is the
developed in 1991 to image the retina in cross section.
precipitating factor in 97% of patients with NAION (2).
It improves in its resolution from 15 um to 3 um. OCT
Multiple risk factors play a role e.g. obstructive sleep
detects depth resolved tissue reflectivity characteristics
apnea, hypertension and diabetes mellitus (3).
by assessing the interference of light reflected from the
Usually the patient with NAION presents in the
biological tissue with reference mirror. This technique
morning with acute painless diminution of vision with
depends on time, so called time domain optical
dyschromatopsia. On examination, we can detect
coherence angiography (6).
relative afferent pupillary defect in the affected eye,
TD OCT, another more developed modality
segmental or diffuse disc edema surrounded with
depends on frequency called spectral domain optical
splinter hemorrhages and decreased C/D ratio in the
coherence tomography (SD OCT) using wavelength of
other eye (4). Arteritic anterior ischemic optic
100 nm so the resolution fades with depth. In addition,
neuropathy (AAION) is the main differential diagnosis.
swept source optical coherence tomography (SS OCT)
Giant cell arteritis (GCA) (granulomatous necrotizing
with wavelength of more than 100 nm (long
arteritis) affecting medium sized arteries e.g. superficial
wavelength) to keep images with good resolution in
temporal and posterior ciliary arteries cause it (5).
deep structures. In 2016 FDA approved a new modality
It is important to differentiate AAION form
called optical coherence tomography angiography
NAION. As AAION is a lethal disease that leads to total
(OCT A) depends on detection of moving RBCs in the
blindness of both eyes. The American college of
vessels to detect the blood vessels. Moreover, this
Rheumatology put 5 criteria for diagnosis of this
technique differentiates vascular tissue at multiple
dangerous disease with sensitivity of 93.5% and
retinal levels (in depth)(6).

Full Paper (vol.756 paper# 19)

c:\work\Jor\vol756_20 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (6), Page 3083-3092

Macular Microstructure Assessment by Optical Coherence Tomography and
Fundus Fluorescein Angiography before and after Silicone Oil Removal
Abu Bakr Farid Abu Al-Naga, Hisham Fawzy Khalil, Mostafa Mahmoud Mostafa,
Bassem Ismail Khalil Gomaa *
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Corresponding author: Bassem Ismail Khalil Gomaa, Tel: (+20)01006281317, E-mail: basemmedicine@yahoo.com

since the early use, silicone oil (SO) has been used as long-term retinal endotamponade to manage
complicated retinal diseases such as proliferative vitreoretinopathy, advanced proliferative diabetic retinopathy, and
complex retinal detachment. A favorable anatomical success was reported after SO injection.
Objective: the aim of this study was to investigate the macular microstructural changes in eyes filled with silicone oil
(SO) and course of these changes after SO removal, to determine the possible cause of unexplained visual loss by the
use of optical coherence tomography and fundus fluorescein angiography.
Patients and Methods: This prospective observational study included a total of 40 eyes of 40 adult patients of both
sexes with rhegmatogenous retinal detachment and scheduled for pars plana vitrectomy with silicone oil tamponade
attending at ophthalmology outpatient clinic of Al-Azhar University Hospitals. This study was conducted between
October 2015 to August 2018. Results: There were insignificant differences in visual prognosis between the group
with persistent SRF and the group without. But VA bad prognosis can be explained through the other OCT finding
not only the SRF. This confirm our conclusion of the importance of OCT examination after successful retinal
detachment repair operation for VA prognosis prediction. In our study there was no difference between OCT finding
before SOR and after, this means that duration of 3-month silicon oil tamponading is a safe duration.
Conclusion: Delayed or incomplete visual recovery after uncomplicated surgery for macula-off retinal detachment
may be related not only to persistent subretinal fluid, but also to other pathological changes.
Keywords: Optical Coherence Tomography, Fundus Fluorescein Angiography, Silicone Oil

situ (3). The condition has been estimated to occur in up
Cibis et al. 1962 was the first to describe the use
to 10% of silicone oil­filled eyes (5).
of silicone oil (SO) for the treatment of otherwise
Many studies published have used time domain
inoperable retinal detachments (1). Since the early use,
optical coherence tomography (OCT) soon after visual
silicone oil (SO) has been used as long-term retinal
loss in these patients and have failed to detect any
endotamponade to manage complicated retinal diseases
abnormalities in macular or optic disc architecture.
such as proliferative vitreoretinopathy, advanced
Advances in OCT technology, particular with the advent
proliferative diabetic retinopathy, and complex retinal
of spectral domain imaging, permit significantly
detachment. A favorable anatomical success was
improved resolution now and have helped identify
reported after SO injection (2). Prolonged silicone oil
pathologic findings in a wide variety of both retinal and
tamponade has been demonstrated to induce many
neurologic diseases (6). The aim of this study was to
investigate the macular microstructural changes in eyes
keratopathy (mainly band shape keratopathy) and optic
filled with silicone oil (SO) and course of these changes
neuropathy associated with progressive visual
after SO removal, to determine the possible cause of
deterioration. In addition, the microstructural retinal
unexplained visual loss by the use of optical coherence
damages related to mechanical stress or biochemical
tomography and fundus fluorescein angiography.
toxicity, which called silicone retinopathy (3).

Therefore, some authors recommended the
removal of the SO as soon as possible when a stable
This prospective observational study included a
retina situation is achieved. Profound visual loss
total of 40 eyes of 40 adult patients of both sexes with
following SO use without any apparent explanation has
rhegmatogenous retinal detachment and scheduled for
been reported in a number of case series (4).
pars plana vitrectomy with silicone oil tamponade
In 2004, the first case series of visual loss
attending at ophthalmology outpatient clinic of Al-
secondary to removal of silicone oil was published. This
Azhar University Hospitals. Approval of the research
described seven patients who experienced sudden
ethical committee and a written informed consent
deterioration in central vision at the time of silicon
from all the subjects were obtained. This study was
removal, and for which no obvious cause could be
conducted between October 2015 to August 2018.
determined. Visual acuity was frequently found to be
Macular was evaluated before and after SO removal.
20/200 or worse. Since then, several other investigators
Silicone oil was removed when the eyes are confirmed
have described case series of this phenomenon to occur
to have attached retina after at least 3 months of SO
both at the time of removal and while silicone oil is in


Full Paper (vol.756 paper# 20)

c:\work\Jor\vol756_21 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (6), Page 3093-3098

