Utilization of Ophthalmic Technology and Advances in Endothelial Keratoplasty: A Case Report.

INTRODUCTION AND IMPORTANCE: The authors report a case of a 65-year-old male with corneal decompensation associated with poor vision with a recent history of cataract surgery. CASE PRESENTATION: A patient presented with complaints of poor vision in the left eye. The patient had undergone phacoemulsification surgery 4 months prior to presentation. The presenting best corrected vision was 20/400 in the left eye with the presence of corneal edema and central Descemet's membrane detachment (DMD) extending to the inferior two-thirds of the cornea with a fibrotic demarcation line separating detached Descemet's from intact, attached Descemet's. CLINICAL DISCUSSION: Anterior segment optical coherence tomography (AS-OCT) confirmed the diagnosis of Type 1 DMD. The patient was managed with femtosecond laser-assisted descematorrhexis with intraoperative AS-OCT, and a ready preloaded Descemet stripping endothelial keratoplasty graft. CONCLUSIONS: This report emphasizes that many technological advancements in the field can be employed to improve the outcomes of endothelial keratoplasty, especially when fibrosis is associated with the combined PDL and DMD.

Management of Acute Corneal Hydrops Using Compression Sutures and Intracameral Air Injection.

BACKGROUND Acute corneal hydrops, a rare complication of keratoconus, is characterized by sudden onset of corneal stroma edema. It typically manifests as an acute decrease in visual acuity, accompanied by pain and photophobia. Prompt recognition and interventions are critical for effective resolution of hydrops and prevention of corneal vascularization. Herein, we present a case of a patient with keratoconus who developed corneal hydrops, successfully managed using full-thickness compression sutures and intracameral air injection. CASE REPORT A woman in her early 30s, with a history of keratoconus, presented with symptoms of acute hydrops in her left eye. On presentation, best corrected visual acuity was hand motion. Slit-lamp examination revealed marked corneal edema with multiple stromal clefts. The decision was made to perform full-thickness compression sutures combined with intracameral air injection to expedite edema resolution and prevent neovascularization. Three full-thickness sutures were placed across Descemet membrane breaks, and an air bubble was left, filling 50% of the anterior chamber. At 3-month follow-up, a clear, compact cornea was noted, with no evidence of vascularization. The patient was scheduled for penetrating keratoplasty for visual rehabilitation. CONCLUSIONS The combination of full-thickness compression sutures and intracameral air seems to be an effective and safe method for preventing corneal angiogenesis following hydrops. As corneal scaring is often an inevitable complication of acute corneal hydrops, keratoplasty is necessary for improving visual acuity. Hence, the prevention of corneal vascularization should be the major aim in the management of corneal hydrops to ensure successful keratoplasty.

Assessment of refractive outcomes in eyes that underwent intraocular lens implantation in the posterior chamber but not "in-the-capsular bag:" A comparative retrospective study.

PURPOSE: The purpose of this study was to report visual and refractive outcomes in eyes that underwent intraocular lens (IOL) fixation in the absence of capsular support. METHODS: This was a retrospective chart review of cases undergoing posterior chamber iris-fixated IOL (IFIOL) and scleral-fixated IOL (SFIOL) implants from June 2014 to March 2020 with more than 3 months of follow-up and having a preoperative best-corrected visual acuity of 20/80 and more. RESULTS: Records of 120 eyes of 112 patients were reviewed. The mean age of the patients was 46.9 ± 22.3 (14.4-98.0) years, and 62% (n = 70) of participants were male. Most of the eyes (102: 85%) were aphakic at the time of surgery. The mean follow-up was 22.95 ± 17.1 months. The efficacy index of sutured IFIOL and glued SFIOL outperformed sutured SFIOL at 3 months and final visits postoperatively (P < 0.001). All techniques studied here resulted in a similar safety index at 3 months (P = 0.4). The mean predictive error (postoperative spherical equivalent refraction minus intended target refraction) was +0.07 ± 1.5 D and -0.12 ± 1.4 D at 3 months and the final postoperative visit, respectively. CONCLUSION: The studied techniques have relatively good visual and refractive outcomes in this series. In addition, techniques involving a small corneal incision with foldable IOL fixation to the iris or scleral tissue have superior efficacy and safety indices compared to creating large corneoscleral wounds for rigid IOL fixation techniques.

