Clinical characteristics of human fascioliasis in Egypt.

There is a lack of epidemiological data on fascioliasis in Egypt regarding disease characteristics and treatment outcomes across different governorates. We aimed to identify the demographic, epidemiologic, clinical, laboratory, and radiological characteristics and treatment outcomes of patients diagnosed with fascioliasis in Egypt. Data on human fascioliasis were collected retrospectively from patients' medical records in the period between January 2018 and January 2020. The study included 261 patients. More than 40% of enrolled patients were in the age group of 21-40 years old. Geographically, 247 (94.6%) were from Assiut Governorate with 69.3% were from rural areas. The most frequent symptoms were right upper quadrant pain (96.9%), and fever (80.1%). Eosinophilia was found in 250 cases (95.8%). Hepatic focal lesions were detected in 131 (50.2%); out of them 64/131 (48.9%) had a single lesion. All patients received a single dose of 10 mg/kg of triclabendazole, 79.7% responded well to a single dose, while in 20.3% a second ± a third dose of treatment was requested. After therapy, there was a reduction in leucocytes, Fasciola antibodies titer, eosinophilic count, bilirubin, and liver enzymes with an increase in hemoglobin level. According to our findings, a high index of suspicion should be raised in cases with fever, right upper abdominal pain, and peripheral eosinophilia, and further imaging workup is mandated to detect hepatic focal lesions. Prompt treatment by triclabendazole can serve as a standard-of-care regimen even for suspected cases.

Clinical, Radiological, and Endoscopic Ultrasound Findings in Groove Pancreatitis: A Multicenter Retrospective Study.

BACKGROUND/AIMS: Groove pancreatitis is a rare form of focal pancreatitis that affects the groove area. Since groove pancreatitis may be mistaken for malignancy, it should be considered in patients with pancreatic head mass lesions or duodenal stenosis to avoid unnecessary surgical procedures. The aim of the study was to document the clinical, radiologic, endoscopic characteristics, and treatment outcomes of patients with groove pancreatitis. MATERIALS AND METHODS: This retrospective multicenter observational study included all patients diagnosed with one or more imaging criteria suggestive of groove pancreatitis in the participating centers. Patients with proven malignant fine-needle aspiration/biopsy results were excluded. All patients were followed in their own centers and were retrospectively evaluated. RESULTS: Out of the initially included 30 patients with imaging criteria suggestive of groove pancreatitis, 9 patients (30%) were excluded because of malignant endoscopic ultrasound fine-needle aspiration or biopsy results. The mean age of the included 21 patients was 49 ± 10.6 years, with a male predominance of 71%. There was a history of smoking in 66.7% and alcohol consumption in 76.2% of patients. The main endoscopic finding was gastric outlet obstruction observed in 16 patients (76%). There was duodenal wall thickening in 9 (42.8%), 5 (23.8%), and 16 (76.2%) patients on computed tomography, magnetic resonance imaging, and endoscopic ultrasound, respectively. Moreover, pancreatic head enlargement/mass was observed in 10 (47.6%), 8 (38%), and 12 (57%) patients, and duodenal wall cysts in 5 (23.8%), 1 (4.8%), and 11 (52.4%) patients, respectively. Conservative and endoscopic treatment has achieved favorable outcomes in more than 90% of patients. CONCLUSIONS: Groove pancreatitis should be considered in any case with duodenal stenosis, duodenal wall cysts, or thickening of the groove area. Various imaging modalities, including computerized tomography, endoscopic ultrasound, and magnetic resonance imaging, have a valuable role in characterizing groove pancreatitis. However, endoscopic fine-needle aspiration or biopsy should be considered in all cases to diagnose groove pancreatitis and exclude malignancy, which can have similar findings.

Surgical outcomes of complicated cataract with pediatric trematode granulomatous uveitis.