Detection of Occult Hepatitis C Virus Infection (OCI) in
Bone Marrow Mononuclear Cells
Mohamed Darwish Ahmed Abd Alla1, Yasser Mohamed Mohamed El-Dessouky1,
Khaled Abdelmoamen Ahmed Ali2, Moukhtar Ragab Ramadan3, Raefat Mohamed Abd El Fattah2,
Abdel Ghany Abdel Sattar Aish4, and Mostafa Kamel El Awady5
1Department of hepatology, Gastroenterology and Infectious Diseases, 3Radiology Department, Faculty of Medicine,
Al-Azhar University; 2Nasser Institute for Research and Treatment; 4Shebin El-Koum Teaching Hospital; 5Department
of Microbial Biotechnology, National Research Center, Cairo, Egypt.
Correspondence to: Mohamed Darwish Ahmed Abd Alla, Tel: +2 0109-417-5209, E-mail: darwish0716@azhar.edu.eg


Background and aim: Occult HCV infection (OCI) diagnosis by cellular-PCR encourages further research for more
understanding of extrahepatic tissues affection during non-viremias. OCI among Egyptians recruits more attention
because of the convenient diagnostic tools and the availability of direct acting antivirals (DAAs). Our study aims to
recognize HCV-infection of bone marrow mononuclear cells (BMMCs) in antiviral IgG-antibody seropositive non-
viremic subjects.
Subjects and Methodology: Our case control study included 70 subjects who were divided into three groups: - I:
non-viremic IgG-seronegative controls (n=25), II: naļve HCV-RNA viremic IgG-seropositive controls (n=15), III:
naļve non-viremic IgG-seropositive patients (n=30). Sera of all study subjects were screened for anti-HCV IgG-
antibodies by ELISA and for HCV-RNA by PCR. BMMCs and peripheral blood mononuclear cells (PBMCs) of all
study populations were tested for HCV-RNA infections by cellular-PCR.
Results and conclusions: HCV-RNA viremias were seen when bone-marrow is functioning (P<0.05), while non-
viremias were common in bone-marrow failure (P<0.05). There was 100% concordant positivity between serum and
cellular HCV-RNA-PCRs in viremic patients. HCV-BMMCs and PBMCs PCRs respectively added extra 20%
(P=0.024) and 13.33% (P=0.119) as newly diagnosed infections compared to none by serum-PCR in IgG-antibody
seropositive non-viremic subjects. Respectively, non-viremic population (n=55) showed 14.29% and 9.1% positive
intra-mononuclear cells HCV-RNA infection in bone marrow (P=0.002) and peripheral blood (P=0.057) compared
to serum PCR. In conclusion, consecutive screening of peripheral blood and bone marrow mononuclear cells for
HCV-RNA detection by cellular-PCR recognizes naļve OCI in IgG-seropositive non-viremic patients. Functioning
bone marrow would be required for persistence of HCV-RNA viremia.
Keywords: Occult HCV Infection, Bone Marrow and Peripheral Blood Mononuclear cell-PCRs.

viremias, would confirm concordant disappearance of
Management of occult HCV infection (OCI) in
the virus from serum and cells (6,7). Despite the reported
naļve and experienced patients has been questionable
90% post-DAAs therapy SVR, only serologic relapse
because in addition to diagnostic difficulties, the fates
was considered (8). No enough attention was paid to
of treatment trials haven't been thoroughly evaluated.
posttreatment intracellular persistent or relapse of viral-
Before availability of the noninvasive peripheral blood
RNA infection that leads to serologic relapse with
mononuclear cells (PBMCs) PCR (1), diagnosis of OCI
progressive hepatic damage (4,5), and global aggravation
required hepatocyte testing for intracellular HCV-RNA
of HCV health problem worldwide (9). More
existence (2). The use of PBMCs-PCR in detecting
comprehensive investigations and new therapeutic
intracellular HCV-RNA genomic materials is specific
protocols should be proposed to continue management
with high negative predictive values, however its
of HCV infection beyond the false clinical recovery (10-
sensitivity is around 60% in diagnosing cryptogenic
13). In 2018, Abd Alla et al. evaluated post-DAAs
hepatitis C virus infection (2). Consistency and
therapy outcomes before end of treatment (EOT); they
relationship between intra-PBMCs and intra-bone
extended DAAs therapy beyond 12 weeks in those who
marrow mononuclear cells (BMMCs) HCV-RNA
had intra-PBMCs HCV-RNA genomic materials till the
detection has been unveiled. Despite the documented
end of 24th week. The intracellular HCV-RNA was
HCV hepatotropism, isolation of HCV-RNA from
cleared in most cases and SVR was improved (7).
extra-hepatocytes sources was successful (3).
The relationship between HCV infection and
Replications of genomic HCV-RNA inside
bone marrow disease syndrome was reported in
PBMCs from naļve and posttreatment patients were
found to be followed by overt viremia after
disappearance of serum virus particles (4,5). Therefore,
lymphoma and other hematological malignancies (14-16).
serum and cellular testing for extracellular and intra-
It was reported that association may be related to HCV
PBMCs HCV-RNA genomic materials, in spontaneous
genotypes variations in different parts of the world,
and post-therapy disappearance of viral particles in non-
however regional and racial factors may play a


Full Paper (vol.756 paper# 21)

c:\work\Jor\vol756_22 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (6), Page 3099-3106

Role of Multi-Parametric Magnetic Resonance Imaging (MRI) in
Assessment of Malignant Prostatic Lesions
Wafek Ibrahim Ali, Mohamed Ismail Hammad and
Tarek Mohamed Sayed Alazab Alshazly*
Department of Radiodiagnosis, Al-Azhar Faculty of Medicine, Cairo, Egypt
*Corresponding author: Tarek Mohamed Sayed Alazab Alshazly, Mobile: 01270342658;
Email: tantawy_wael@yahoo.com
carcinoma of the prostate is an important health problem. It is the one of the most frequently diagnosed
solid malignant tumor among men. Multi-parametric MRI of the prostate has been increasingly used as an imaging
technique through the last years. Objective: our study aimed to evaluate the sensitivity of multiparametric magnetic
resonance (MR) imaging in detection of cancer prostate, using the Prostate Imaging Reporting and Data System (PI-
RADS) version 2.0. Patients and Methods: thirty patients were enrolled in the study. All patients with elevated PSA
values greater than 4 ng/ml underwent sextant TRUS guided biopsies. MRI examination was done either prior to the
TRUS biopsy or at least 3 weeks after the TRUS biopsy.
Results: the application of PI-RADS version 2 has significantly improved the diagnostic performance in detection of
clinically significant cancer. Considering PIRADS score greater than 3 as a strong indicator for malignancy, the
sensitivity of PI-RADS version 2 was 80% for detection of malignant lesions in general (significant and
insignificant). Moreover, our study revealed an 88% sensitivity and 33% specificity of mp-MRI in detection of
clinically significant cancer prostate (with PIRADS score 4 or more for clinically significant caner that have a
Gleason score 7 or more, or extraprostatic extension), with a significant p value <0. 001.
Conclusion: as a preoperative imaging tool, use of PI-RADS version 2 helps to diagnose clinically significant
prostate cancer, considering PI-RADS scores of 4 and 5 to be associated with the presence of clinically significant
Keywords: MRI, Malignant Prostatic Lesions, PI-RADS.

