Summary and ConclusionThis study included 30 patients, they were 20 males and 10 females and their age ranged from 1 year to 15 years old.Detailed personal history was taken, full clinical examination and laboratory investigation were performed prior imaging.Abdominal distention was the most common presentation seen in 53.3% of cases.Ultrasonography and abdominal computed tomograhpy were performed in all cases.NHL accounts for about 63.3% of cases and HD for about 36.7% of cases.The results of these diagnostic modalities were recorded, analyzed and compared to the final diagnosis. Which was based on clinical follow up and histopathological findings.From the study we can conclude the following points:? HD and NHL may involve any organ or organ system where lymphoid tissue is found.? US are modalities of choice for the initial imaging of the abdomen and pelvis in children, the technique is non-invasive and? most children can be examined without sedation. The lack of exposure to radiation is important and examination can be repeated at frequent interval if required.? Sensitivity in the detection of different groups of lymph node enlargement is definitely higher using CT (100%) than US (70%).? Regarding accuracy in the evaluation of extranodal lymphoma CT was better than US with a sensitivity of (95%) and specificity of (90.9%). CT in addition to visualizing lymph node enlargement, offer more information about the extent of the lesion with involvement of the intra-abdominal nodes and extranodal organs.? On gastrointestinal lymphoma US can be used as an initial approach whenever there is a clinical suspicion of the intestinal lymphoma. However, the US demonstration of the small bowel loops may be obscured by over lying air in the adjacent loops, there fore, negative US findings cannot excluded the diagnosis of intestinal lymphoma, with a sensitivity of (55.6%) and specificity of (71.4%).? Regarding gastrointestinal lymphoma CT has been proven to be more sensitive than US in revealing bowel wall thickening with sensitivity of (100%), so CT must be performed for staging of the disease and assessment of the extension of the mass.Summary and ConclusionThis study included 30 patients, they were 20 males and 10 females and their age ranged from 1 year to 15 years old.Detailed personal history was taken, full clinical examination and laboratory investigation were performed prior imaging.Abdominal distention was the most common presentation seen in 53.3% of cases.Ultrasonography and abdominal computed tomograhpy were performed in all cases.NHL accounts for about 63.3% of cases and HD for about 36.7% of cases.The results of these diagnostic modalities were recorded, analyzed and compared to the final diagnosis. Which was based on clinical follow up and histopathological findings.From the study we can conclude the following points:? HD and NHL may involve any organ or organ system where lymphoid tissue is found.? US are modalities of choice for the initial imaging of the abdomen and pelvis in children, the technique is non-invasive and? most children can be examined without sedation. The lack of exposure to radiation is important and examination can be repeated at frequent interval if required.? Sensitivity in the detection of different groups of lymph node enlargement is definitely higher using CT (100%) than US (70%).? Regarding accuracy in the evaluation of extranodal lymphoma CT was better than US with a sensitivity of (95%) and specificity of (90.9%). CT in addition to visualizing lymph node enlargement, offer more information about the extent of the lesion with involvement of the intra-abdominal nodes and extranodal organs.? On gastrointestinal lymphoma US can be used as an initial approach whenever there is a clinical suspicion of the intestinal lymphoma. However, the US demonstration of the small bowel loops may be obscured by over lying air in the adjacent loops, there fore, negative US findings cannot excluded the diagnosis of intestinal lymphoma, with a sensitivity of (55.6%) and specificity of (71.4%).? Regarding gastrointestinal lymphoma CT has been proven to be more sensitive than US in revealing bowel wall thickening with sensitivity of (100%), so CT must be performed for staging of the disease and assessment of the extension of the mass.Summary and ConclusionThis study included 30 patients, they were 20 males and 10 females and their age ranged from 1 year to 15 years old.Detailed personal history was taken, full clinical examination and laboratory investigation were performed prior imaging.Abdominal distention was the most common presentation seen in 53.3% of cases.Ultrasonography and abdominal computed tomograhpy were performed in all cases.NHL accounts for about 63.3% of cases and HD for about 36.7% of cases.The results of these diagnostic modalities were recorded, analyzed and compared to the final diagnosis. Which was based on clinical follow up and histopathological findings.From the study we can conclude the following points:? HD and NHL may involve any organ or organ system where lymphoid tissue is found.? US are modalities of choice for the initial imaging of the abdomen and pelvis in children, the technique is non-invasive and? most children can be examined without sedation. The lack of exposure to radiation is important and examination can be repeated at frequent interval if required.? Sensitivity in the detection of different groups of lymph node enlargement is definitely higher using CT (100%) than US (70%).? Regarding accuracy in the evaluation of extranodal lymphoma CT was better than US with a sensitivity of (95%) and specificity of (90.9%). CT in addition to visualizing lymph node enlargement, offer more information about the extent of the lesion with involvement of the intra-abdominal nodes and extranodal organs.? On gastrointestinal lymphoma US can be used as an initial approach whenever there is a clinical suspicion of the intestinal lymphoma. However, the US demonstration of the small bowel loops may be obscured by over lying air in the adjacent loops, there fore, negative US findings cannot excluded the diagnosis of intestinal lymphoma, with a sensitivity of (55.6%) and specificity of (71.4%).? Regarding gastrointestinal lymphoma CT has been proven to be more sensitive than US in revealing bowel wall thickening with sensitivity of (100%), so CT must be performed for staging of the disease and assessment of the extension of the mass.Summary and ConclusionThis study included 30 patients, they were 20 males and 10 females and their age ranged from 1 year to 15 years old.Detailed personal history was taken, full clinical examination and laboratory investigation were performed prior imaging.Abdominal distention was the most common presentation seen in 53.3% of cases.Ultrasonography and abdominal computed tomograhpy were performed in all cases.NHL accounts for about 63.3% of cases and HD for about 36.7% of cases.The results of these diagnostic modalities were recorded, analyzed and compared to the final diagnosis. Which was based on clinical follow up and histopathological findings.From the study we can conclude the following points:? HD and NHL may involve any organ or organ system where lymphoid tissue is found.? US are modalities of choice for the initial imaging of the abdomen and pelvis in children, the technique is non-invasive and? most children can be examined without sedation. The lack of exposure to radiation is important and examination can be repeated at frequent interval if required.? Sensitivity in the detection of different groups of lymph node enlargement is definitely higher using CT (100%) than US (70%).? Regarding accuracy in the evaluation of extranodal lymphoma CT was better than US with a sensitivity of (95%) and specificity of (90.9%). CT in addition to visualizing lymph node enlargement, offer more information about the extent of the lesion with involvement of the intra-abdominal nodes and extranodal organs.? On gastrointestinal lymphoma US can be used as an initial approach whenever there is a clinical suspicion of the intestinal lymphoma. However, the US demonstration of the small bowel loops may be obscured by over lying air in the adjacent loops, there fore, negative US findings cannot excluded the diagnosis of intestinal lymphoma, with a sensitivity of (55.6%) and specificity of (71.4%).? Regarding gastrointestinal lymphoma CT has been proven to be more sensitive than US in revealing bowel wall thickening with sensitivity of (100%), so CT must be performed for staging of the disease and assessment of the extension of the mass.Summary and ConclusionThis study included 30 patients, they were 20 males and 10 females and their age ranged from 1 year to 15 years old.Detailed personal history was taken, full clinical examination and laboratory investigation were performed prior imaging.Abdominal distention was the most common presentation seen in 53.3% of cases.Ultrasonography and abdominal computed tomograhpy were performed in all cases.NHL accounts for about 63.3% of cases and HD for about 36.7% of cases.The results of these diagnostic modalities were recorded, analyzed and compared to the final diagnosis. Which was based on clinical follow up and histopathological findings.From the study we can conclude the following points:? HD and NHL may involve any organ or organ system where lymphoid tissue is found.? US are modalities of choice for the initial imaging of the abdomen and pelvis in children, the technique is non-invasive and? most children can be examined without sedation. The lack of exposure to radiation is important and examination can be repeated at frequent interval if required.? Sensitivity in the detection of different groups of lymph node enlargement is definitely higher using CT (100%) than US (70%).? Regarding accuracy in the evaluation of extranodal lymphoma CT was better than US with a sensitivity of (95%) and specificity of (90.9%). CT in addition to visualizing lymph node enlargement, offer more information about the extent of the lesion with involvement of the intra-abdominal nodes and extranodal organs.? On gastrointestinal lymphoma US can be used as an initial approach whenever there is a clinical suspicion of the intestinal lymphoma. However, the US demonstration of the small bowel loops may be obscured by over lying air in the adjacent loops, there fore, negative US findings cannot excluded the diagnosis of intestinal lymphoma, with a sensitivity of (55.6%) and specificity of (71.4%).? Regarding gastrointestinal lymphoma CT has been proven to be more sensitive than US in revealing bowel wall thickening with sensitivity of (100%), so CT must be performed for staging of the disease and assessment of the extension of the mass.Summary and ConclusionThis study included 30 patients, they were 20 males and 10 females and their age ranged from 1 year to 15 years old.Detailed personal history was taken, full clinical examination and laboratory investigation were performed prior imaging.Abdominal distention was the most common presentation seen in 53.3% of cases.Ultrasonography and abdominal computed tomograhpy were performed in all cases.NHL accounts for about 63.3% of cases and HD for about 36.7% of cases.The results of these diagnostic modalities were recorded, analyzed and compared to the final diagnosis. Which was based on clinical follow up and histopathological findings.From the study we can conclude the following points:? HD and NHL may involve any organ or organ system where lymphoid tissue is found.? US are modalities of choice for the initial imaging of the abdomen and pelvis in children, the technique is non-invasive and? most children can be examined without sedation. The lack of exposure to radiation is important and examination can be repeated at frequent interval if required.? Sensitivity in the detection of different groups of lymph node enlargement is definitely higher using CT (100%) than US (70%).? Regarding accuracy in the evaluation of extranodal lymphoma CT was better than US with a sensitivity of (95%) and specificity of (90.9%). CT in addition to visualizing lymph node enlargement, offer more information about the extent of the lesion with involvement of the intra-abdominal nodes and extranodal organs.? On gastrointestinal