AIM: To describe the clinical characteristics and surgical outcomes of complicated cataract with pediatric trematodal granulomatous uveitis (TGU). METHODS: Patients of cataract with TGU in the membranous (inactive) stage underwent cataract surgery with intraocular lens (IOL) implantation. Preoperative history and ophthalmic examination were conducted for all cases, whereas Schimphlug imaging and corneal topography were done for some patients. Postoperative follow up was done on the 1st, 2nd, and 5th postoperative days after surgery. Then, it was done at least at one, three, and six months postoperatively. Intraoperative and postoperative complications and the methods of their management were reported. RESULTS: Twelve eyes of 12 male children were included in this study ranging from 8 to 16y. The mean best corrected Snellen visual acuity (BCVA) was significantly improved from 0.09±0.06 preoperatively to 0.37±0.11 at the final visit 6mo postoperatively (P<0.001). Schimphlug imaging and corneal topography showed flattening of the anterior surface of the inferior cornea. Intraoperative difficulties and complications included the poor dilatability of the drown down pupil, strong posterior synechia between the anterior lens capsule and the iris at the site of the inferior retrocorneal vascularized membrane and hyphema. All cases underwent primary hydrophobic IOL implantation. CONCLUSION: Surgery for this type of cataract is relatively safe and effective. It is associated with some specific difficulties and complications that should be considered during surgery and follow up.

Specular Microscopic Corneal Endothelial Cell Changes following Uneventful Phacoemulsification in Patients with Gout.

Purpose: To assess the effects of phacoemulsification on the corneal endothelium in patients with gout and age-related cataracts. Methods: Eighty-eight patients who underwent uneventful phacoemulsification for age-related cataracts were included in this retrospective comparative study. The patients were divided into two groups: group A included 31 patients with gout and tight control of uric acid levels and group B included 57 patients without gout or any other systemic disease. All patients completed follow-up assessments over 6 months, and the two groups were compared in terms of changes to their specular microscopic values. Results: Both groups showed marked improvement in uncorrected and best-corrected visual acuity at the end of the follow-up period. Corneal endothelial cell loss was more severe in group A than in group B, with a mean difference of 221.35 ± 43.87 in group A and 169.88 ± 52.67 in group B at the sixth month (p < 0.001). The difference between the two groups in terms of other specular microscopic values did not reach statistical significance. Conclusion: Patients with gout are more prone to corneal endothelial cell damage after phacoemulsification than those without gout. To confirm these results, future studies with a prospective design and longer durations of follow-up are needed.

Clinical characteristics, risk factors and diagnostic outcomes of patients presented with indeterminate biliary stricture: A multicenter study.

Background and aim: Indeterminate biliary stricture (IBS) is a frequently encountered clinical problem. In this study, we aimed to highlight the clinical characteristics, risk factors and diagnostic outcomes of patients presented with indeterminate biliary stricture. Method: A Retrospective multicenter study included all patients diagnosed with IBS in the participating centers between 2017 and 2021. Data regarding IBS such as presentations, patient characteristics, diagnostic and therapeutic modalities were collected from the patients' records and then were analyzed. Results: Data of 315 patients with IBS were retrospectively collected from 7 medical centers with mean age: 62.6 ± 11 years, females: 40.3% and smokers: 44.8%. For diagnosing stricture; Magnetic resonance imaging/Magnetic resonance cholangiopancreatography (MRI/MRCP) was the most frequently requested imaging modality in all patients, Contrast enhanced computerized tomography (CECT) in 85% and endoscopic ultrasound (EUS) in 23.8%. Tissue diagnosis of cholangiocarcinoma was achieved in 14% only. The used therapeutic modalities were endoscopic retrograde cholangiopancreatography (ERCP)/stenting in 70.5%, percutaneous trans-hepatic biliary drainage (PTD): 17.8%, EUS guided drainage: 0.3%, and surgical resection in 8%. The most frequent type of strictures was distal stricture in 181 patients, perihilar in 128 and intrahepatic in 6. Distal strictures had significant male predominance, with higher role for EUS for diagnosis and higher role for ERCP/stenting for drainage, while in the perihilar strictures, there was higher role for CECT and MRI/MRCP for diagnosis and more frequent use of PTD for drainage. Conclusion: Indeterminate biliary stricture is a challenging clinical problem with lack of tissue diagnosis in most of cases mandates an urgent consensus diagnostic and treatment guidelines.