aiding in the detection, localization, and staging of
Prostate carcinoma is the second most
prostate cancer, multiplanar T2-weighted endorectal
frequent cause of cancer-related death in men. The
MR imaging can facilitate more appropriate treatment
increase in the number of the aged, as well as the
selection and planning. However, for distinguishing
advent and the ever more frequent use of the prostate-
prostate cancer from nonmalignant tissue, T2-
specific antigen serum test for detection, has resulted
weighted MR imaging has high sensitivity but low
in an increase in prostate cancer incidence (1).
specificity. To further improve the specificity and
The major goal for prostate cancer imaging in
sensitivity of MR imaging, functional MR imaging
the upcoming years is more accurate disease
techniques such as three dimensional (3D) hydrogen 1
characterization through gathering more accurate
(1H) MR spectroscopic imaging, dynamic contrast
anatomic, functional, and molecular imaging
material enhanced MR imaging, and diffusion-
information (2).
weighted imaging have been proposed (5).
Localization of prostate cancer is an important
The implementation of multiparametric
given in the emergence of disease- targeted therapies,
magnetic resonance imaging (mpMRI) into a
such as intensity- modulated radiation therapy,
screening program may reduce the risk of
interstitial brachytherapy, and cryosurgery, as a part of
overdetection of non-significant PC and improve the
patient care. Identifying the tumor location within the
early detection of clinically significant PC. A mpMRI
prostate can help directing maximal therapy to the
consists of T2-weighted images supplemented with
largest focus of the tumor while minimizing damage
to the surrounding healthy structures, such as the
enhanced imaging, and/or magnetic resonance
neurovascular bundles, the rectal wall, and the neck of
spectroscopic imaging and is preferably performed
the bladder (3).
and reported according to the uniform quality
These modalities are ultrasound based
standards of the Prostate Imaging Reporting and Data
(including color Doppler Ultrasonography, ultrasound
System (PIRADS). International guidelines currently
contrast agents, and harmonic ultrasound imaging),
recommend mpMRI in patients with persistently
MR based including (dynamic MR contrast imaging,
rising PSA and previous negative biopsies, but
MR spectroscopy and Diffusion weighted MR
mpMRI may also be used before first biopsy to
imaging) (4).
improve the biopsy yield by targeting suspicious
Magnetic resonance (MR) imaging has shown
lesions or to assist in the selection of low-risk patients
great promise as a noninvasive diagnostic tool in the
in whom consideration could be given for surveillance
evaluation and management of prostate cancer. By


Full Paper (vol.756 paper# 22)

Study of the uses of fibrin glue in treatment of types of anal fistula The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (6), Page 3107-3112
Comparative Study between Fibrin Glue and
Surgical Treatment of Pilonidal Sinus
El-Sayed Ahmed Mostafa1, Mahmoud Abdalla Abd-Elrazik 1,
Zahraa Futtoh Mohammed1, Mohamed Mahmoud Gharieb2
1Department of General Surgery, Faculty of Medicine for Girls, Al-Azhar University Egypt
2Benha Teaching Hospital, Kalubia, Egypt
Corresponding author: Mohamed Mahmoud Gharieb ,Tel.: 01000700320

Background: Published results have shown that fibrin glue may be effective in closure of pilonidal fistula. We
report the final results of a randomized clinical trial evaluating the use of fibrin glue in treatment of pilonidal
Objectives: to determine the efficacy of a new simple with minimal tissue loss and a low recurrence rate
technique that uses fibrin glue in the closure of pilonidal sinus (PS) in comparison with surgical technique.
Methods: the results of treatment of pilonidal fistula by fibrin glue in 10 patients were compared with those
obtained by conventional surgery in another 30 patients, we carried out this study on 40 patients at Al-Zharaa
University Hospital, Egypt between March 2017 and March 2019. The outcome was evaluated by recurrence or
Results: out of 40 patients, 19 patients were male and 21 were female. Fibrin glue injection was done in 25% of
patients and surgery was done in 75%. Recurrence occur in 10 % in fibrin glue and 36 % by surgical treatment.
Conclusion: fibrin glue is a simple, reasonable, feasible, reproducible technique and competitive alternative to
other surgical intervention. It is accompanied by a reduction in pain, reducing hospital stay, minimizing tissue
assault, promoting early work resumption and with lower recurrence rate. Inspite of the surgical approach is still
the standard modality for pilonidal sinus treatment.
Keywords: Pilonidal fistula, Fibrin glue and Rhomboidal flap.


Pilonidal sinus is a common and often
problem, which is frequently encountered, and can
difficult condition to treat. It most frequently affects
result in complications such as "dead space",
men (male-to-female ratio is 3:1) between the ages
hematoma, wound infection, and wound separation
of 18­40 years. It is a chronic inflammatory
during the early postoperative period (4).
condition with hairs found in midline natal pits and
The ideal management strategy should be
associated secondary tract extensions. The
simple with minimal tissue loss and a low recur-
presentation of the disease varies from acute
rence rate. Furthermore, both shorter hospital stay
abscess formation to chronic non-healing pits (1).
and postoperative disability from active life should
Many conservative and surgical methods
be minimal, with low cost and high cosmoses.
have been described for the treatment of pilonidal
Therefore, simple methods such as pit excision and
sinus disease, but the standard and optimal surgical
the mechanical clearance of sinus, as well as
method remains controversial. The main principle
in the treatment is to enable patients to return to
acceptance in the management of PS. Fibrin glue
their normal life at the earliest after a complication-
has been used for three decades in many fistula
free surgical procedure as well as to prevent
diseases with varying success. It has been applied in
recurrence (2). Although it affects mainly the most
enterocutaneous fistulas, repairing dura tears,
active portion of society, creating a considerable
bronchial fistulas and for achieving hemostasis after
health and economic burden, the best disease
spleen and liver trauma (5).
management strategy for PS remains unclear. A
The use of fibrin glue in PS is relatively new
variety of operations have been described: from
and encouraging results have been reported. It is a
minimal surgical methods including simple
tissue sealant, which uses the activation of
excision, lying open, marsupialization, elliptical,
fibrinogen to form a fibrin clot. It has been used as
medial or para-medial excision and primary closure,
an adjunct to wound closure in excisional pilonidal
to complicated flap procedures such as rhomboid
surgery, its suggested benefit being in obliterating
and rotation (3).
potential space underneath the wound. Now fibrin
In all techniques (primary closure or flap), a
glue is used alone as a line of treatment with an
cavity is created after the excision of the pilonidal
excellent cosmoses and minimal tissue loss, without
cyst accompanying healthy tissue; this should be
excision of large amounts of tissue (6).
filled or closed, or else it causes is a technical