lymphoma US can be used as an initial approach whenever there is a clinical suspicion of the intestinal lymphoma. However, the US demonstration of the small bowel loops may be obscured by over lying air in the adjacent loops, there fore, negative US findings cannot excluded the diagnosis of intestinal lymphoma, with a sensitivity of (55.6%) and specificity of (71.4%).? Regarding gastrointestinal lymphoma CT has been proven to be more sensitive than US in revealing bowel wall thickening with sensitivity of (100%), so CT must be performed for staging of the disease and assessment of the extension of the mass.Summary and ConclusionThis study included 30 patients, they were 20 males and 10 females and their age ranged from 1 year to 15 years old.Detailed personal history was taken, full clinical examination and laboratory investigation were performed prior imaging.Abdominal distention was the most common presentation seen in 53.3% of cases.Ultrasonography and abdominal computed tomograhpy were performed in all cases.NHL accounts for about 63.3% of cases and HD for about 36.7% of cases.The results of these diagnostic modalities were recorded, analyzed and compared to the final diagnosis. Which was based on clinical follow up and histopathological findings.From the study we can conclude the following points:? HD and NHL may involve any organ or organ system where lymphoid tissue is found.? US are modalities of choice for the initial imaging of the abdomen and pelvis in children, the technique is non-invasive and? most children can be examined without sedation. The lack of exposure to radiation is important and examination can be repeated at frequent interval if required.? Sensitivity in the detection of different groups of lymph node enlargement is definitely higher using CT (100%) than US (70%).? Regarding accuracy in the evaluation of extranodal lymphoma CT was better than US with a sensitivity of (95%) and specificity of (90.9%). CT in addition to visualizing lymph node enlargement, offer more information about the extent of the lesion with involvement of the intra-abdominal nodes and extranodal organs.? On gastrointestinal lymphoma US can be used as an initial approach whenever there is a clinical suspicion of the intestinal lymphoma. However, the US demonstration of the small bowel loops may be obscured by over lying air in the adjacent loops, there fore, negative US findings cannot excluded the diagnosis of intestinal lymphoma, with a sensitivity of (55.6%) and specificity of (71.4%).? Regarding gastrointestinal lymphoma CT has been proven to be more sensitive than US in revealing bowel wall thickening with sensitivity of (100%), so CT must be performed for staging of the disease and assessment of the extension of the mass.Summary and ConclusionThis study included 30 patients, they were 20 males and 10 females and their age ranged from 1 year to 15 years old.Detailed personal history was taken, full clinical examination and laboratory investigation were performed prior imaging.Abdominal distention was the most common presentation seen in 53.3% of cases.Ultrasonography and abdominal computed tomograhpy were performed in all cases.NHL accounts for about 63.3% of cases and HD for about 36.7% of cases.The results of these diagnostic modalities were recorded, analyzed and compared to the final diagnosis. Which was based on clinical follow up and histopathological findings.From the study we can conclude the following points:? HD and NHL may involve any organ or organ system where lymphoid tissue is found.? US are modalities of choice for the initial imaging of the abdomen and pelvis in children, the technique is non-invasive and? most children can be examined without sedation. The lack of exposure to radiation is important and examination can be repeated at frequent interval if required.? Sensitivity in the detection of different groups of lymph node enlargement is definitely higher using CT (100%) than US (70%).? Regarding accuracy in the evaluation of extranodal lymphoma CT was better than US with a sensitivity of (95%) and specificity of (90.9%). CT in addition to visualizing lymph node enlargement, offer more information about the extent of the lesion with involvement of the intra-abdominal nodes and extranodal organs.? On gastrointestinal lymphoma US can be used as an initial approach whenever there is a clinical suspicion of the intestinal lymphoma. However, the US demonstration of the small bowel loops may be obscured by over lying air in the adjacent loops, there fore, negative US findings cannot excluded the diagnosis of intestinal lymphoma, with a sensitivity of (55.6%) and specificity of (71.4%).? Regarding gastrointestinal lymphoma CT has been proven to be more sensitive than US in revealing bowel wall thickening with sensitivity of (100%), so CT must be performed for staging of the disease and assessment of the extension of the mass.Summary and ConclusionThis study included 30 patients, they were 20 males and 10 females and their age ranged from 1 year to 15 years old.Detailed personal history was taken, full clinical examination and laboratory investigation were performed prior imaging.Abdominal distention was the most common presentation seen in 53.3% of cases.Ultrasonography and abdominal computed tomograhpy were performed in all cases.NHL accounts for about 63.3% of cases and HD for about 36.7% of cases.The results of these diagnostic modalities were recorded, analyzed and compared to the final diagnosis. Which was based on clinical follow up and histopathological findings.From the study we can conclude the following points:? HD and NHL may involve any organ or organ system where lymphoid tissue is found.? US are modalities of choice for the initial imaging of the abdomen and pelvis in children, the technique is non-invasive and? most children can be examined without sedation. The lack of exposure to radiation is important and examination can be repeated at frequent interval if required.? Sensitivity in the detection of different groups of lymph node enlargement is definitely higher using CT (100%) than US (70%).? Regarding accuracy in the evaluation of extranodal lymphoma CT was better than US with a sensitivity of (95%) and specificity of (90.9%). CT in addition to visualizing lymph node enlargement, offer more information about the extent of the lesion with involvement of the intra-abdominal nodes and extranodal organs.? On gastrointestinal lymphoma US can be used as an initial approach whenever there is a clinical suspicion of the intestinal lymphoma. However, the US demonstration of the small bowel loops may be obscured by over lying air in the adjacent loops, there fore, negative US findings cannot excluded the diagnosis of intestinal lymphoma, with a sensitivity of (55.6%) and specificity of (71.4%).? Regarding gastrointestinal lymphoma CT has been proven to be more sensitive than US in revealing bowel wall thickening with sensitivity of (100%), so CT must be performed for staging of the disease and assessment of the extension of the mass.Summary and ConclusionThis study included 30 patients, they were 20 males and 10 females and their age ranged from 1 year to 15 years old.Detailed personal history was taken, full clinical examination and laboratory investigation were performed prior imaging.Abdominal distention was the most common presentation seen in 53.3% of cases.Ultrasonography and abdominal computed tomograhpy were performed in all cases.NHL accounts for about 63.3% of cases and HD for about 36.7% of cases.Postoperative spherical equivalent within one diopter of emmetropia was achieved in 76.67%, 86.67%, 70% of cases in group A, B and C respectively. Postoperative defocus equivalent equal to or less than one diopter was achieved in 50%, 80% and 60% of cases group A, B and C respectively.The contrast sensitivity curves improved in the first postoperative month in all spatial frequencies in cases of group A and C without significant change in the subsequent visits. However; in cases of group B the contrast sensitivity curves decreased in the first postoperative month in all spatial frequencies, then improved at the third month visit to the preoperative level to exceed it in the sixth month without significant change in the subsequent ninth month visit.There was transient rise in IOP in cases of group A and C during the first postoperative week however; in group B IOP showed significant decline all through the follow up period.There was statistically significant loss of endothelial cells at one and nine months postoperatively however, the degree of loss varied in different groups. The loss in the mean endothelial cell count from preoperative level to the first month postoperatively was 6.29%, 1.56% and 9.78% and from the first month to the ninth month postoperatively was 0.99%, 1.28% and 0.92% in group A, B and C respectively.Regarding complications; in group (A), 6.67% of cases developed mild intraoperative hyphaema. Pupil ovalization occurred in 6.67% of cases, In 3.33% of cases rotation of the lens occurred due to too short haptics. In group (B), 3.33% of cases had decentered flap 3.33 % had decentered ablation. Interface deposits as well as bleeding to the interface were observed in 6.67%. The incidence of epithelial ingrowth, DLK and flap stria was 3.33% where as that of pseudoDLK was 6.67%. while in group (C), 3.33% of cases had intraoperative iris trauma while developed 6.67% posterior capsule opacification.CONCLUSIONSurgical correction of moderate to high myopia proved to be effective, safe and predictable. The choice of the procedure should be based on the patient’s condition, the surgeon’s expertise as well as the resources of the health care facility. The main procedures for correction of high myopia are Phakic IOLs, LASIK and clear lens extraction. Each of these procedures has its own indications, precautions as well as its most feared complications.Phakic IOLs despite the excellent initial outcome in terms of predictability and quality of vision imply certain risk for endothelial damage therefore should be followed up regularly. Phakic IOL should be removed as soon as serious decline in endothelial cell density occurs. As large proportion of high myopes will develop cataract, care should be taken to interfere before endothelial cell count decreases below safe limit for performing cataract extraction. The younger the patient at time of PIOL implantation, the higher the endothelial cell count required before PIOL implantation.LASIK is less invasive but irreversible procedure. Concerns about LASIK include degradation in quality of vision especially with marked flattening of the cornea which directly increases the higher order aberrations, the compromise between the optical zone and the possible correction respecting the minimal residual stromal bed. At any cost the risk of post LASIK keratectasia, the most devastating complication of LASIK nowadays, should be minimized. It should be kept in mind that theoretical calculations do not make up for the common error in the flap thickness.Clear lens extraction is more appealing in patients over forty five years especially if there is lens sclerosis as phakic IOL may enhance the cataract. LASIK also complicates IOL calculation should cataract progress necessitating removal. CLE should be performed through as small incision as possible to decrease the fluctuation in anterior chamber depth. Complete cortical clean up as well as capsular polishing must be performed to decrease the incidence of posterior capsular opacification and consequently YAG laser capsulotomy which is a very important added risk factor for retinal detachment in high myopes.Finally, due to the possible risks and elective nature of these procedures, they should only be offered to patients who refuse glasses and do not tolerate contact lenses. Clear explanation and proper informed consent is mandatory in every case.SUMMARYAs refractive surgery gets simpler, safer, more predictable and more effective, it becomes more popular. While cases of simple myopia are usually easy to handle and get satisfactory results when corrected with excimer laser, those with high myopia still represent some challenges.To get the best possible outcome, the surgical plan should be tailored