Colorectal cancer in Arab world: A systematic review.

BACKGROUND: The incidence of colorectal cancer (CRC) is increasing among young individuals in the Arab world as well as in other regions of the world. AIM: To explore the incidence and prevalence of CRC in the Arab world. METHODS: The PubMed, Scopus, Web of Science, EBSCO and Wiley databases were searched to retrieve relevant articles irrespective of the language or the publication year. The search terms were "("colon OR rectum OR sigmoid OR rectal OR colonic OR colorectal") AND ("cancer OR malignancy OR malignant OR neoplasm") AND ("Jordan" OR "United Arab Emirates" OR "Bahrain" OR "Tunisia" OR "Algeria" OR "Djibouti" OR "Saudi Arabia" OR "Sudan" OR "Syria" OR "Somalia" OR "Iraq" OR "Oman" OR "Palestine" OR "Qatar" OR "Comoros" OR "Kuwait" OR "Lebanon" OR "Libya" OR "Egypt" OR "Morocco" OR "Mauritania" OR "Yemen"). Reviews, meta-analyses, and articles containing nonoriginal data were excluded. Retrieved articles were screened, and relevant data were extracted. Descriptive statistics were used for data analysis. RESULTS: Nine studies were included. Five of the studies provided information regarding the prevalence of CRC. The prevalence of CRC was 0.72% in Saudi Arabia and 0.78% in the United Arab Emirate, while in Egypt, it ranged from 0.4% to 14%. Four studies showed information regarding the incidence. The annual incidence rate of CRC in Qatar was 7.5/100000/year. In Egypt, the crude incidence rate (CIR) in males was 3.1 for colon cancer and 1 for rectal cancer, while in females, it was 2.3 for colon cancer and 0.8 for rectal cancer. The age-standardized rate for CRC incidence in 2003 was 36.90 for males, 26.50 for females, and 30.49 for both sexes in Saudi Arabia. In 2016, the CIRs in Saudi Arabia were 3.6 and 2.1 in females for colon cancer and rectal cancer, respectively, while in males, it was 3.3 and 2.8 for colon cancer and rectal cancer, respectively. One study in Egypt revealed that 25% of CRC cases occurred among individuals younger than 40 years old. CONCLUSION: There is a considerable prevalence of CRC in some Arab countries. More studies are needed to explore the incidence and prevalence of CRC in the rest of the Arab world.

Efficacy and safety of sofosbuvir plus daclatasvir or ravidasvir in patients with COVID-19: A randomized controlled trial.

Only a few treatments are approved for coronavirus disease-2019 (COVID-19) infections, with continuous debate about their clinical impact. Repurposing antiviral treatments might prove the fastest way to identify effective therapy. This trial aimed to evaluate the efficacy and safety of sofosbuvir (SOF) plus daclatasvir (DCV) or ravidasvir (RDV) added to standard care (SOC) for patients with moderate and severe COVID-19 infection. Multicentre parallel randomized controlled open-label trial. One hundred and twenty eligible patients with moderate and severe COVID-19 infection were randomized to one of the study arms. Ten days of treatment with SOF plus DCV or RDV in addition to the standard of care compared to SOC. Follow up in 7 days. Sum of the counted symptoms at 7 and 10 days, mean change in oxygen saturation level, viral negativity, and rate of intensive care unit (ICU) admission. Compared to SOC, the SOF-DCV group experienced a significantly lower sum of the counted symptoms (fever, headache, generalized aches, or respiratory distress) combined with no evidence of deterioration (ICU admission and mechanical ventilation) on Days 7 and 10 of treatment. Oxygen saturation also significantly improved among the SOF-DCV group compared to SOC starting from Day 4. The study also showed positive trends regarding the efficacy of SOF-DCV with a lower incidence of mortality. On the other hand, adding SOF-RDV to SOC did not show significant improvements in endpoints. The results support the efficacy and safety of SOF-DCV as an add-on to SOC for the treatment of moderate to severe COVID-19 infections.