Full Paper (vol.756 paper# 23)

c:\work\Jor\vol756_24 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (6), Page 3113-3118
Comparative Study between Doppler-Guided Haemorrhoidal Artery
Ligation (HAL) and Conventional Haemorrhoidectomy for Treatment of
III& IV Degree Haemorrhoids
Mohammed Mohsen Ibraheem Khalil, Shawky Mohamed Deabes, Yasser Ahmed Amer
Surgery department,faculty of medicine,Al-Azhar university
Correspondence author: Mohammed Mohsen Ibraheem Khalil, Mobile: (+20) 0101-9636968,
E mail: khalilmohammed35@azhar.edu.eg

Haemorrhoidal disease is probably the most frequent reason for consultation in proctology with an
estimated prevalence about 4.4%. The gold standard treatment is still excisional hemorrhoidectomy, which is
considered a safe and definitive method.
Objective: The study was designed to compare the clinical and functional outcome of Doppler-guided (DG)
haemorrhoidal artery ligation (HAL) and conventional haemorrhoidectomy for treatment of grade III & IV
Patients and methods: This study was conducted on 60 patients, divided into two groups: group A included 30
patients that were operated upon through the conventional haemorrhoidectomy and group B include 30 patients that
were operated upon through Doppler-guided haemorrhoidal artery ligation (DG- HAL), and comparison between two
groups as regard outcomes and complications.
Results: It was found from this study that DG- HAL is a painless, easily learned, and minimally invasive therapeutic
technique that offers a good alternative to all other known treatments of symptomatic hemorrhoids. During the
postoperative check-up 6 weeks after the procedure, scar tissue that had been firmly connected to the underlying
tissue structure was seen in areas where ligatures had been placed.
Conclusion: Using DG-HAL complications are comparable with those associated with other methods, with no severe
complications. The DG-HAL procedure is synonymous with a high level of patient comfort and is perfect for
outpatient treatment.
Keywords: DG-HAL, haemorrhoidectomy, Mucopexy, Hemorrhoids.

alternative to all other surgical treatment of
Hemorrhoids affect between 4 and 36 percent of
symptomatic hemorrhoids and is also associated with
population. The pathogenesis of this disease remains
less postoperative pain. The HAL technique is designed
controversial but might be a conjunction of the two
to interrupt the arterial blood supply to the anal cushions
theories often discussed: the mechanical explanation in
by using a Doppler probe and pulling up the prolapse by
which the muscular fibroblastic supportive tissue of the
bunching up the mucosa. The connective tissue in the
haemorrhoidal plexus degenerates and the vascular
collapsed hemorrhoid regenerates until the resolution of
explanation in which the arteriovenous shunts open,
the prolapse (5).
leading to dilation of the haemorrhoidal venous plexus

(1). Hemorrhoids become symptomatic through
prolapse, bleeding, pain, pruritus, and/or mucus
To compare the clinical and functional outcome of
discharge. Grade of hemorrhoids does not always
Doppler-guided haemorrhoidal artery ligation (HAL)
correlate with symptoms (2).
and conventional haemorrhoidectomy for treatment of
Traditionally, the initial treatment of grade III & IV
grade III & IV haemorrhoids.
haemorrhoids is conservative management, if

symptoms prevail. There is wide range of treatment
modalities include injection sclerotherapy, infrared
Sixty patients were treated for haemorrhoids by
either Haemorrhoidal artery ligation or by conventional
hemorrhoidectomy (open, closed or stapled) (3).
haemorrhoidectomy at Al-Azhar University Hospitals,
Common complications of hemorrhoidectomy are
Cairo, Egypt during the period from November 2018 to
pain, bleeding, infection, fissure, delayed healing,
May 2019, after obtaining the Local Ethics
stenosis, soiling and anal incontinence (4).
Committee approval. All patients admitted to the
In 1995, a new method was introduced by a
surgery department and signed a written informed
Japanese surgeon , Kazumasa Morinaga in which the
consent. They were randomized using close-envelope
arterial blood supply of haemorrhoidal plexus are bound
into two groups:
with ligatures (Doppler ­Guided Haemorrhoidal artery
Group I: 30 patients, operated upon through the
ligation) (5). Doppler ­Guided HAL is easy to perform
conventional haemorrhoidectomy.
and is a minimally invasive technique that offers a good


Full Paper (vol.756 paper# 24)

c:\work\Jor\vol756_25 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (6), Page 3119-3123

Patient's Awareness of Using Antibiotic without Prescription
Hattan Mohammed Baismail 1, Ali Salem AlSalem2, Mai Atef Abdulaziz3
1Lublin Medical University-Poland, Dentist in Ministry of Health-Tabuk,
The Future University Q
- assim, Dentist in Ministry of Health H
- ail

sr International University E
- gypt, Dentist at Royal Commission Medial Center Y
- anbu

there are many types of antibiotic drugs with different dosages and indications. Many patients often use
antibiotics inappropriately and even without doctor's prescriptions, in this study we want to determine the antibiotics
knowledge among general population of Makkah and to determine the proportion of population using antibiotics without
prescriptions. Aim of the work: this study aimed to determine the severity of misuse of antibiotics and to educate the
general population regarding the same. Methods: 500 questionnaires were distributed to the general adult population of
Makkah. Data were analyzed to compare education level with the antibiotic knowledge, proportion of population taking
antibiotics without prescription. Results: when comparing the males with females, statistically significant differences
were obtained when inquired about knowledge of different types of antibiotics (p-value: 0.004), allergies related to
antibiotics use (p-value: 0.007), differences in doses of several antibiotics (p-value: 0.019). Second comparison was done
on the basis of educational levels, which revealed statistically significant differences when inquired about basic function
of antibiotics (p-value: 0.000), knowledge of different antibiotic types (p-value: 0.017), allergies related to antibiotics use
(p-value: 0.029). Conclusion: the overall level of knowledge among the studied subjects was found to be on the lower
side. Females tend to have a better attitude towards the use of antibiotics as compared to males. Higher education groups
utilized more antibiotics without prescription as compared to lower education groups.
Keywords: patient's awareness, antibiotics, prescription, Makkah, KSA.