individually to suit each particular case with its peculiar characteristics regarding patients age, activities, visual needs, expectations and of course not the least his own eye parameters.In an attempt to better understand this issue, this study was conducted including ninety eyes of 48 patients, 22 males (45.8 %) and 26 (54.2%) females with a mean age of 40.66±12.03 (range 20 to 63) years and mean spherical equivalent of -12.67±4.64 (range -24 to -7.5) diopters. They were divided into three equal groups.The first group (A) underwent phakic intraocular lens implantation namely Kelman duet lens which is an angle supported anterior chamber phakic lens with rigid tripod haptic and foldable optic that can be injected through a self sealed clear corneal incision of as small size as two mm to be assembled to the previously implanted haptic.The second group (B) under went LASIK after doing the necessary investigations to exclude keratoconus suspects and to make sure that the cornea has enough thickness to allow complete correction of the refractive error in an ablation diameter that matches the scotopic pupil size.The third group (C) underwent clear lens extraction using micro-incision cataract surgery followed by implantation of acrylic foldable posterior chamber IOLs.The mean efficacy index three months postoperatively was 0.99, 0.874 and 0.916 in group A, B and C respectively. UCVA of 0.5 (6/12) or better was achieved in 80%, 93.33%, 63.3% of cases of group A, B and C respectively, while UCVA of 1.0 (6/6) was achieved in 16.67% and 33.3% of cases of group A and B.The mean postoperative safety index was 1.268, 1.03 and 1.249 in group A, B and C respectively. BCVA of 0.5 (6/12) or better was achieved in all cases however, 50%, 60% and 26.67% of cases in group A, B and C respectively achieved postoperative BCVA of 1.0 (6/6)Postoperative spherical equivalent within one diopter of emmetropia was achieved in 76.67%, 86.67%, 70% of cases in group A, B and C respectively. Postoperative defocus equivalent equal to or less than one diopter was achieved in 50%, 80% and 60% of cases group A, B and C respectively.The contrast sensitivity curves improved in the first postoperative month in all spatial frequencies in cases of group A and C without significant change in the subsequent visits. However; in cases of group B the contrast sensitivity curves decreased in the first postoperative month in all spatial frequencies, then improved at the third month visit to the preoperative level to exceed it in the sixth month without significant change in the subsequent ninth month visit.There was transient rise in IOP in cases of group A and C during the first postoperative week however; in group B IOP showed significant decline all through the follow up period.There was statistically significant loss of endothelial cells at one and nine months postoperatively however, the degree of loss varied in different groups. The loss in the mean endothelial cell count from preoperative level to the first month postoperatively was 6.29%, 1.56% and 9.78% and from the first month to the ninth month postoperatively was 0.99%, 1.28% and 0.92% in group A, B and C respectively.Regarding complications; in group (A), 6.67% of cases developed mild intraoperative hyphaema. Pupil ovalization occurred in 6.67% of cases, In 3.33% of cases rotation of the lens occurred due to too short haptics. In group (B), 3.33% of cases had decentered flap 3.33 % had decentered ablation. Interface deposits as well as bleeding to the interface were observed in 6.67%. The incidence of epithelial ingrowth, DLK and flap stria was 3.33% where as that of pseudoDLK was 6.67%. while in group (C), 3.33% of cases had intraoperative iris trauma while developed 6.67% posterior capsule opacification.CONCLUSIONSurgical correction of moderate to high myopia proved to be effective, safe and predictable. The choice of the procedure should be based on the patient’s condition, the surgeon’s expertise as well as the resources of the health care facility. The main procedures for correction of high myopia are Phakic IOLs, LASIK and clear lens extraction. Each of these procedures has its own indications, precautions as well as its most feared complications.Phakic IOLs despite the excellent initial outcome in terms of predictability and quality of vision imply certain risk for endothelial damage therefore should be followed up regularly. Phakic IOL should be removed as soon as serious decline in endothelial cell density occurs. As large proportion of high myopes will develop cataract, care should be taken to interfere before endothelial cell count decreases below safe limit for performing cataract extraction. The younger the patient at time of PIOL implantation, the higher the endothelial cell count required before PIOL implantation.LASIK is less invasive but irreversible procedure. Concerns about LASIK include degradation in quality of vision especially with marked flattening of the cornea which directly increases the higher order aberrations, the compromise between the optical zone and the possible correction respecting the minimal residual stromal bed. At any cost the risk of post LASIK keratectasia, the most devastating complication of LASIK nowadays, should be minimized. It should be kept in mind that theoretical calculations do not make up for the common error in the flap thickness.Clear lens extraction is more appealing in patients over forty five years especially if there is lens sclerosis as phakic IOL may enhance the cataract. LASIK also complicates IOL calculation should cataract progress necessitating removal. CLE should be performed through as small incision as possible to decrease the fluctuation in anterior chamber depth. Complete cortical clean up as well as capsular polishing must be performed to decrease the incidence of posterior capsular opacification and consequently YAG laser capsulotomy which is a very important added risk factor for retinal detachment in high myopes.Finally, due to the possible risks and elective nature of these procedures, they should only be offered to patients who refuse glasses and do not tolerate contact lenses. Clear explanation and proper informed consent is mandatory in every case.SUMMARYAs refractive surgery gets simpler, safer, more predictable and more effective, it becomes more popular. While cases of simple myopia are usually easy to handle and get satisfactory results when corrected with excimer laser, those with high myopia still represent some challenges.To get the best possible outcome, the surgical plan should be tailored individually to suit each particular case with its peculiar characteristics regarding patients age, activities, visual needs, expectations and of course not the least his own eye parameters.In an attempt to better understand this issue, this study was conducted including ninety eyes of 48 patients, 22 males (45.8 %) and 26 (54.2%) females with a mean age of 40.66±12.03 (range 20 to 63) years and mean spherical equivalent of -12.67±4.64 (range -24 to -7.5) diopters. They were divided into three equal groups.The first group (A) underwent phakic intraocular lens implantation namely Kelman duet lens which is an angle supported anterior chamber phakic lens with rigid tripod haptic and foldable optic that can be injected through a self sealed clear corneal incision of as small size as two mm to be assembled to the previously implanted haptic.The second group (B) under went LASIK after doing the necessary investigations to exclude keratoconus suspects and to make sure that the cornea has enough thickness to allow complete correction of the refractive error in an ablation diameter that matches the scotopic pupil size.The third group (C) underwent clear lens extraction using micro-incision cataract surgery followed by implantation of acrylic foldable posterior chamber IOLs.The mean efficacy index three months postoperatively was 0.99, 0.874 and 0.916 in group A, B and C respectively. UCVA of 0.5 (6/12) or better was achieved in 80%, 93.33%, 63.3% of cases of group A, B and C respectively, while UCVA of 1.0 (6/6) was achieved in 16.67% and 33.3% of cases of group A and B.The mean postoperative safety index was 1.268, 1.03 and 1.249 in group A, B and C respectively. BCVA of 0.5 (6/12) or better was achieved in all cases however, 50%, 60% and 26.67% of cases in group A, B and C respectively achieved postoperative BCVA of 1.0 (6/6)Postoperative spherical equivalent within one diopter of emmetropia was achieved in 76.67%, 86.67%, 70% of cases in group A, B and C respectively. Postoperative defocus equivalent equal to or less than one diopter was achieved in 50%, 80% and 60% of cases group A, B and C respectively.The contrast sensitivity curves improved in the first postoperative month in all spatial frequencies in cases of group A and C without significant change in the subsequent visits. However; in cases of group B the contrast sensitivity curves decreased in the first postoperative month in all spatial frequencies, then improved at the third month visit to the preoperative level to exceed it in the sixth month without significant change in the subsequent ninth month visit.There was transient rise in IOP in cases of group A and C during the first postoperative week however; in group B IOP showed significant decline all through the follow up period.There was statistically significant loss of endothelial cells at one and nine months postoperatively however, the degree of loss varied in different groups. The loss in the mean endothelial cell count from preoperative level to the first month postoperatively was 6.29%, 1.56% and 9.78% and from the first month to the ninth month postoperatively was 0.99%, 1.28% and 0.92% in group A, B and C respectively.Regarding complications; in group (A), 6.67% of cases developed mild intraoperative hyphaema. Pupil ovalization occurred in 6.67% of cases, In 3.33% of cases rotation of the lens occurred due to too short haptics. In group (B), 3.33% of cases had decentered flap 3.33 % had decentered ablation. Interface deposits as well as bleeding to the interface were observed in 6.67%. The incidence of epithelial ingrowth, DLK and flap stria was 3.33% where as that of pseudoDLK was 6.67%. while in group (C), 3.33% of cases had intraoperative iris trauma while developed 6.67% posterior capsule opacification.CONCLUSIONSurgical correction of moderate to high myopia proved to be effective, safe and predictable. The choice of the procedure should be based on the patient’s condition, the surgeon’s expertise as well as the resources of the health care facility. The main procedures for correction of high myopia are Phakic IOLs, LASIK and clear lens extraction. Each of these procedures has its own indications, precautions as well as its most feared complications.Phakic IOLs despite the excellent initial outcome in terms of predictability and quality of vision imply certain risk for endothelial damage therefore should be followed up regularly. Phakic IOL should be removed as soon as serious decline in endothelial cell density occurs. As large proportion of high myopes will develop cataract, care should be taken to interfere before endothelial cell count decreases below safe limit for performing cataract extraction. The younger the patient at time of PIOL implantation, the higher the endothelial cell count required before PIOL implantation.LASIK is less invasive but irreversible procedure. Concerns about LASIK include degradation in quality of vision especially with marked flattening of the cornea which directly increases the higher order aberrations, the compromise between the optical zone and the possible correction respecting the minimal residual stromal bed. At any cost the risk of post LASIK keratectasia, the most devastating complication of LASIK nowadays, should be minimized. It should be kept in mind that theoretical calculations do not make up for the common error in the flap thickness.Clear lens extraction is more appealing in patients over forty five years especially if there is lens sclerosis as phakic IOL may enhance the cataract. LASIK also complicates IOL calculation should cataract progress necessitating removal. CLE should be performed through as small incision as possible to decrease the