Practical approach to linear EUS examination of the liver.

EUS has become a substantial diagnostic and therapeutic modality for digestive tract conditions. The extent of endosonographic assessment is wide, and, among others, it allows for the evaluation of liver anatomy and related pathologies. Moreover, EUS assessment has proved more accurate in detecting small focal liver lesions missed by standard imaging examinations such as computed tomography or magnetic resonance. Endosonographically, various liver segments can be visualized by transgastric and transduodenal scanning following anatomical landmarks, thus providing arranged systematic examination. In addition, knowledge considering the correct position during examination is crucial for EUS-guided procedures such as hepaticogastrostomy, ablation of tumors, and measurement of portal pressure gradient. The evolution of EUS-guided intervention has contributed to the increasing importance of understanding the hepatic segmental anatomy during the EUS examination.

Experience of a Tertiary-Level Urology Center in Clinical Urological Events of Rare and Very Rare Incidence. V. Urological Tumors: 1. Adrenal Myelolipoma.

OBJECTIVES: To present our center's experience in the management of adrenal myelolipoma in the context of shifting from the open to the laparoscopic adrenalectomy approach. MATERIALS AND METHODS: A retrospective search of our center's records was done for reported cases of adrenal myelolipoma during the period July 2001-June 2016. All the cases with histopathologically-documented adrenal myelolipoma diagnosis were included. Relevant demographic and clinical variables were studied with a comparison between the open and laparoscopic approaches. RESULTS: Of more than 82,000 urological surgeries, 238 adrenalectomies were done with only 22 cases of myelolipoma that had a mean age and body mass index of 52.4 ± 10.3 years and 30.23 kg/m2, respectively. The main clinical presentation was accidental discovery. The largest dimension of tumors varied from 6 to 16 cm. Computed tomography described a characteristic picture of hypodense heterogeneous adrenal tumors in all cases, while magnetic resonance imaging was indicated for malignancy suspicion in only 5 cases. Adrenal tumor markers were normal in all cases. Open and transperitoneal laparoscopic adrenalectomies were used in 14 and 8 cases, respectively. The latter approach was insignificantly advantageous in the need for blood transfusion, postoperative pain degree, need for analgesia, and hospital stay duration (p = 0.22). Histo-pathological examination revealed benign adipose tissue and myeloid cells and confirmed the diagnosis of adrenal myelolipoma in all cases. CONCLUSIONS: Adrenal myelolipoma is a rare non-functioning benign tumor. Laparoscopic excision seems to be a promising alternative approach to the traditional open adrenalectomy, even in the context of large tumors and obesity.

Extrusion of Femtosecond Laser-Implanted Intrastromal Corneal Ring Segments in Keratoconic Eyes: Prevalence, Risk Factors, and Clinical Outcomes.

PURPOSE: To evaluate the prevalence, possible risk factors, and clinical results of femtosecond laser implanted intrastromal corneal ring segment (ICRS) extrusion in keratoconic eyes. Patients and Methods. This is a retrospective observational study evaluating 333 eyes of 269 patients who were subjected to femtosecond laser-implanted Keraring ICRS in the Sohag Refractive Center, Sohag, Egypt, from January 2014 to January 2019. The study included eyes with channels created by a femtosecond laser (60 kHz IntraLase femtosecond system; Advanced Medical Optics, Santa Ana, California, USA) with implantation of Keraring intrastromal corneal ring segments (Mediphacos, Belo Horizonte, Brazil). Patient data and causes of Keraring extrusions were identified as being those rings that migrated or showed melting of the cornea with no other reason which required segment removal. RESULTS: Seven eyes were found to fit the criteria of ring extrusion (2.1%) out of the 333 eyes which had Keraring implantation. All extruded rings were from patients with keratoconus grade 3, with eccentric cones, and with femtosecond creation of the tunnel. Four eyes belonging to 3 patients (57.1%) had a history of vernal Keratoconjunctivitis, yet they did not show signs of activity at the time of implantation. They reported excessive rubbing just before they presented with conjunctival hyperemia and foreign body sensation. Five eyes (71.4%) showed chronic sun exposure. The mean minimal corneal thickness was 401.85 µm (range 384-420 µm), while the mean maximum keratometry was 61 D (range 55.18-68.96 D). Most of the extruded rings had large arcs. Six eyes had crosslinking (CXL) at the same session of the Keraring implantation. The simultaneous CXL treatment is considered as a possible significant risk factor for ring extrusion. CONCLUSION: ICRS is an effective reversible option for patients with keratoconus who are intolerant to hard contact lenses, yet the choice of cases and ring segments is mandatory for satisfactory results. Moreover, meticulous history taking and examination reduces the incidence of complications including extrusion.