towards the use of antibiotics without prescription and
There are many types of antibiotics with different
to compare the survey responses on the basis of gender
dosages and indications. Many patients often use
and educational level.
antibiotics inappropriately and even without doctor's

prescriptions. Unnecessary use of antibiotics has
resulted in resistant forms of bacteria, which pose a
Study design:
great challenge to the health of patients (1). There are
500 questionnaires were distributed to the general
several factors associated with the use of antibiotics
adult's population of Makkah. Data was analyzed to
without prescription among general public. These
compare educational levels and gender on questions
include social, cultural, historical and economic
related to antibiotics without prescription.
factors, which play an important role in patients'

decision towards the use of antibiotics without
Statistical Analysis Plan:
prescription(2).There are different demographical
The data were analyzed by using descriptive and
groups of population who have the history and habit of
inferential statistics using Chi-square test in SPSS
using antibiotics without any rationale. Students are
version 21.
one of them, who tend to consume antibiotics without
Ethical part and confidentiality:
doctor's supervision. Most common use of antibiotics
Waiver of informed consent was requested because it
was observed when the studied subjects were suffered
was a questionnaire-based study and ethical approval was
from flu (3). Few adverse affects of irrational antibiotics
sought from KAMC IRB. No study activities were
use have been reported, which included adverse
started until the IRB approval was obtained.
reactions of the drug and masking of underlying

infection (4). Self medication has been an issue of
conversation among many countries. Developing as
A total of 500 male and females filled up the online
well as developed countries have reported their citizens
survey, which comprised 57% males and 43% females.
to use antibiotics without prescription, which included
The sample was divided into subgroups on the basis of
Spain, Jordan, Netherlands, Sweden, United Kingdom,
educational level, which demonstrated that 3% were
Italy and many more(5-7). Additionally, few studies in
primary school, 5% were secondary school, 39% were
Saudi Arabia have demonstrated the use of antibiotics
high school, 47% were graduates and 6% were post
without their doctor's prescription (8,9). This work
aimed to determine the awareness of Saudi citizens

Full Paper (vol.756 paper# 25)

c:\work\Jor\vol756_26 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (6), Page 3124-3130
Endoscopic Treatment of Insertional Achilles Tendinopathy
Ali ElGioshy, Emad Zayed, Mohamed Mostafa
Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Mohamed Mostafa,email: mohamedelkady.ortho88@gmail.com
The purpose of this study was to evaluate the outcome of endoscopic treatment of insertional Achilles
tendinopathy. Patient and Methods: This prospective study was held on 15 patients suffered from insertional achilles
tendinopathy at Alazhar University Hospitals. There were 7 males and 8 females with mean age 46.27 years (28 to 60
years). Clinical examination, lateral weightbearing Xray of ankle and MRI of ankle were done for all patients. All patients
were evaluated preoperatively and postoperatively by AOFAS hindfoot scale with mean follow up 6 months.
Results: The Mean Preoperative AOFAS hindfoot scale of 15 patients in this study was 58.2 (36 to 80) and mean
postoperative AOFAS hindfoot scale after 6 months follow up was 86.53 (67 to 97) with P value (.001). There were 3
patients with postoperative scar tenderness. There was neither sural nerve injury nor achilles tendon rupture during follow
up period. Conclusion: Endoscopic treatment of insertional achilles tendinopathy had a lot of advantages as being safe
and efficient procedure with small incision and cosmetic scar. This technique also could avoid catastrophic complications
of open procedures in the form of wound dehiscence, ugly scar and affection of Achilles tendon insertion.
Insertional Achilles tendinopathy , Haglund syndrome , endoscopic treatment , sural nerve.

Achilles tendinopathy is a disorder of hindfoot
This prospective study has been approved by
which occurs frequently in both the active and non-active
the Ethical Committee of Al-Azhar University. A total
population. There are two types of Achilles tendinopathy
of 15 patients with insertional Achilles tendinopathy were
which are insertional and non-insertional Achilles
treated in Al-Azhar University Hospitals using endoscopy.
All patients had signed an informative consent form.
accounted for 20% to 25% of total disorders related to
We included Patients with insertional Achilles
Achilles tendon(2).
tendonopathy with failed conservative treatment for more
The location of pathology is the insertion of
than 6 months.
Achilles tendon and is usually associated with formation
Exclusion criteria were: a) Previous surgery to
of calcifications and bone spurs of Achilles tendon.
calceneus or Achilles tendon., b) Achilles tendon rupture,
Insertional Achilles tendinopathy has been defined as a
c) Vascular insufficiency (impalpable posterior tibial or
clinical syndrome consisting of swelling , pain and
dorsalis pedis pulse) , d) Patients less than 18 years old
function impairment(3). Symptoms of Haglund deformity,
and e) Insertional Achilles tendinopathy with more than
retrocalcaneal bursitis and retrocalcaneal exostosis could
50% affection of tendon circumference.
be reflective of insertional Achilles tendinopathy(4).
There were 8 females and 7 males with mean age
Clinically, tenderness has been located at the distal 2 cm
46.27years (28 to 60years) with standard deviation 9.17
Achilles tendon, and the Haglund deformity could be
and there were 3 diabetic patients.3 patients out of them
prominently felt at the superior aspect of the posterolateral
were smokers while 2 patient had previous local platelet
calcaneal tuberosity(5).
rich plasma injection. The mean body math index (BMI)
Lateral weightbearing xray is done to assess
of patients in our study was 28.92 (19.59 to 35.05) with
posterior calcaneal angle (fowler and Philip angle) (6) and
standard deviation 4.76 . All patients had preoperative
MRI for assessment of integrity or degeneration of
clinical assessment in the form of general, local
achilles tendon and retrocalcaneal bursitis(7).
examination and special tests as two finger squeeze test
Non-operative modalities of treatment are rest,
and Thompson test (Fig.1) . Lateral weightbearing xray of
ice packs, NSAIDS, heel lifts(8,9) , physiotherapy (10) ,
ankle was done for all patients pre-operatively to asses
extracorporal shock wave therapy (11) , local platelet rich
haglund deformity by posterior calcaneal angle (fowler
plasma injection (12) and low level laser therapy (13).
and Philip angle) and parallel pitch lines (Fig.2).
Operative treatment is recommended after failure
MRI was done as routine pre-operative investigation to
of conservative treatment for 6 months in the form of open
assess the integrity of Achilles tendon, retrocalcaneal
surgery (14) and minimally invasive endoscopic treatment
bursitis and Achilles tendon degeneration (Fig.3) . By
(15). This article presents 15 patients with insertional
lateral wightbearing Xray and MRI there were 2 patients
Achilles tendinopathy after failure of conservative
(13.3%) have retrocalcaneal bursitis only, 3 patients
measures for more than 6 months treated with endoscopic
(20%) have (Haglund deformity, retrocalcaneal bursitis
removal of thickened synovium,inflamed bursa, resection
and retrocalcaneal exostosis) and 10 patients (66.7%)
of postero-superior part of calcaneus (Haglund deformity)
have Haglund deformity deformity, retrocalcaneal
and debridment of diseased fibers of Achilles tendon. The
bursitis. All patients were assessed pre-operatively by
purpose of this study was to evaluate the clinical and
AOFAS hindfoot scale(16).
functional results of endoscopic treatment of insertional