fluctuation in anterior chamber depth. Complete cortical clean up as well as capsular polishing must be performed to decrease the incidence of posterior capsular opacification and consequently YAG laser capsulotomy which is a very important added risk factor for retinal detachment in high myopes.Finally, due to the possible risks and elective nature of these procedures, they should only be offered to patients who refuse glasses and do not tolerate contact lenses. Clear explanation and proper informed consent is mandatory in every case.SUMMARYAs refractive surgery gets simpler, safer, more predictable and more effective, it becomes more popular. While cases of simple myopia are usually easy to handle and get satisfactory results when corrected with excimer laser, those with high myopia still represent some challenges.To get the best possible outcome, the surgical plan should be tailored individually to suit each particular case with its peculiar characteristics regarding patients age, activities, visual needs, expectations and of course not the least his own eye parameters.In an attempt to better understand this issue, this study was conducted including ninety eyes of 48 patients, 22 males (45.8 %) and 26 (54.2%) females with a mean age of 40.66±12.03 (range 20 to 63) years and mean spherical equivalent of -12.67±4.64 (range -24 to -7.5) diopters. They were divided into three equal groups.The first group (A) underwent phakic intraocular lens implantation namely Kelman duet lens which is an angle supported anterior chamber phakic lens with rigid tripod haptic and foldable optic that can be injected through a self sealed clear corneal incision of as small size as two mm to be assembled to the previously implanted haptic.The second group (B) under went LASIK after doing the necessary investigations to exclude keratoconus suspects and to make sure that the cornea has enough thickness to allow complete correction of the refractive error in an ablation diameter that matches the scotopic pupil size.The third group (C) underwent clear lens extraction using micro-incision cataract surgery followed by implantation of acrylic foldable posterior chamber IOLs.The mean efficacy index three months postoperatively was 0.99, 0.874 and 0.916 in group A, B and C respectively. UCVA of 0.5 (6/12) or better was achieved in 80%, 93.33%, 63.3% of cases of group A, B and C respectively, while UCVA of 1.0 (6/6) was achieved in 16.67% and 33.3% of cases of group A and B.The mean postoperative safety index was 1.268, 1.03 and 1.249 in group A, B and C respectively. BCVA of 0.5 (6/12) or better was achieved in all cases however, 50%, 60% and 26.67% of cases in group A, B and C respectively achieved postoperative BCVA of 1.0 (6/6)Postoperative spherical equivalent within one diopter of emmetropia was achieved in 76.67%, 86.67%, 70% of cases in group A, B and C respectively. Postoperative defocus equivalent equal to or less than one diopter was achieved in 50%, 80% and 60% of cases group A, B and C respectively.The contrast sensitivity curves improved in the first postoperative month in all spatial frequencies in cases of group A and C without significant change in the subsequent visits. However; in cases of group B the contrast sensitivity curves decreased in the first postoperative month in all spatial frequencies, then improved at the third month visit to the preoperative level to exceed it in the sixth month without significant change in the subsequent ninth month visit.There was transient rise in IOP in cases of group A and C during the first postoperative week however; in group B IOP showed significant decline all through the follow up period.There was statistically significant loss of endothelial cells at one and nine months postoperatively however, the degree of loss varied in different groups. The loss in the mean endothelial cell count from preoperative level to the first month postoperatively was 6.29%, 1.56% and 9.78% and from the first month to the ninth month postoperatively was 0.99%, 1.28% and 0.92% in group A, B and C respectively.Regarding complications; in group (A), 6.67% of cases developed mild intraoperative hyphaema. Pupil ovalization occurred in 6.67% of cases, In 3.33% of cases rotation of the lens occurred due to too short haptics. In group (B), 3.33% of cases had decentered flap 3.33 % had decentered ablation. Interface deposits as well as bleeding to the interface were observed in 6.67%. The incidence of epithelial ingrowth, DLK and flap stria was 3.33% where as that of pseudoDLK was 6.67%. while in group (C), 3.33% of cases had intraoperative iris trauma while developed 6.67% posterior capsule opacification.CONCLUSIONSurgical correction of moderate to high myopia proved to be effective, safe and predictable. The choice of the procedure should be based on the patient’s condition, the surgeon’s expertise as well as the resources of the health care facility. The main procedures for correction of high myopia are Phakic IOLs, LASIK and clear lens extraction. Each of these procedures has its own indications, precautions as well as its most feared complications.Phakic IOLs despite the excellent initial outcome in terms of predictability and quality of vision imply certain risk for endothelial damage therefore should be followed up regularly. Phakic IOL should be removed as soon as serious decline in endothelial cell density occurs. As large proportion of high myopes will develop cataract, care should be taken to interfere before endothelial cell count decreases below safe limit for performing cataract extraction. The younger the patient at time of PIOL implantation, the higher the endothelial cell count required before PIOL implantation.LASIK is less invasive but irreversible procedure. Concerns about LASIK include degradation in quality of vision especially with marked flattening of the cornea which directly increases the higher order aberrations, the compromise between the optical zone and the possible correction respecting the minimal residual stromal bed. At any cost the risk of post LASIK keratectasia, the most devastating complication of LASIK nowadays, should be minimized. It should be kept in mind that theoretical calculations do not make up for the common error in the flap thickness.Clear lens extraction is more appealing in patients over forty five years especially if there is lens sclerosis as phakic IOL may enhance the cataract. LASIK also complicates IOL calculation should cataract progress necessitating removal. CLE should be performed through as small incision as possible to decrease the fluctuation in anterior chamber depth. Complete cortical clean up as well as capsular polishing must be performed to decrease the incidence of posterior capsular opacification and consequently YAG laser capsulotomy which is a very important added risk factor for retinal detachment in high myopes.Finally, due to the possible risks and elective nature of these procedures, they should only be offered to patients who refuse glasses and do not tolerate contact lenses. Clear explanation and proper informed consent is mandatory in every case.SUMMARYAs refractive surgery gets simpler, safer, more predictable and more effective, it becomes more popular. While cases of simple myopia are usually easy to handle and get satisfactory results when corrected with excimer laser, those with high myopia still represent some challenges.To get the best possible outcome, the surgical plan should be tailored individually to suit each particular case with its peculiar characteristics regarding patients age, activities, visual needs, expectations and of course not the least his own eye parameters.In an attempt to better understand this issue, this study was conducted including ninety eyes of 48 patients, 22 males (45.8 %) and 26 (54.2%) females with a mean age of 40.66±12.03 (range 20 to 63) years and mean spherical equivalent of -12.67±4.64 (range -24 to -7.5) diopters. They were divided into three equal groups.The first group (A) underwent phakic intraocular lens implantation namely Kelman duet lens which is an angle supported anterior chamber phakic lens with rigid tripod haptic and foldable optic that can be injected through a self sealed clear corneal incision of as small size as two mm to be assembled to the previously implanted haptic.The second group (B) under went LASIK after doing the necessary investigations to exclude keratoconus suspects and to make sure that the cornea has enough thickness to allow complete correction of the refractive error in an ablation diameter that matches the scotopic pupil size.The third group (C) underwent clear lens extraction using micro-incision cataract surgery followed by implantation of acrylic foldable posterior chamber IOLs.The mean efficacy index three months postoperatively was 0.99, 0.874 and 0.916 in group A, B and C respectively. UCVA of 0.5 (6/12) or better was achieved in 80%, 93.33%, 63.3% of cases of group A, B and C respectively, while UCVA of 1.0 (6/6) was achieved in 16.67% and 33.3% of cases of group A and B.The mean postoperative safety index was 1.268, 1.03 and 1.249 in group A, B and C respectively. BCVA of 0.5 (6/12) or better was achieved in all cases however, 50%, 60% and 26.67% of cases in group A, B and C respectively achieved postoperative BCVA of 1.0 (6/6)Postoperative spherical equivalent within one diopter of emmetropia was achieved in 76.67%, 86.67%, 70% of cases in group A, B and C respectively. Postoperative defocus equivalent equal to or less than one diopter was achieved in 50%, 80% and 60% of cases group A, B and C respectively.The contrast sensitivity curves improved in the first postoperative month in all spatial frequencies in cases of group A and C without significant change in the subsequent visits. However; in cases of group B the contrast sensitivity curves decreased in the first postoperative month in all spatial frequencies, then improved at the third month visit to the preoperative level to exceed it in the sixth month without significant change in the subsequent ninth month visit.There was transient rise in IOP in cases of group A and C during the first postoperative week however; in group B IOP showed significant decline all through the follow up period.There was statistically significant loss of endothelial cells at one and nine months postoperatively however, the degree of loss varied in different groups. The loss in the mean endothelial cell count from preoperative level to the first month postoperatively was 6.29%, 1.56% and 9.78% and from the first month to the ninth month postoperatively was 0.99%, 1.28% and 0.92% in group A, B and C respectively.Regarding complications; in group (A), 6.67% of cases developed mild intraoperative hyphaema. Pupil ovalization occurred in 6.67% of cases, In 3.33% of cases rotation of the lens occurred due to too short haptics. In group (B), 3.33% of cases had decentered flap 3.33 % had decentered ablation. Interface deposits as well as bleeding to the interface were observed in 6.67%. The incidence of epithelial ingrowth, DLK and flap stria was 3.33% where as that of pseudoDLK was 6.67%. while in group (C), 3.33% of cases had intraoperative iris trauma while developed 6.67% posterior capsule opacification.CONCLUSIONSurgical correction of moderate to high myopia proved to be effective, safe and predictable. The choice of the procedure should be based on the patient’s condition, the surgeon’s expertise as well as the resources of the health care facility. The main procedures for correction of high myopia are Phakic IOLs, LASIK and clear lens extraction. Each of these procedures has its own indications, precautions as well as its most feared complications.Phakic IOLs despite the excellent initial outcome in terms of predictability and quality of vision imply certain risk for endothelial damage therefore should be followed up regularly. Phakic IOL should be removed as soon as serious decline in endothelial cell density occurs. As large proportion of high myopes will develop cataract, care should be taken to interfere before endothelial cell count decreases below safe limit for performing cataract extraction. The younger the patient at time of PIOL implantation, the higher the endothelial cell count required before PIOL