Clinical outcomes of transepithelial photorefractive keratectomy versus femtosecond laser assisted keratomileusis for correction of high myopia in South Egyptian population.

AIM: To evaluate the safety and efficacy of transepithelial photorefractive keratectomy (t-PRK) with adjuvant mitomycin C (MMC) versus femtosecond laser assisted keratomileusis (Femto-LASIK) in correction of high myopia. METHODS: Prospective randomized comparative study including 156 eyes of 156 patients with high myopia and a spherical equivalent refraction (SER) <-6.00 D. They were divided randomly into two groups: Group A included 72 eyes treated with t-PRK with adjuvant MMC and Group B included 84 eyes treated with Femto-LASIK. Visual acuity, SER, corneal topography, pachymetry and keratometry were assessed for 12mo postoperatively. RESULTS: The preoperative mean SER was -8.86±1.81 and -9.25±1.70 D in t-PRK MMC group and Femto-LASIK respectively (P=0.99) which improved to -0.65±0.43 D and -0.69±0.50 D at 12mo follow up. Mean SER remained stable during the 12mo of follow-up, with no statistically significant difference between the two groups (P=0.64). In t-PRK MMC group, only six eyes needed retreatment after six months of follow up. And two eyes showed haze (one reversible haze grade 2, while the other had dense irreversible haze grade 4). CONCLUSION: t-PRK MMC provides safe and satisfactory visual outcomes and acceptable risk as Femto-LASIK in patients with high myopia.

Pattern of Intermediate Uveitis in an Egyptian Cohort.

Purpose: To describe the clinical experience with intermediate uveitis at six Egyptian tertiary eye centers.Methods: A multicenter retrospective chart review of all patients with intermediate uveitis seen at six ocular inflammation referral clinics in Egypt between January 2010 and January 2017.Results: The study included a total of 781 patients with intermediate uveitis. The study cohort comprised of 282 male and 499 female patients. In over half of our cohort (58.77%), no specific cause could be confirmed. The remaining patients had sarcoidosis (16.26%), tuberculosis (14.85%), multiple sclerosis (9.09%), and TINU (1.02%). By the end of our study, 62% of the affected eyes had a BCVA better than 20/40Conclusion: More than 40% of our patients with intermediate uveitis had sarcoidosis, tuberculosis, multiple sclerosis, or TINU as the underlying etiology. Owing to their potential morbidity, these diseases need to be considered in Egyptian patients presenting with intermediate uveitis.

Update on vesicovaginal fistula: A systematic review.