Achilles tendinopathy.

Full Paper (vol.756 paper# 26)

c:\work\Jor\vol756_27 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (6), Page 3131-3138

The Therapeutic Effects of Vitamin C on Changes of
Some Biochemical Parameters in Male Albino Rats Treated with Mixture of
Food Additives (Sodium Benzoate + Mono Sodium glutamate + Chlorophyllin)
Eman G.E. Helal1*, Mohamed A. Abdelaziz2, Hewaida A.E. Fadel3, Nahla S.A. EL-Shenawe1
1Department of Zoology, Faculty of Science (Girls), Al-Azhar University; 2Department of Physiology,
Faculty of Medicine,(Boys), Al-Azhar University; 3Department of Physiology and Ntritional Chemistry,
National Nutrition Institute, Egypt
*Corresponding Author: Eman Helal, Email: emanhelal@azhar.edu.eg,
Mobile: 00201001025364, orcid.org/0000-0003-0527-7028

Food additives are substances intentionally added to food to change its characteristics, maintain and
improve safety, maintain the nutrient value and to improve taste, texture, and appearance.
Aim of the work: This study aimed to determine the therapeutic effects of vitamin C against the hazardous effects
of sodium benzoate, chlorophyllin and monosodium glutamate on some physiological parameters in male albino rats.
Materials and Methods: this study had been done on thirty male albino rats with an average body weight 120-140
g. The animals were divided into three groups. Group 1: control, Group 2: rats treated with mixture sodium benzoate,
chlorophyllin and monosodium glutamate and Group 3: rats treated with food additives mixture and vitamin C. Blood
samples were collected and the separated sera were used for estimation of some biochemical parameters (liver
enzymes, kidney functions, glucose, protein profile and lipid profile) and hormonal levels [testosterone,
triiodothyronine (T3) and thyroxine (T4)].
Results: The biochemical results showed an increase in levels of fasting glucose, insulin, HOMA-IR, activities of
AST and ALT, urea, creatinine, total cholesterol (TC), triglycerides (TG), LDL-C, VLDL, ratios of TC/HDL-C and
LDL-C/HDL-C (risk factors) in mixture group accomphined by a significant decrease in protein profile (total protein,
albumin and globulin), HDL-and testosterone hormone levels . On the other hand, these results turned back nearly
to normal values after receiving vitamin C.
Conclusion: The present study revealed capability of vitamin C to fight the grievous effects of food additives mixture
on major physiological parameters.
Keywords: food additives, sodium benzoate (SB), Chlorophyllin(CHL), monosodium glutamate (MSG), Vitamin C
(VIT. C).


Monosodium glutamate (MSG) is a common
replaced with sodium or potassium to convert into
example of one of the chemicals used in our modern
foods. It is sodium salt for glutamic acids. Glutamate
Despite the industrial chemical changes that
is one of the most common amino acids in nature and
occur in chlorophyllin, this continues to provide the
is the main component of many proteins and peptides
same functional properties of chlorophyll, a product
in most tissues. Monosodium glutamate contains 78%
found in various sources such as fruits, and vegetables
glutamic acid, 22% sodium and water. If large amounts
because of its more stable production compared to
of glutamate are taken, the levels of glutamate will
chlorophyll. Chlorophyllin has been widely used as a
increase in the portal circulation, which increases the
food additive, accelerating healing, in the treatment of
metabolism of the glutamate, leading to the release of
calcium oxalate kidney stones, in body control, urinary
glucose, lactate, glutamine and other amino acids in
and fecal odors for patients with aging (2).
the systemic blood circulation. Glutamic acid turns
Sodium benzoate is a common preservative
into alanine in the intestinal mucosa and lactate in the
used in many foods including salads, soft drinks,
jams, fruit juices as well as pharmaceuticals to keep
Glutamic acid is absorbed from the intestine
liquid medicines.
by the active transport system of amino acids.
This compound is widely consumed
Monosodium glutamate, which changes the metabolic
indirectly by this compound, which has been reported
rate of glucose use and low antioxidant defenses. It
to cause serious adverse effects in the body as a food
additive. Benzoate is metabolized in the liver by
association with glycine, leading to the formation of
Chlorophyllin is a derivative of sodium
hyboric acid. The use of glycine in detoxification of
chloride and copper chlorophyll, where the central
benzoate leads to depletion in the level of glycine in
magnesium nucleus is replaced with other metals such
the body, which can affect the metabolism of glycine
as copper, iron or cobalt and methyl ether groups are
involved. Low levels of glycine in the body can lead

to lower levels of creatinine, glutamine, urea and uric

Full Paper (vol.756 paper# 27)

c:\work\Jor\vol756_28 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (6), Page 3139-3142