implantation.LASIK is less invasive but irreversible procedure. Concerns about LASIK include degradation in quality of vision especially with marked flattening of the cornea which directly increases the higher order aberrations, the compromise between the optical zone and the possible correction respecting the minimal residual stromal bed. At any cost the risk of post LASIK keratectasia, the most devastating complication of LASIK nowadays, should be minimized. It should be kept in mind that theoretical calculations do not make up for the common error in the flap thickness.Clear lens extraction is more appealing in patients over forty five years especially if there is lens sclerosis as phakic IOL may enhance the cataract. LASIK also complicates IOL calculation should cataract progress necessitating removal. CLE should be performed through as small incision as possible to decrease the fluctuation in anterior chamber depth. Complete cortical clean up as well as capsular polishing must be performed to decrease the incidence of posterior capsular opacification and consequently YAG laser capsulotomy which is a very important added risk factor for retinal detachment in high myopes.Finally, due to the possible risks and elective nature of these procedures, they should only be offered to patients who refuse glasses and do not tolerate contact lenses. Clear explanation and proper informed consent is mandatory in every case.SUMMARYAs refractive surgery gets simpler, safer, more predictable and more effective, it becomes more popular. While cases of simple myopia are usually easy to handle and get satisfactory results when corrected with excimer laser, those with high myopia still represent some challenges.To get the best possible outcome, the surgical plan should be tailored individually to suit each particular case with its peculiar characteristics regarding patients age, activities, visual needs, expectations and of course not the least his own eye parameters.In an attempt to better understand this issue, this study was conducted including ninety eyes of 48 patients, 22 males (45.8 %) and 26 (54.2%) females with a mean age of 40.66±12.03 (range 20 to 63) years and mean spherical equivalent of -12.67±4.64 (range -24 to -7.5) diopters. They were divided into three equal groups.The first group (A) underwent phakic intraocular lens implantation namely Kelman duet lens which is an angle supported anterior chamber phakic lens with rigid tripod haptic and foldable optic that can be injected through a self sealed clear corneal incision of as small size as two mm to be assembled to the previously implanted haptic.The second group (B) under went LASIK after doing the necessary investigations to exclude keratoconus suspects and to make sure that the cornea has enough thickness to allow complete correction of the refractive error in an ablation diameter that matches the scotopic pupil size.The third group (C) underwent clear lens extraction using micro-incision cataract surgery followed by implantation of acrylic foldable posterior chamber IOLs.The mean efficacy index three months postoperatively was 0.99, 0.874 and 0.916 in group A, B and C respectively. UCVA of 0.5 (6/12) or better was achieved in 80%, 93.33%, 63.3% of cases of group A, B and C respectively, while UCVA of 1.0 (6/6) was achieved in 16.67% and 33.3% of cases of group A and B.The mean postoperative safety index was 1.268, 1.03 and 1.249 in group A, B and C respectively. BCVA of 0.5 (6/12) or better was achieved in all cases however, 50%, 60% and 26.67% of cases in group A, B and C respectively achieved postoperative BCVA of 1.0 (6/6)Postoperative spherical equivalent within one diopter of emmetropia was achieved in 76.67%, 86.67%, 70% of cases in group A, B and C respectively. Postoperative defocus equivalent equal to or less than one diopter was achieved in 50%, 80% and 60% of cases group A, B and C respectively.The contrast sensitivity curves improved in the first postoperative month in all spatial frequencies in cases of group A and C without significant change in the subsequent visits. However; in cases of group B the contrast sensitivity curves decreased in the first postoperative month in all spatial frequencies, then improved at the third month visit to the preoperative level to exceed it in the sixth month without significant change in the subsequent ninth month visit.There was transient rise in IOP in cases of group A and C during the first postoperative week however; in group B IOP showed significant decline all through the follow up period.There was statistically significant loss of endothelial cells at one and nine months postoperatively however, the degree of loss varied in different groups. The loss in the mean endothelial cell count from preoperative level to the first month postoperatively was 6.29%, 1.56% and 9.78% and from the first month to the ninth month postoperatively was 0.99%, 1.28% and 0.92% in group A, B and C respectively.Regarding complications; in group (A), 6.67% of cases developed mild intraoperative hyphaema. Pupil ovalization occurred in 6.67% of cases, In 3.33% of cases rotation of the lens occurred due to too short haptics. In group (B), 3.33% of cases had decentered flap 3.33 % had decentered ablation. Interface deposits as well as bleeding to the interface were observed in 6.67%. The incidence of epithelial ingrowth, DLK and flap stria was 3.33% where as that of pseudoDLK was 6.67%. while in group (C), 3.33% of cases had intraoperative iris trauma while developed 6.67% posterior capsule opacification.CONCLUSIONSurgical correction of moderate to high myopia proved to be effective, safe and predictable. The choice of the procedure should be based on the patient’s condition, the surgeon’s expertise as well as the resources of the health care facility. The main procedures for correction of high myopia are Phakic IOLs, LASIK and clear lens extraction. Each of these procedures has its own indications, precautions as well as its most feared complications.Phakic IOLs despite the excellent initial outcome in terms of predictability and quality of vision imply certain risk for endothelial damage therefore should be followed up regularly. Phakic IOL should be removed as soon as serious decline in endothelial cell density occurs. As large proportion of high myopes will develop cataract, care should be taken to interfere before endothelial cell count decreases below safe limit for performing cataract extraction. The younger the patient at time of PIOL implantation, the higher the endothelial cell count required before PIOL implantation.LASIK is less invasive but irreversible procedure. Concerns about LASIK include degradation in quality of vision especially with marked flattening of the cornea which directly increases the higher order aberrations, the compromise between the optical zone and the possible correction respecting the minimal residual stromal bed. At any cost the risk of post LASIK keratectasia, the most devastating complication of LASIK nowadays, should be minimized. It should be kept in mind that theoretical calculations do not make up for the common error in the flap thickness.Clear lens extraction is more appealing in patients over forty five years especially if there is lens sclerosis as phakic IOL may enhance the cataract. LASIK also complicates IOL calculation should cataract progress necessitating removal. CLE should be performed through as small incision as possible to decrease the fluctuation in anterior chamber depth. Complete cortical clean up as well as capsular polishing must be performed to decrease the incidence of posterior capsular opacification and consequently YAG laser capsulotomy which is a very important added risk factor for retinal detachment in high myopes.Finally, due to the possible risks and elective nature of these procedures, they should only be offered to patients who refuse glasses and do not tolerate contact lenses. Clear explanation and proper informed consent is mandatory in every case.SUMMARYAs refractive surgery gets simpler, safer, more predictable and more effective, it becomes more popular. While cases of simple myopia are usually easy to handle and get satisfactory results when corrected with excimer laser, those with high myopia still represent some challenges.To get the best possible outcome, the surgical plan should be tailored individually to suit each particular case with its peculiar characteristics regarding patients age, activities, visual needs, expectations and of course not the least his own eye parameters.In an attempt to better understand this issue, this study was conducted including ninety eyes of 48 patients, 22 males (45.8 %) and 26 (54.2%) females with a mean age of 40.66±12.03 (range 20 to 63) years and mean spherical equivalent of -12.67±4.64 (range -24 to -7.5) diopters. They were divided into three equal groups.The first group (A) underwent phakic intraocular lens implantation namely Kelman duet lens which is an angle supported anterior chamber phakic lens with rigid tripod haptic and foldable optic that can be injected through a self sealed clear corneal incision of as small size as two mm to be assembled to the previously implanted haptic.The second group (B) under went LASIK after doing the necessary investigations to exclude keratoconus suspects and to make sure that the cornea has enough thickness to allow complete correction of the refractive error in an ablation diameter that matches the scotopic pupil size.The third group (C) underwent clear lens extraction using micro-incision cataract surgery followed by implantation of acrylic foldable posterior chamber IOLs.The mean efficacy index three months postoperatively was 0.99, 0.874 and 0.916 in group A, B and C respectively. UCVA of 0.5 (6/12) or better was achieved in 80%, 93.33%, 63.3% of cases of group A, B and C respectively, while UCVA of 1.0 (6/6) was achieved in 16.67% and 33.3% of cases of group A and B.The mean postoperative safety index was 1.268, 1.03 and 1.249 in group A, B and C respectively. BCVA of 0.5 (6/12) or better was achieved in all cases however, 50%, 60% and 26.67% of cases in group A, B and C respectively achieved postoperative BCVA of 1.0 (6/6)Postoperative spherical equivalent within one diopter of emmetropia was achieved in 76.67%, 86.67%, 70% of cases in group A, B and C respectively. Postoperative defocus equivalent equal to or less than one diopter was achieved in 50%, 80% and 60% of cases group A, B and C respectively.The contrast sensitivity curves improved in the first postoperative month in all spatial frequencies in cases of group A and C without significant change in the subsequent visits. However; in cases of group B the contrast sensitivity curves decreased in the first postoperative month in all spatial frequencies, then improved at the third month visit to the preoperative level to exceed it in the sixth month without significant change in the subsequent ninth month visit.There was transient rise in IOP in cases of group A and C during the first postoperative week however; in group B IOP showed significant decline all through the follow up period.There was statistically significant loss of endothelial cells at one and nine months postoperatively however, the degree of loss varied in different groups. The loss in the mean endothelial cell count from preoperative level to the first month postoperatively was 6.29%, 1.56% and 9.78% and from the first month to the ninth month postoperatively was 0.99%, 1.28% and 0.92% in group A, B and C respectively.Regarding complications; in group (A), 6.67% of cases developed mild intraoperative hyphaema. Pupil ovalization occurred in 6.67% of cases, In 3.33% of cases rotation of the lens occurred due to too short haptics. In group (B), 3.33% of cases had decentered flap 3.33 % had decentered ablation. Interface deposits as well as bleeding to the interface were observed in 6.67%. The incidence of epithelial ingrowth, DLK and flap stria was 3.33% where as that of pseudoDLK was 6.67%. while in group (C), 3.33% of cases had intraoperative iris trauma while developed 6.67% posterior capsule opacification.CONCLUSIONSurgical correction of moderate to high myopia proved to be effective, safe and predictable. The choice of the procedure should