Objective: To conduct a systematic review of the literature on vesicovaginal fistula (VVF), including reporting on the aetiology, in both developed and underdeveloped countries; diagnosis; intraoperative prevention; and management. Methods: We conducted a systematic review of the literature on VVF through the PubMed and the Cochrane Library according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The search was conducted from 1985 to 2018 in English, using the keywords 'fistula' and 'vesicovaginal fistula'. Prospective studies were preferred; however, retrospective studies and case reports were used when no prospective studies were available. All authors' extracted relevant data related to the proposed review of VVF and carefully examined collected articles. Results: In all, 116 relevant articles were identified and 43 articles were included in this systematic review. The outcome of surgical reconstruction was >90%, but the outcome may be suboptimal in radiotherapy (RT)-induced VVFs. Absolute indications for an abdominal approach included: ureteric involvement, the need for concomitant bladder augmentation, severe vaginal stenosis, and an inability to tolerate the dorsal lithotomy position (e.g. due to muscular spasticity). Typically, it was recommended to wait at least 3 months to allow the inflammatory response to subside before definitive surgery. Early fistula repair can be performed in the absence of infection and in patients who have not received pelvic RT. Conclusion: VVF is rare in developed countries. Surgical treatment is the primary method of repair. The outcome of surgical reconstruction exceeds 90%, but the outcome may be suboptimal in RT-induced VVFs. Abbreviations: PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RT: radiotherapy; (S)UI: (stress) urinary incontinence; UVF: ureterovaginal fistula; VVF: vesicovaginal fistula.

Evaluation of Corneal Higher-Order Aberrations by Scheimpflug-Placido Topography in Patients with Different Refractive Errors: A Retrospective Observational Study.

PURPOSE: To report the characteristics of anterior and posterior corneal high-order aberrations in patients with different refractive errors. SETTING: This study was conducted at Sohag Refractive Center, Sohag, Egypt. DESIGN: This is a retrospective observational study. METHODS: This study evaluated 750 patients (750 eyes) who were seeking refractive surgery. The eyes were stratified into five groups (150 eyes/group) based on refractive error: mild-to-moderate myopia, high myopia, hyperopia, simple myopic astigmatism, and simple hypermetropic astigmatism. All patients were subjected to comprehensive ophthalmological examination including corneal topography and corneal aberrometry using the Scheimpflug-Placido topography (Sirius, CSO, Italy). RESULTS: Coma aberration was statistically significant when compared in all five groups (P=0.01). It was highest in the hypermetropia group (0.26 ± 0.12 µm) but lower in the moderate myopia, high myopia, myopic astigmatism, and hypermetropic astigmatism groups. Spherical aberration was lowest in the hypermetropia group and significantly different from that in the other groups. Trefoil was statistically insignificant when all groups were compared (P=0.062) but was highest in the myopic astigmatism group (0.24 ± 0.25 µm). Total RMS peaked in the hypermetropia group (0.99 ± 0.70). CONCLUSIONS: In normal corneas and regular refractive errors, the cornea-induced high-order aberration was minimal, and all types of refractive errors were associated with certain types of high-order aberrations, with a significant increase in spherical aberration in the hypermetropia group.

Central retinal vein occlusion complicating spontaneous dural carotid-cavernous fistula after phacoemulsification.

In this report, we are presenting a case of a 49-year-old female complaining of defective vision in the left eye. The main complaints were: pain, redness, mild proptosis, and high intraocular pressure. She had a history of uneventful phacoemulsification surgery 3 months prior to presenting to us. Investigations revealed a macular edema caused by central retinal vein occlusion and computed tomography angiography showed an early opacified left cavernous sinus with a dilated superior ophthalmic vein along with a fistula between the meningeal branches of the carotid arteries and the cavernous sinus. Improvement of ocular symptoms was achieved after endovascular treatment by transarterial and transvenous embolization.

Corneal Endothelial Cell Density and Morphology in Healthy Egyptian Eyes.