The Role of Acetic Acid Chromoendoscopy and Narrow Band Imaging in
Diagnosis of Esophageal Barrett Dysplasia
Magdy Eldahshan1, Ashraf Albahrawy1, Zakarya Mohamed Zkareya1, Shadia Hussein Mabrouk2, Alaa Alsawak1
1 Department of Internal Medicine, Faculty of Medicine, Al-Azhar University,
2 Department of Pathology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
Corresponding author: Alaa Alsawak, email: alaaalsawak5@gmail.com
Barrett's esophagus (BE) is an important risk factor for the occurrence esophageal adenocarcinoma.
Endoscopic surveillance for Barrett's dysplasia is indicated in all patients with BE. Recent data found that with the use of
advanced endoscopic techniques there is an increased diagnostic yield for dysplasia.
Aim: The aim of this study is to assess the accuracy of acetic acid assisted narrow band imaging (AA-NBI) endoscopy in
detection of Barrett's dysplasia. Patients and Methods: Forty patients with BE surveyed for Barrett's dysplasia by AA-
NBI endoscopy. Patients with difficult sampling (n=1) or not proved to have Barrett's mucosa by histopathology (n=5)
were excluded. Patients with positive and negative dysplasia underwent targeted and random endoscopic biopsy,
respectively. The diagnosis of BE based on Prague endoscopic classification. The pathological assessment of Barrett's
dysplasia based on Vienna classification. Results: A total of 34 patients were included; their mean age was 39.03±14.23
years; they were 19 (55.88%) males and 15 (44.11%) females. Of them 28 (82.35%) had cardiac type BE, 3 (8.82%) had
fundic type BE and 3 (8.82%) had intestinal type BE. Five patients were depicted as Barrett's dysplasia by AA-NBI. Low
grade dysplasia was proved in 3 of them by histopathology. The sensitivity, specificity, positive predictive value, negative
predictive value and accuracy of AA-NBI in diagnosis of Barrett's dysplasia were 100%, 93.5%, 60%, 100%, and 94.1%
respectively. Conclusion: Nine percent of patients with BE are positive for dysplasia. AA-NBI has promising sensitivity,
specificity and accuracy in prediction of Barrett's dysplasia.
Keywords: Barrett's esophagus. Dysplasia. Acetic acid chromoendoscopy. Narrow band imaging. esophageal

a major proportion of Barrett's neoplasia is not visible on
The incidence of esophageal cancer is rising 1
high definition white-light endoscopy alone, with reported
representing the seventh most common cancer worldwide.
sensitivity in the range 40%-64% and specificity 98%-
It is well known that Barrett's esophagus (BE) is
100% 9. In addition, 4QBS are time-consuming, costly
considered an important risk factor for the occurrence of
and poorly accepted by patients. These drawbacks have
esophageal adenocarcinoma (EAC) and is present in up to
encouraged evaluation of more effective techniques to
1.6% of the general population 2 and in up to 20% of
improve the diagnostic accuracy for the detection of IM
patients suffering from gastroesophageal reflux disease
and early Barrett's dysplasia used in surveillance 10.
(GERD) 3.

It is postulated that the development of EAC in
Barrett occurs in a progressive fashion from intestinal
The study was performed on 40 consecutive adults
metaplasia (IM) to low grade dysplasia (LGD) to high
with BE who required endoscopic examination at El-
grade dysplasia (HGD) and then EAC. The annual rate of
Hussein University Hospital between December 2017 and
transformation into EAC in BE patients without dysplasia
April 2019, Department of Internal Medicine,
is estimated to be between 0.07% and 0.82% 4. While the
Gastroenterology and Hepatology Unit.
annual rate of progression from LGD to HGD or EAC is
Patients with advanced esophageal cancer, previous
as high as 8.8% 5 and from HGD to EAC is 12% to 40% 6.
esophageal resection, on-going treatment with antiplatelet
The aim of endoscopic surveillance for Barrett
medication, or anticoagulant medication, and those with
dysplasia is to change the natural history of the disease
hemorrhagic diseases, were excluded.
through recognizing dysplasia at an earlier stage and thus

introducing beneficial endoscopic treatment. Established
Ethics and Patient Consent
surveillance protocols suggest Seattle protocol with taking
The study was approved by the Ethics Board of Al-
targeted biopsies of visible lesions and random four
Azhar University and an informed written consent was
quadrant biopsies (4QBS) every 1-2 cm which seemingly
taken from each participant in the study.
offers the maximum yield of dysplasia in comparison with
Endoscopic procedure:
other biopsy protocols 7. However, there are several
Surveillance of BE was conducted by white light
disadvantages to this Seattle protocol including only 13%
imaging (WLI), and narrow band imaging (NBI).
of early neoplastic lesions appearing as visible nodules 8,
Endoscopic diagnosis of BE was based on the detection of

Full Paper (vol.756 paper# 28)

c:\work\Jor\vol756_29 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (6), Page 3143-3147

Prevalence of Open Angle Glaucoma in Patients with Obstructive Sleep Apnea
Ahmed Abdelfattah1*, Ahmed Ibrahim Zaghloul2 and Mostafa Mahmoud3
Departments of 1,2Otorhinolaryngology and 3Ophthalmology,
Faculty of Medicine, 1,3Cairoand 2Damietta, Al-Azhar University
*Corresponding author: Ahmed Abdelfattah, E-Mail: ahmedfatah10@hotmail.com

obstructive sleep apnea seems to have multi-organ harmful effects. Its association with glaucoma was
previously reported. However, the debate exists around prevalence of glaucoma and the pathophysiology explains its
association with obstructive sleep apnea is not fully known.
Objective: the present study was designed to estimate the incidence of normal tension glaucoma among patients with
obstructive sleep apnea.
Patients and Methods: sixty patients with obstructive sleep apnea and another age and sex matched 60controls were
included. Five patients in the study group refused to complete the study and only 55 patients constitute the study
group.Allparticipants underwent polysomnographic and ophthalmologic (measurement of intraocular pressure and
fundus examination) studies. Data was collected, documented and statistically analyzed.
Results: both study and control groups were comparable regarding patients' demographic and associated chronic
medical disease. The prevalence of normal tension glaucoma in patients with obstructive sleep apnea was 27.3% and
it was 3.3% in control subjects. Cup disk ratio and oxygen desaturation index were significantly increased, while
oxygen saturation significantly decreased in patients with obstructive sleep apnea. In addition, obstructive sleep apnea
index (measure of severity) was proportionately correlated with intraocular pressure, oxygen desaturation index, cup
to disk ratio and negatively correlated with oxygen saturation.
Conclusion: open angle glaucoma significantly increased in obstructive sleep apnea and significantly associated with
disease severity.
Keywords: obstructive sleep apnea; polysomnography; normal tension glaucoma; open angle glaucoma.