be based on the patient’s condition, the surgeon’s expertise as well as the resources of the health care facility. The main procedures for correction of high myopia are Phakic IOLs, LASIK and clear lens extraction. Each of these procedures has its own indications, precautions as well as its most feared complications.Phakic IOLs despite the excellent initial outcome in terms of predictability and quality of vision imply certain risk for endothelial damage therefore should be followed up regularly. Phakic IOL should be removed as soon as serious decline in endothelial cell density occurs. As large proportion of high myopes will develop cataract, care should be taken to interfere before endothelial cell count decreases below safe limit for performing cataract extraction. The younger the patient at time of PIOL implantation, the higher the endothelial cell count required before PIOL implantation.LASIK is less invasive but irreversible procedure. Concerns about LASIK include degradation in quality of vision especially with marked flattening of the cornea which directly increases the higher order aberrations, the compromise between the optical zone and the possible correction respecting the minimal residual stromal bed. At any cost the risk of post LASIK keratectasia, the most devastating complication of LASIK nowadays, should be minimized. It should be kept in mind that theoretical calculations do not make up for the common error in the flap thickness.Clear lens extraction is more appealing in patients over forty five years especially if there is lens sclerosis as phakic IOL may enhance the cataract. LASIK also complicates IOL calculation should cataract progress necessitating removal. CLE should be performed through as small incision as possible to decrease the fluctuation in anterior chamber depth. Complete cortical clean up as well as capsular polishing must be performed to decrease the incidence of posterior capsular opacification and consequently YAG laser capsulotomy which is a very important added risk factor for retinal detachment in high myopes.Finally, due to the possible risks and elective nature of these procedures, they should only be offered to patients who refuse glasses and do not tolerate contact lenses. Clear explanation and proper informed consent is mandatory in every case.SUMMARYAs refractive surgery gets simpler, safer, more predictable and more effective, it becomes more popular. While cases of simple myopia are usually easy to handle and get satisfactory results when corrected with excimer laser, those with high myopia still represent some challenges.To get the best possible outcome, the surgical plan should be tailored individually to suit each particular case with its peculiar characteristics regarding patients age, activities, visual needs, expectations and of course not the least his own eye parameters.In an attempt to better understand this issue, this study was conducted including ninety eyes of 48 patients, 22 males (45.8 %) and 26 (54.2%) females with a mean age of 40.66±12.03 (range 20 to 63) years and mean spherical equivalent of -12.67±4.64 (range -24 to -7.5) diopters. They were divided into three equal groups.The first group (A) underwent phakic intraocular lens implantation namely Kelman duet lens which is an angle supported anterior chamber phakic lens with rigid tripod haptic and foldable optic that can be injected through a self sealed clear corneal incision of as small size as two mm to be assembled to the previously implanted haptic.The second group (B) under went LASIK after doing the necessary investigations to exclude keratoconus suspects and to make sure that the cornea has enough thickness to allow complete correction of the refractive error in an ablation diameter that matches the scotopic pupil size.The third group (C) underwent clear lens extraction using micro-incision cataract surgery followed by implantation of acrylic foldable posterior chamber IOLs.The mean efficacy index three months postoperatively was 0.99, 0.874 and 0.916 in group A, B and C respectively. UCVA of 0.5 (6/12) or better was achieved in 80%, 93.33%, 63.3% of cases of group A, B and C respectively, while UCVA of 1.0 (6/6) was achieved in 16.67% and 33.3% of cases of group A and B.The mean postoperative safety index was 1.268, 1.03 and 1.249 in group A, B and C respectively. BCVA of 0.5 (6/12) or better was achieved in all cases however, 50%, 60% and 26.67% of cases in group A, B and C respectively achieved postoperative BCVA of 1.0 (6/6)Postoperative spherical equivalent within one diopter of emmetropia was achieved in 76.67%, 86.67%, 70% of cases in group A, B and C respectively. Postoperative defocus equivalent equal to or less than one diopter was achieved in 50%, 80% and 60% of cases group A, B and C respectively.The contrast sensitivity curves improved in the first postoperative month in all spatial frequencies in cases of group A and C without significant change in the subsequent visits. However; in cases of group B the contrast sensitivity curves decreased in the first postoperative month in all spatial frequencies, then improved at the third month visit to the preoperative level to exceed it in the sixth month without significant change in the subsequent ninth month visit.Fig (6): The suggested algorithm of diagnosis of exudative pleural effusionsSummaryThirty patients with exudative pleural effusions were 17 males and 13 females. Their age ranged from 18-77 years, according to Light’s criteria, were fit for pleural biopsy and didn’t have any of the following; bleeding disorders, positive culture of pleural fluid, frank pus, chylothorax, recent history of chest trauma, recent abdominal operation or recent coronary artery bypass, were selected from Patients with pleural effusions, who were admitted at Chest and Internal Medicine Departments, Zagazig University Hospitals, in the period from July 2004 to August 2005, and subjected to the following:1) Thorough medical history2) Full clinical examination.3) Plain Chest X- ray (postero-anterior and lateral views).4) Hematological investigations including:a) Complete blood picture.b) Liver function tests (total proteins, albumin, SGOT, SGPT, and total and direct bilirubin).c) Kidney function tests (blood urea and serum creatinine).d) Prothrombin time and partial thromboplastin time.e) Erythrocyte sedimentation rate (ESR).f) Fasting blood sugar; simultaneous with measurement of pleural fluid glucose level.g) Serum LDH simultaneous with measurement of pleural fluid value of LDH.h) Bone marrow biopsy from the sternum, under local anesthesia, was done in one case which diagnosed as chronic lymphocytic leukemia.5) Sputum analysis: was done for 5 patients with expectoration• Z.N. staining.• Cytological examination for malignant cells.6) Tuberculin skin test. (Mantoux method)7) Serological studies including some selected tests:a) Serum rheumatoid factor (RF).b) Serum antinuclear antibody (ANA)8) Pelvi-abdominal ultrasound.9) Ultrasound guided thoracocentesis.10) Pleural fluid analysis:(pH, protein, glucose, LDH, total and differential leukocytic count, gram stain, culture and sensitivity for aerobic, anaerobic organisms and AFB, ZN staining and cytological examination for malignant cells)11) Blind pleural biopsy by Abrams’ needle: biopsy taken was sent for culture for AFB and histopathological examination.12) Contrast enhanced CT chest.13) CT guided pleural biopsy: from the maximum area of parietal pleural thickening detected in CT chest and sent for histopathological examination.14) Fiberoptic bronchoscope: was done for 8 patients with parenchymal lesions detected in radiological examination and one patient with hemoptysis. The biopsy was sent for histopathological examination and BAL was sent for both ZN staining and cytological examination.15) Medical thoracoscope: with biopsy taken using the ”Storz” rigid thoracoscope 9 mm diameter was performed. The procedure of thoracoscopy was done under local anaesthesia and through a single puncture, that was made before for Abrams’ needle, at the posterior axillary line in the 6th-8th intercostal space while the patient lying in the lateral decubitus position with affected hemithorax up.The results of current study were as follow:1) The final diagnosis as established by different diagnostic tools was reached in 30 cases (100%) and distributed as follow; 8 patients (26.7%) with tuberculosis, one patient (3.3%) with rheumatoid arthritis, 4 patients (13.3%) with primary lung cancer (3 adenocarcinoma and 1 small cell carcinoma), 10 patients (33.3%) with metastatic carcinoma, 2 patients (6.7%) with hematological malignancies (one lymphoma and the other leukemia), and 5 patients (16.7%) with mesothelioma.2) Pleural fluid cytology achieved the diagnosis in 8 /21cases with sensitivity (38 %) of malignant pleural effusion, among them 2 cases (50%) with primary lung cancer, 5 cases (50%) with metastatic carcinoma and one case (20%) with mesothelioma.3) Abrams’ pleural biopsy yielded an overall sensitinity in 21 patients (70%) was obtained. It was positive (pathology and culture for AFB) in 7 patients of tuberculous pleural effusion (87.5%), while the corresponding result for malignancy was 14 patients (66.7%) which distributed as follow; 3 patients (75%) with primary lung cancer, 8 patients (80%) with metastatic carcinoma and 3 patients (60%) with malignant pleural mesothelioma.4) The magnitude of the maximum site of the parietal pleural thickening, detected by CT chest, ranged from 2-28 mm (9.4 ± 6). CT guided cutting needle biopsy from the maximum site of the parietal pleural thickening was positive for the diagnosis in 15/30 patients with overall sensitivity (50%) and was distributed as follow; 3 patients (37.5%) with tuberculosis, and 12 patients (57.1%) with malignant group that distributed as follow; 2 cases (50%) with primary lung cancer, 5 patients (50%) with metastatic carcinoma, 4 cases (80%) with malignant pleural mesothelioma and 1 case (50%) with hematological malignancy (lymphoma). No complication was reported in the procedure of CT-guided cutting needle biopsy.5) Diagnosis was reached by thoracoscopic pleural biopsy in 27 patients with overall sensitivity (90%), amoung them 7/8 patients (87.5%) tuberculous pleural effusion, 19/21 patients (90.5%) malignant pleural effusion and one patient with rheumatoid arthritis. Thoacoscopy was negative in 3/30 patients (10%); one patient in tuberculous group was diagnosed by Abrams’needle, one patient with metastatic carcinoma was diagnosed by cytological examination of pleural fluid and the third patient with lymphoma was diagnosed by bronchoscopic biopsy and CT-guided. 