PURPOSE: To evaluate the corneal endothelial cell density and morphology in normal Egyptian eyes. METHODS: In total, 568 healthy eyes of 568 Egyptian volunteers aged 20 to 85 years were examined using noncontact specular microscopy for the central corneal thickness (CCT), mean endothelial cell density (MCD), coefficient of variation (CV) in cell area, mean cell area (MCA), and hexagonal cell (Hex) percentage. Variables were compared between sexes and between different age groups. RESULTS: The mean CCT, MCD, and MCA were 514.45 ± 43.04 µm, 2647.50 ± 382.62 cells/mm2, and 390.59 ± 149.94 µm2, respectively. MCD and MCA showed no significant differences between men and women (P=0.171 and 0.099, respectively), whereas CV (%) and Hex (%) showed significant differences (P=0.024 and 0.015, respectively). CCT (P=0.007, r = -0.113) and MCD (P < 0.001, r = -0.357) exhibited a significant negative correlation with age, whereas CV (%) (P < 0.001, r = 0.341) and MCA (P=0.008, r = 0.111) exhibited a significant positive correlation. The mean rate of endothelial cell loss from 20 to 85 years of age was 0.3% per year. CONCLUSIONS: Our results provide normative data for the corneal endothelium in healthy Egyptian eyes, thus increasing the knowledge base for corneal endothelial cell parameters in healthy Egyptian eyes. Furthermore, our findings can be used as baseline values for comparisons between Egyptian and other populations and for studies of the endothelial cell reserve and capacity for intraocular surgery and corneal transplantation.

Right Ventricular Function After Creation of an Atriovenous Fistula in Patients With End Stage Renal Disease.

BACKGROUND: Right ventricular (RV) dysfunction is associated with increased risk of heart failure and mortality in end stage renal disease (ESRD) patients. Accumulating evidence suggests an association between atriovenous fistula (AVF) and RV dysfunction; however, there is no adequate data on the relation between AVF characteristics and risk of RV dysfunction after AVF creation. METHODS: The study included 30 ESRD patients (median age: 44years, 17 male) who had their first autogenous mature AVF. Before and 6months after AVF creation the following were measured: myocardial performance index of RV (MPI-RV) using tissue Doppler imaging echocardiography and flow rate (Qa), feeding artery and receiving vein diameters using colour-flow Doppler ultrasound. Change (Δ) in MPI-RV was calculated by subtracting follow-up value from baseline value. Worsening RV function was defined as Δ MPI-RV>0.015 and high AVF flow as Qa≥950ml/min. RESULTS: Compared to patients with lower AVF flow, patients with higher flow showed increased Δ in MPI-RV (0.12 vs. -0.03, p=0.04), basal RV diameter (0.3 vs. -0.02cm, p=0.014), left ventricular end diastolic volume index (9.9 vs. 0ml/m2, p=0.004) and left atrial volume index (3 vs. 1ml/m2, p=0.016). Among all clinical, echocardiographic and AVF-related parameters, univariate predictors of worsening of RV function were: high Qa, upper arm AVF, and large feeding artery diameter at baseline. Δ MPI-RV showed significant correlations with feeding artery diameter at baseline (r=0.46, p=0.01), and Qa (0.37, p=0.04) and no significant correlation with pulmonary artery pressures. Qa≥950ml/min, feeding artery diameter at baseline≥4mm and upper arm AVF can predict worsening of RV function with 73%, 73%, 75% sensitivity and 67%, 67%, 70% specificity, respectively. CONCLUSIONS: In patients with ESRD, higher AVF flow adversely affects RV remodelling, manifested as increased size and worsening function. Predictors of worsening of RV function are: higher AVF flow rate, AVF in the upper arm, and large feeding artery diameter.

Analysis of the Outcomes of Combined Cross-Linking with Intracorneal Ring Segment Implantation for the Treatment of Pediatric Keratoconus.