The short episodes of partial or complete
The present study was designed to evaluate the
airway collapse during sleep were defined as
prevalence of normal tension glaucoma among patients
obstructive sleep apnea-hypopneasyndrome. When
with obstructive sleep apnea.
episodes occur five or more times during an hour, there

is pathological state of breathing. Obstructive sleep
apnea (OSA) usually presented with snoring and
The present study is a case-control study. The
excessive day-time sleeping and diagnosed by
study included 60patients with confirmed diagnosis of
polysomnographic (PSG) apnea-hypopnea index
obstructive sleep apnea. Another age and sex matched
(AHI), which is a measure of disease severity(1,2).
60 subjects without OSA were included as a
Numerous diseases of the eye encountered
comparative (control) group. All patients and controls
frequently in association withOSA. These may include
were selected from Otorhinolaryngology departments
floppy-eyelid syndrome and optic nerve disorders
in Al-Azhar University hospitals (Cairo and New
(papilledema, glaucoma, ischemic neuropathy)(3,4,5).
Damietta) during the period from October 2016 to
Normal-tension glaucoma (NTG) is defined as optic
January 2019. Both patients and control groups were
neuropathy with a glaucomatous optic nerve head,
picked up by the Otolaryngology authors. The diagnosis
progressive thinning of retinal nerve fiber layer,
of consecutive patients was confirmed by
specific visual field defects, open angle of anterior
polysomnography as having OSA andthesubjects
chamber and normal intraocular pressure (IOP < 21
proved by the polysomnogram that they don't have
mmHg)(6). Known risk factors for NTG include
OSA were enrolled on this current study as patients and
abnormalities in ocular blood (abnormal flow and
control groups respectively. In addition, subjects in
coagulation), hypotension, ischemic disorders of blood
control group were matched with patients in the study
group regarding their demographics and comorbid
pathogenesis is not fully understood. It is most likely
medical conditions.
that NTG is a complex syndrome consisting of a variety
Inclusion criteria:
of pathological pathways such as: lower tolerance of
Patients who underwent an overnight
normal IOP, perfusion deficit and vascular
polysomnography with their results at hand and
dysregulation, trans-laminar pressure gradient and
confirmed diagnosis of OSA (study group). In addition,
impaired cerebrospinal fluid circulation(8).

examination were included.

Full Paper (vol.756 paper# 29)

c:\work\Jor\vol756_30 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (6), Page 3148-3162

One-Site Versus Two-Site Phacotrabeculectomy
Hosny Hassan, Mohamed AE Soliman Mahdy, Mahmoud Saleh and Nehad Yousef*
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University
*Corresponding Author: Nehad Yousef, Phone Number: +201006995526, Email: nehadyusef@yahoo..com

surgical treatment for patients with concurrent glaucoma and cataract includes sequential surgery and
combined phacotrabeculectomy. When combined surgery is planned, the next issue that must to deal with is whether
two-site surgery is better or one-site surgery. Aim: the study aimed to compare the outcomes and to report on the
efficacy and safety of the two procedures.
Patients and Methods: this prospective randomized comparative interventional study included fifty subjects. Patients
were recruited from those who attended to the outpatient Ophthalmology Clinic of Sayed Galal hospital, Al-Azhar
University. The study was conducted in the period from October 2016 until May 2018. Patients were randomized into
two groups: Group I (n=25), who was subjected to one-site phacotrabeculectomy and Group II (n=25), who was
subjected to the two-site procedure performed by one experienced anterior segment surgeon.
Results: no significant differences were observed in the main outcome measures of IOP and the need for supplemental
antiglaucoma medications between the two glaucoma groups.
Conclusion: both surgical techniques were effective in reducing IOP and to eliminate the need for antiglaucoma
medications in many eyes over the entire study period.
Keywords: phacotrabeculectomy, glaucoma, cataract.

Cataract and glaucoma are frequently coexisting
Fifty eight eyes of 48 patients who met the inclusion
ocular conditions in the elderly population. Recently, as
criteria were included in the study. Patients were
the surgical techniques used to treat both cataracts and
randomized into two groups: Group I (n=29 eyes of 25
glaucoma have advanced, there has been an increased
number of reports in the literature regarding the optimal
phacotrabeculectomy and Group II (n=29 eyes of 23
management of these conditions (1).
patients), who was subjected to the two-site procedure
Treatment for patients with concurrent cataract
performed by the author.
and glaucoma includes sequential surgery and

Eight eyes of 6 patients were excluded from
combined phacotrabeculectomy (2).
analysis because of loss at the follow-up (4 eyes of 2
The increased risk of cataract development in
patients from group I and 2 eyes of 2 patients from
some glaucoma patients the significantly increased risk
group II) and due to phaco related complications (2 eyes
of cataract development after glaucoma surgery and the
of 2 patients from group II). Therefore, we report on the
need to minimize both trauma and cost induced by two
findings of the remaining 50 eyes of 42 patients.
separate surgical procedures, has made combined

cataract and glaucoma surgery an appealing therapeutic
Approval Consideration:
Written informed consent was obtained from all
Combined phacotrabeculectomy has its
patients before proceeding with surgery, and after
advantages. First, it reduces risks of additional intra-
explanation of the nature of the procedure and the
possible complications. The study protocol, patient
trabeculectomy, there is rapid progression of lens
information sheet, and consent form were approved
opacities into visually significant cataracts that require
by the Ethics Board of Al-Azhar University.
cataract surgery. Secondly, sequential cataract surgery

is associated with increased risk of trabeculectomy
Inclusion criteria were:
failure which may be minimized by combined
Visually and Functionally Significant Cataract:
phacotrabeculectomy (4).
Cataract surgery was indicated in patients who has

cataract as the main cause of a noticeable decrease
in vision and interferes with a person's ability to
In this prospective randomized interventional
perform necessary or desired tasks. Grading of
study, our purpose was to compare the outcomes of one-
nuclear density was done according to Lens Opacity
site versus two-site combined phacoemulsification with
Classification System (LOCS III).
a foldable intraocular lens (IOL) implantation and
Primary Open Angle Glaucoma: Glaucoma surgery
trabeculectomy and to report on the efficacy and safety
was indicated in patients who fail to respond to
of the two procedures.
maximally tolerated medical therapy or who


Full Paper (vol.756 paper# 30)