2/30 cases were persistent pneumothorax post thoracoscopy, these two cases were shown to have metastatic carcinoma to the pleura.Comparison of the diagnostic yield of different diagnostic tool versus the diagnostic yield of medical thoracoscopy in the studied patients:1) Pleural fluid cytology was positive in 8/21 patients (38%) with malignancy while thoracoscopic biopsy was positive in 19/21 patients (90.5%) with the same group (p<0.001).2) Abrams’ needle biopsy and thoracoscopy were positive in 7/8 patients (87.5%) with tuberculosis with non significant difference, while Abrams was positive in 14/21 patients (66.7%) of malignant group when compared to thoracoscopy which revealed positive in 19/21 patients (90.5%) of the same group with statistically significant improved yield with thoracoscopy (p0.05).3) CT guided biopsy was inferior with significant statistical difference to thoracoscopy in the diagnosis of tuberculous effusions, as it diagnosed 3 patients (37.5%) while thoracoscopy was positive in 7 patients (87.5%) of the same group (p0.05).4) As regard the total sensitivity of both Abrams’ biopsy and CT guided biopsy; it was 87.5% in TB, 75% in primary lung cancer, 80% in metastatic carcinoma, 50% in hematological malignancy, 100% in mesothelioma and 80.95% in total malignancy.5) Thoracoscopy was the only positive tool in the case of rheumatoid arthritis.Comparison of the diagnostic yield of Abrams’ needle biopsy versus CT guided biopsy in different groups:Abrams’ needle biopsy is superior significantly to CT guided biopsy in the diagnosis of tuberculous effusions (pConclusion1. The available Abrams’ needle biopsy is still an excellent and relatively safe procedure in the diagnosis of exudative pleural effusion especially tuberculous one.2. Percutaneous CT-guided cutting needle biopsy is safe and less invasive and diagnostic tool in patients with exudative pleural effusion.3. CT-guided biopsy is the diagnostic modality of choice in patients with mesothelioma and should precede thoracoscopy in those patients.4. CT-guided biopsy and Abrams’ needle biopsy are complementary to each others in the diagnosis of malignant pleural effusion especially mesothelioma.Recommendation1. Abrams’ needle biopsy should never be neglected as an invaluable diagnostic tool in the diagnosis of exudative pleural effusion that never to be abandoned.2. Based on routine investigations and clinical suspicions, the priority of CT-guided or blind Abrams’ pleural biopsies should be individualized as shown in the following algorithm (fig-11).3. Multiple CT-guided cutting needle pleural biopsies are advisable to be tried in patients with exudative pleural effusion as this guided technique may improve the total sensitivity of this procedure.4. The conclusion of the current study should be challenged widely on larger groups of patients for each of the items included.Fig (6): The suggested algorithm of diagnosis of exudative pleural effusionsSummaryThirty patients with exudative pleural effusions were 17 males and 13 females. Their age ranged from 18-77 years, according to Light’s criteria, were fit for pleural biopsy and didn’t have any of the following; bleeding disorders, positive culture of pleural fluid, frank pus, chylothorax, recent history of chest trauma, recent abdominal operation or recent coronary artery bypass, were selected from Patients with pleural effusions, who were admitted at Chest and Internal Medicine Departments, Zagazig University Hospitals, in the period from July 2004 to August 2005, and subjected to the following:1) Thorough medical history2) Full clinical examination.3) Plain Chest X- ray (postero-anterior and lateral views).4) Hematological investigations including:a) Complete blood picture.b) Liver function tests (total proteins, albumin, SGOT, SGPT, and total and direct bilirubin).c) Kidney function tests (blood urea and serum creatinine).d) Prothrombin time and partial thromboplastin time.e) Erythrocyte sedimentation rate (ESR).f) Fasting blood sugar; simultaneous with measurement of pleural fluid glucose level.g) Serum LDH simultaneous with measurement of pleural fluid value of LDH.h) Bone marrow biopsy from the sternum, under local anesthesia, was done in one case which diagnosed as chronic lymphocytic leukemia.5) Sputum analysis: was done for 5 patients with expectoration• Z.N. staining.• Cytological examination for malignant cells.6) Tuberculin skin test. (Mantoux method)7) Serological studies including some selected tests:a) Serum rheumatoid factor (RF).b) Serum antinuclear antibody (ANA)8) Pelvi-abdominal ultrasound.9) Ultrasound guided thoracocentesis.10) Pleural fluid analysis:(pH, protein, glucose, LDH, total and differential leukocytic count, gram stain, culture and sensitivity for aerobic, anaerobic organisms and AFB, ZN staining and cytological examination for malignant cells)11) Blind pleural biopsy by Abrams’ needle: biopsy taken was sent for culture for AFB and histopathological examination.12) Contrast enhanced CT chest.13) CT guided pleural biopsy: from the maximum area of parietal pleural thickening detected in CT chest and sent for histopathological examination.14) Fiberoptic bronchoscope: was done for 8 patients with parenchymal lesions detected in radiological examination and one patient with hemoptysis. The biopsy was sent for histopathological examination and BAL was sent for both ZN staining and cytological examination.15) Medical thoracoscope: with biopsy taken using the ”Storz” rigid thoracoscope 9 mm diameter was performed. The procedure of thoracoscopy was done under local anaesthesia and through a single puncture, that was made before for Abrams’ needle, at the posterior axillary line in the 6th-8th intercostal space while the patient lying in the lateral decubitus position with affected hemithorax up.The results of current study were as follow:1) The final diagnosis as established by different diagnostic tools was reached in 30 cases (100%) and distributed as follow; 8 patients (26.7%) with tuberculosis, one patient (3.3%) with rheumatoid arthritis, 4 patients (13.3%) with primary lung cancer (3 adenocarcinoma and 1 small cell carcinoma), 10 patients (33.3%) with metastatic carcinoma, 2 patients (6.7%) with hematological malignancies (one lymphoma and the other leukemia), and 5 patients (16.7%) with mesothelioma.2) Pleural fluid cytology achieved the diagnosis in 8 /21cases with sensitivity (38 %) of malignant pleural effusion, among them 2 cases (50%) with primary lung cancer, 5 cases (50%) with metastatic carcinoma and one case (20%) with mesothelioma.3) Abrams’ pleural biopsy yielded an overall sensitinity in 21 patients (70%) was obtained. It was positive (pathology and culture for AFB) in 7 patients of tuberculous pleural effusion (87.5%), while the corresponding result for malignancy was 14 patients (66.7%) which distributed as follow; 3 patients (75%) with primary lung cancer, 8 patients (80%) with metastatic carcinoma and 3 patients (60%) with malignant pleural mesothelioma.4) The magnitude of the maximum site of the parietal pleural thickening, detected by CT chest, ranged from 2-28 mm (9.4 ± 6). CT guided cutting needle biopsy from the maximum site of the parietal pleural thickening was positive for the diagnosis in 15/30 patients with overall sensitivity (50%) and was distributed as follow; 3 patients (37.5%) with tuberculosis, and 12 patients (57.1%) with malignant group that distributed as follow; 2 cases (50%) with primary lung cancer, 5 patients (50%) with metastatic carcinoma, 4 cases (80%) with malignant pleural mesothelioma and 1 case (50%) with hematological malignancy (lymphoma). No complication was reported in the procedure of CT-guided cutting needle biopsy.5) Diagnosis was reached by thoracoscopic pleural biopsy in 27 patients with overall sensitivity (90%), amoung them 7/8 patients (87.5%) tuberculous pleural effusion, 19/21 patients (90.5%) malignant pleural effusion and one patient with rheumatoid arthritis. Thoacoscopy was negative in 3/30 patients (10%); one patient in tuberculous group was diagnosed by Abrams’needle, one patient with metastatic carcinoma was diagnosed by cytological examination of pleural fluid and the third patient with lymphoma was diagnosed by bronchoscopic biopsy and CT-guided. 2/30 cases were persistent pneumothorax post thoracoscopy, these two cases were shown to have metastatic carcinoma to the pleura.Comparison of the diagnostic yield of different diagnostic tool versus the diagnostic yield of medical thoracoscopy in the studied patients:1) Pleural fluid cytology was positive in 8/21 patients (38%) with malignancy while thoracoscopic biopsy was positive in 19/21 patients (90.5%) with the same group (p<0.001).2) Abrams’ needle biopsy and thoracoscopy were positive in 7/8 patients (87.5%) with tuberculosis with non significant difference, while Abrams was positive in 14/21 patients (66.7%) of malignant group when compared to thoracoscopy which revealed positive in 19/21 patients (90.5%) of the same group with statistically significant improved yield with thoracoscopy (p0.05).3) CT guided biopsy was inferior with significant statistical difference to thoracoscopy in the diagnosis of tuberculous effusions, as it diagnosed 3 patients (37.5%) while thoracoscopy was positive in 7 patients (87.5%) of the same group (p0.05).4) As regard the total sensitivity of both Abrams’ biopsy and CT guided biopsy; it was 87.5% in TB, 75% in primary lung cancer, 80% in metastatic carcinoma, 50% in hematological malignancy, 100% in mesothelioma and 80.95% in total malignancy.5) Thoracoscopy was the only positive tool in the case of rheumatoid arthritis.Comparison of the diagnostic yield of Abrams’ needle biopsy versus CT guided biopsy in different groups:Abrams’ needle biopsy is superior significantly to CT guided biopsy in the diagnosis of tuberculous effusions (pConclusion1. The available Abrams’ needle biopsy is still an excellent and relatively safe procedure in the diagnosis of exudative pleural effusion especially tuberculous one.2. Percutaneous CT-guided cutting needle biopsy is safe and less invasive and diagnostic tool in patients with exudative pleural effusion.3. CT-guided biopsy is the diagnostic modality of choice in patients with mesothelioma and should precede thoracoscopy in those patients.4. CT-guided biopsy and Abrams’ needle biopsy are complementary to each others in the diagnosis of malignant pleural effusion especially mesothelioma.Recommendation1. Abrams’ needle biopsy should never be neglected as an invaluable diagnostic tool in the diagnosis of exudative pleural effusion that never to be abandoned.2. Based on routine investigations and clinical suspicions, the priority of CT-guided or blind Abrams’ pleural biopsies should be individualized as shown in the following algorithm (fig-11).3. Multiple CT-guided cutting needle pleural biopsies are advisable to be tried in patients with exudative pleural effusion as this guided technique may improve the total sensitivity of this procedure.4. The conclusion of the current study should be challenged widely on larger groups of patients for each of the items included.Fig (6): The suggested algorithm of diagnosis of exudative pleural effusionsSummaryThirty patients with exudative pleural effusions were 17 males and 13 females. Their age ranged from 18-77 years, according to Light’s criteria, were fit for pleural biopsy and didn’t have any of the following; bleeding disorders, positive culture of pleural fluid, frank pus, chylothorax, recent history of chest trauma, recent abdominal operation or recent coronary artery bypass, were selected from Patients with pleural effusions, who were admitted at Chest and Internal Medicine Departments, Zagazig University Hospitals, in the period from July 2004 to August 2005, and subjected to the following:1) Thorough medical history2) Full clinical examination.3) Plain Chest X- ray (postero-anterior and lateral views).4) Hematological investigations including:a) Complete blood picture.b) Liver function tests (total proteins, albumin, SGOT, SGPT, and total and direct bilirubin).c) Kidney function tests (blood urea and serum creatinine).d) Prothrombin time and partial thromboplastin time.e) Erythrocyte sedimentation rate (ESR).f) Fasting blood sugar; simultaneous with measurement of pleural fluid glucose level.g) Serum LDH simultaneous with measurement of pleural fluid value of LDH.h) Bone marrow biopsy from the sternum, under local anesthesia, was done in one case which diagnosed as chronic lymphocytic leukemia.5) Sputum analysis: was done for 5 patients with expectoration• Z.N. staining.