PURPOSE: To analyze the visual and refractive outcomes of combined accelerated cross-linking with femtosecond laser intracorneal ring segment implantation for the treatment of pediatric keratoconus. MATERIALS AND METHODS: This retrospective multicenter noncomparative clinical study included 63 eyes of 37 patients (age, 9-17 years) who underwent between August and September 2016 combined cross-linking with intracorneal ring segment implantation for keratoconus. Preoperative and postoperative (6, 12, and 18 months) uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA), subjective refractions, keratometry (K), and pachymetry measurements were compared. RESULTS: The postoperative spherical equivalent refraction was within ±1 D, ±2 D, and ±3 D in 19 (30.2%), 27 (42.9%), and 37 (58.8%) eyes, respectively. Only 27 eyes achieved the attempted preoperative spherical equivalent refraction. The mean spherical equivalent refraction significantly improved from -6.01 ± 2.97 to -3.13 ± 2.78 D postoperatively (P < 0.0001). The mean K average reading significantly decreased from 48.75 ± 4.25 to 46.65 ± 3.89 D postoperatively (P < 0.0001). The mean postoperative myopic, astigmatic, and spherical equivalent corrections were -2.17 ± 2.19, -1.52 ± 2.03, and -2.93 ± 2.35 D, respectively. The mean UDVA and CDVA showed significant improvements (0.89 ± 0.33 to 0.40 ± 0.28, P < 0.0001; 0.35 ± 0.31 to 0.25 ± 0.24, P = 0.004; respectively) at 18 months postoperatively. Keratoconus progression, segment migration, and segment extrusion were seen in four (6.4%), one (1.6%), and three (4.7%) eyes, respectively, probably contributing to the lower mean postoperative CDVA. CONCLUSION: Cross-linking plus is only partially effective for pediatric keratoconus. Despite some improvements in vision and keratometry measures, it resulted in complications such as keratoconus progression, segment extrusion, and segment migration that affected the vision in some patients. These findings suggest an assessment of standard epithelium-off collagen cross-linking as a sole procedure to treat pediatric keratoconus in future studies.

Outcomes of Corneal Tattooing by Rotring Painting Ink in Disfiguring Corneal Opacities.

AIM: To evaluate corneal tattooing with Rotring painting ink (Rotring Ink, Hamburg, Germany) as an available and affordable surgical technique to improve cosmetic appearance in the eyes with disfiguring corneal opacities. METHODS: Fifty-three blind eyes with corneal disfiguring opacities underwent corneal tattooing using Rotring painting ink (Rotring Ink, Hamburg, Germany) by multiple transepithelial intrastromal injections under topical anesthesia. Complete ophthalmic examination and ocular ultrasonography were performed, and photographs of the patients' eyes were taken. Follow-up period was at least 12 months. RESULTS: On the first postoperative day, all patients presented with mild conjunctival injection and foreign body sensation. After the end of the follow-up period, 51 patients (96%) were satisfied of cosmetic appearance while only 2 patients (4%) post-op cosmetic results were less than their expectations; however, they were better in appearance. No major complications like corneal erosions; corneal ulcers or corneal melting was noted in any case. CONCLUSIONS: Corneal tattooing with Rotring painting ink in blind disfigured eyes achieves favourable cosmetic results and is associated with high patient satisfaction. With better case selection, a high post-op satisfaction was achieved. Corneal tattooing acts as an alternative to more sophisticated and expensive cosmetic reconstructive surgery. This trial is registered with ISRCTN46626979.

Femtosecond-assisted intracorneal ring segment complications in keratoconus: from novelty to expertise.

OBJECTIVES: To document the difference between complication rate in the early curve of practicing intracorneal stromal rings and after gaining experience. PATIENTS AND METHODS: A retrospective study of 623 eyes of 417 patients with keratoconus who underwent Keraring implantation using femtosecond laser for channel creation. RESULTS: The main outcome measures were reported intraoperative and postoperative complications. The overall complication rate was 12.7% (79 eyes) over the 4 years with 34 eyes in the first year (5.5%) and six eyes in the fourth year (0.96%). Over the 4 years of our practice, intraoperative complications were 7.1% and postoperative complications were 5.6%. Yet, there was a significant difference in intraoperative complications between the first and the fourth year where it was 3.5% and 0.48%, respectively. This also applies to the postoperative complication rate, which decreased from 1.9% to 0.5% in the fourth year. CONCLUSION: Complications with femtosecond-assisted intracorneal stromal ring procedure can be reduced by experience, making this procedure a safe and effective means of treating keratoconus. Yet, there are some complications that cannot be avoided such as sterile keratitis.