• Cytological examination for malignant cells.6) Tuberculin skin test. (Mantoux method)7) Serological studies including some selected tests:a) Serum rheumatoid factor (RF).b) Serum antinuclear antibody (ANA)8) Pelvi-abdominal ultrasound.9) Ultrasound guided thoracocentesis.10) Pleural fluid analysis:(pH, protein, glucose, LDH, total and differential leukocytic count, gram stain, culture and sensitivity for aerobic, anaerobic organisms and AFB, ZN staining and cytological examination for malignant cells)11) Blind pleural biopsy by Abrams’ needle: biopsy taken was sent for culture for AFB and histopathological examination.12) Contrast enhanced CT chest.13) CT guided pleural biopsy: from the maximum area of parietal pleural thickening detected in CT chest and sent for histopathological examination.14) Fiberoptic bronchoscope: was done for 8 patients with parenchymal lesions detected in radiological examination and one patient with hemoptysis. The biopsy was sent for histopathological examination and BAL was sent for both ZN staining and cytological examination.15) Medical thoracoscope: with biopsy taken using the ”Storz” rigid thoracoscope 9 mm diameter was performed. The procedure of thoracoscopy was done under local anaesthesia and through a single puncture, that was made before for Abrams’ needle, at the posterior axillary line in the 6th-8th intercostal space while the patient lying in the lateral decubitus position with affected hemithorax up.The results of current study were as follow:1) The final diagnosis as established by different diagnostic tools was reached in 30 cases (100%) and distributed as follow; 8 patients (26.7%) with tuberculosis, one patient (3.3%) with rheumatoid arthritis, 4 patients (13.3%) with primary lung cancer (3 adenocarcinoma and 1 small cell carcinoma), 10 patients (33.3%) with metastatic carcinoma, 2 patients (6.7%) with hematological malignancies (one lymphoma and the other leukemia), and 5 patients (16.7%) with mesothelioma.2) Pleural fluid cytology achieved the diagnosis in 8 /21cases with sensitivity (38 %) of malignant pleural effusion, among them 2 cases (50%) with primary lung cancer, 5 cases (50%) with metastatic carcinoma and one case (20%) with mesothelioma.3) Abrams’ pleural biopsy yielded an overall sensitinity in 21 patients (70%) was obtained. It was positive (pathology and culture for AFB) in 7 patients of tuberculous pleural effusion (87.5%), while the corresponding result for malignancy was 14 patients (66.7%) which distributed as follow; 3 patients (75%) with primary lung cancer, 8 patients (80%) with metastatic carcinoma and 3 patients (60%) with malignant pleural mesothelioma.4) The magnitude of the maximum site of the parietal pleural thickening, detected by CT chest, ranged from 2-28 mm (9.4 ± 6). CT guided cutting needle biopsy from the maximum site of the parietal pleural thickening was positive for the diagnosis in 15/30 patients with overall sensitivity (50%) and was distributed as follow; 3 patients (37.5%) with tuberculosis, and 12 patients (57.1%) with malignant group that distributed as follow; 2 cases (50%) with primary lung cancer, 5 patients (50%) with metastatic carcinoma, 4 cases (80%) with malignant pleural mesothelioma and 1 case (50%) with hematological malignancy (lymphoma). No complication was reported in the procedure of CT-guided cutting needle biopsy.5) Diagnosis was reached by thoracoscopic pleural biopsy in 27 patients with overall sensitivity (90%), amoung them 7/8 patients (87.5%) tuberculous pleural effusion, 19/21 patients (90.5%) malignant pleural effusion and one patient with rheumatoid arthritis. Thoacoscopy was negative in 3/30 patients (10%); one patient in tuberculous group was diagnosed by Abrams’needle, one patient with metastatic carcinoma was diagnosed by cytological examination of pleural fluid and the third patient with lymphoma was diagnosed by bronchoscopic biopsy and CT-guided. 2/30 cases were persistent pneumothorax post thoracoscopy, these two cases were shown to have metastatic carcinoma to the pleura.Comparison of the diagnostic yield of different diagnostic tool versus the diagnostic yield of medical thoracoscopy in the studied patients:1) Pleural fluid cytology was positive in 8/21 patients (38%) with malignancy while thoracoscopic biopsy was positive in 19/21 patients (90.5%) with the same group (p<0.001).2) Abrams’ needle biopsy and thoracoscopy were positive in 7/8 patients (87.5%) with tuberculosis with non significant difference, while Abrams was positive in 14/21 patients (66.7%) of malignant group when compared to thoracoscopy which revealed positive in 19/21 patients (90.5%) of the same group with statistically significant improved yield with thoracoscopy (p0.05).3) CT guided biopsy was inferior with significant statistical difference to thoracoscopy in the diagnosis of tuberculous effusions, as it diagnosed 3 patients (37.5%) while thoracoscopy was positive in 7 patients (87.5%) of the same group (p0.05).4) As regard the total sensitivity of both Abrams’ biopsy and CT guided biopsy; it was 87.5% in TB, 75% in primary lung cancer, 80% in metastatic carcinoma, 50% in hematological malignancy, 100% in mesothelioma and 80.95% in total malignancy.5) Thoracoscopy was the only positive tool in the case of rheumatoid arthritis.Comparison of the diagnostic yield of Abrams’ needle biopsy versus CT guided biopsy in different groups:Abrams’ needle biopsy is superior significantly to CT guided biopsy in the diagnosis of tuberculous effusions (pConclusion1. The available Abrams’ needle biopsy is still an excellent and relatively safe procedure in the diagnosis of exudative pleural effusion especially tuberculous one.2. Percutaneous CT-guided cutting needle biopsy is safe and less invasive and diagnostic tool in patients with exudative pleural effusion.3. CT-guided biopsy is the diagnostic modality of choice in patients with mesothelioma and should precede thoracoscopy in those patients.4. CT-guided biopsy and Abrams’ needle biopsy are complementary to each others in the diagnosis of malignant pleural effusion especially mesothelioma.Recommendation1. Abrams’ needle biopsy should never be neglected as an invaluable diagnostic tool in the diagnosis of exudative pleural effusion that never to be abandoned.2. Based on routine investigations and clinical suspicions, the priority of CT-guided or blind Abrams’ pleural biopsies should be individualized as shown in the following algorithm (fig-11).3. Multiple CT-guided cutting needle pleural biopsies are advisable to be tried in patients with exudative pleural effusion as this guided technique may improve the total sensitivity of this procedure.4. The conclusion of the current study should be challenged widely on larger groups of patients for each of the items included.Fig (6): The suggested algorithm of diagnosis of exudative pleural effusionsSummaryThirty patients with exudative pleural effusions were 17 males and 13 females. Their age ranged from 18-77 years, according to Light’s criteria, were fit for pleural biopsy and didn’t have any of the following; bleeding disorders, positive culture of pleural fluid, frank pus, chylothorax, recent history of chest trauma, recent abdominal operation or recent coronary artery bypass, were selected from Patients with pleural effusions, who were admitted at Chest and Internal Medicine Departments, Zagazig University Hospitals, in the period from July 2004 to August 2005, and subjected to the following:1) Thorough medical history2) Full clinical examination.3) Plain Chest X- ray (postero-anterior and lateral views).4) Hematological investigations including:a) Complete blood picture.b) Liver function tests (total proteins, albumin, SGOT, SGPT, and total and direct bilirubin).c) Kidney function tests (blood urea and serum creatinine).d) Prothrombin time and partial thromboplastin time.e) Erythrocyte sedimentation rate (ESR).f) Fasting blood sugar; simultaneous with measurement of pleural fluid glucose level.g) Serum LDH simultaneous with measurement of pleural fluid value of LDH.h) Bone marrow biopsy from the sternum, under local anesthesia, was done in one case which diagnosed as chronic lymphocytic leukemia.5) Sputum analysis: was done for 5 patients with expectoration• Z.N. staining.• Cytological examination for malignant cells.6) Tuberculin skin test. (Mantoux method)7) Serological studies including some selected tests:a) Serum rheumatoid factor (RF).b) Serum antinuclear antibody (ANA)8) Pelvi-abdominal ultrasound.9) Ultrasound guided thoracocentesis.10) Pleural fluid analysis:(pH, protein, glucose, LDH, total and differential leukocytic count, gram stain, culture and sensitivity for aerobic, anaerobic organisms and AFB, ZN staining and cytological examination for malignant cells)11) Blind pleural biopsy by Abrams’ needle: biopsy taken was sent for culture for AFB and histopathological examination.12) Contrast enhanced CT chest.13) CT guided pleural biopsy: from the maximum area of parietal pleural thickening detected in CT chest and sent for histopathological examination.14) Fiberoptic bronchoscope: was done for 8 patients with parenchymal lesions detected in radiological examination and one patient with hemoptysis. The biopsy was sent for histopathological examination and BAL was sent for both ZN staining and cytological examination.15) Medical thoracoscope: with biopsy taken using the ”Storz” rigid thoracoscope 9 mm diameter was performed. The procedure of thoracoscopy was done under local anaesthesia and through a single puncture, that was made before for Abrams’ needle, at the posterior axillary line in the 6th-8th intercostal space while the patient lying in the lateral decubitus position with affected hemithorax up.The results of current study were as follow:1) The final diagnosis as established by different diagnostic tools was reached in 30 cases (100%) and distributed as follow; 8 patients (26.7%) with tuberculosis, one patient (3.3%) with rheumatoid arthritis, 4 patients (13.3%) with primary lung cancer (3 adenocarcinoma and 1 small cell carcinoma), 10 patients (33.3%) with metastatic carcinoma, 2 patients (6.7%) with hematological malignancies (one lymphoma and the other leukemia), and 5 patients (16.7%) with mesothelioma.2) Pleural fluid cytology achieved the diagnosis in 8 /21cases with sensitivity (38 %) of malignant pleural effusion, among them 2 cases (50%) with primary lung cancer, 5 cases (50%) with metastatic carcinoma and one case (20%) with mesothelioma.3) Abrams’ pleural biopsy yielded an overall sensitinity in 21 patients (70%) was obtained. It was positive (pathology and culture for AFB) in 7 patients of tuberculous pleural effusion (87.5%), while the corresponding result for malignancy was 14 patients (66.7%) which distributed as follow; 3 patients (75%) with primary lung cancer, 8 patients (80%) with metastatic carcinoma and 3 patients (60%) with malignant pleural mesothelioma.4) The magnitude of the maximum site of the parietal pleural thickening, detected by CT chest, ranged from 2-28 mm (9.4 ± 6). CT guided cutting needle biopsy from the maximum site of the parietal pleural thickening was positive for the diagnosis in 15/30 patients with overall sensitivity (50%) and was distributed as follow; 3 patients (37.5%) with tuberculosis, and 12 patients (57.1%) with malignant group that distributed as follow; 2 cases (50%) with primary lung cancer, 5 patients (50%) with metastatic carcinoma, 4 cases (80%) with malignant pleural mesothelioma and 1 case (50%) with hematological malignancy (lymphoma). No complication was reported in the procedure of CT-guided cutting needle biopsy.5) Diagnosis was reached by thoracoscopic pleural biopsy in 27 patients with overall sensitivity (90%), amoung them 7/8 patients (87.5%) tuberculous pleural effusion, 19/21 patients (90.5%) malignant pleural effusion and one patient with rheumatoid arthritis. Thoacoscopy was negative in 3/30 patients (10%); one patient in tuberculous group was diagnosed by Abrams’needle, one patient with metastatic carcinoma was diagnosed by cytological examination of pleural fluid and the third patient with lymphoma was diagnosed by bronchoscopic biopsy and CT-guided. 2/30 cases were persistent pneumothorax post thoracoscopy, these two cases were shown to have metastatic carcinoma to the pleura.Comparison of the diagnostic yield of different diagnostic tool versus the diagnostic yield of medical thoracoscopy in the studied patients:1) Pleural fluid cytology was positive in 8/21 patients (38%) with malignancy while thoracoscopic biopsy was positive in 19/21 patients (90.5%) with the same group (p<0.001).2) Abrams’ needle biopsy and thoracoscopy were positive in 7/8 patients (87.5%) with tuberculosis with non significant difference, while Abrams was positive in 14/21 patients (66.7%) of malignant group when compared to thoracoscopy which revealed positive in 19/21 patients (90.5%) of the same group with statistically significant improved yield with thoracoscopy (p0.05).• The aim of this study is evaluation the levels of some coagulation inhibitors such as protein C and antithrombin III in neonates at risk for development of thrombosis and correlation of the studied parameters with the D-dimer level as indicator of thrombosis.• Each neonates subjected to full prenatal, natal and postnatal history, Full clinical examination and for patients with perinatal asphyxia :CT scan, Na, Ca, glucose, kidney function, for RDS neonates chest X rays was done and for sepsis group chest X ray, C reactive protein, .