Spherical equivalent pre- and post-implantable collamer lens implantation in patients with myopia, hyperopia, and stable keratoconus.

PURPOSE: Refractive errors are common in Saudi Arabia and keratorefractive surgeries are usually done to correct them. However, not all patients are fit and complications postoperatively are a concern. Implantable collamer lens (ICL) implantation can be used for patients who are not fit for keratorefractive surgeries. ICL can also be used for keratoconus. We elected to evaluate the outcomes of patients who had ICL implantation for refractive errors or keratoconus. METHODS: We retrospectively reviewed patients aged between 21 and 45 years old, who attended the anterior segment clinic at King Khaled Eye Specialist Hospital and who had spherical equivalent (SE) ranging between (+16 to -23 diopters), and had ICL implantation between February 2015 and September 2017. The SE was documented before and after the surgery. Depending on the SE, patients were divided into two groups (myopia and hyperopia). Statistical analysis was done to evaluate the change in mean SE before and after surgery for patients. RESULTS: We identified 169 eyes and 155 (92%) were myopic before the surgery. Before surgery, the mean SE was -8.6 and the standard deviation (SD) was 4.4. Only 14 eyes (8%) were hyperopic before the surgery with a mean SE of +5.5 and SD of 4.8. The difference in the mean of SE between after and before the surgery for myopic eyes was statistically significant (mean difference: 7.8, SD: 5, P < 0.0001). The difference in the mean of SE between post- and pre-operatively was also significant for hyperopic eyes (mean difference: -6.1, SD: 5.2, P = 0.0007). In 32 eyes with keratoconus, the mean SE before surgery was -7.9 with an SD of 4.1. For the keratoconus eyes, the mean difference of SE between after and before surgery was statistically significant as the mean difference in SE was 7.2 with an SD of 4.6 (P < 0.0001). CONCLUSION: The effect of ICL implantation was significant in improving the SE for myopic, hyperopic, and keratoconus eyes.

Preferred surgical techniques for secondary intraocular lens implantation in adults with aphakia.

AIM: To identify the current surgical management of aphakia and the outcomes and complications of each technique. METHODS: This cross-sectional study included ophthalmic surgeons with at least one-year experience in surgery for aphakia. A study questionnaire was formulated to collect data in Saudi Arabia and other regional countries. The questionnaire included 22 questions on demographics, preferred surgical techniques, complications and the factors related to surgeon decision and the choice for managing aphakia. RESULTS: The study included 145 participants (111; 76.6% were males) with mean age of 46.7 ± 11.5 years. The mean duration of cataract surgery experience was 17.6 ± 11.1 years. Most participants (86.2%) were trained in cataract surgery. Scleral fixation of intraocular lens (SFIOL) was the most commonly preferred technique, followed by iris fixation IOL, and anterior chamber IOL (75.2%, 9%, and 15.9%, respectively). The main determinants for selection of a surgical technique were simplicity (56.6%), surgical instrument availability (48.3%), and training on the technique (47.6%). The most frequent postoperative complications were pupil distortion, high intraocular pressure (IOP), pupillary capture of the IOL, and IOL decentration. CONCLUSIONS: SFIOL is the preferred surgical technique for managing aphakia. The decision to choose one technique over another is complex and is based on several factors, including technical difficulty, previous training, anatomical variations, ocular comorbidities, and the potential complications. The most frequent complications after surgical correction of aphakia are pupil distortion, high IOP, pupillary capture of the IOL, and decentered IOLs.

Splinter Cataract in Patients with Keratoconus and Frequent Eye Rubbing: A Novel Finding.

BACKGROUND Patients with keratoconus are at increased risk of developing cataract at a younger age compared to the normal population. Predisposing factors include atopy and topical steroid use. In this case series we report the novel observation of splinter-shaped cortical cataract in 16 eyes of 14 patients with keratoconus in the absence of other risk factors of cataract development from a single center in Riyadh, Saudi Arabia. CASE REPORT This is a retrospective review of 16 eyes of 14 patients diagnosed with keratoconus and found to have splinter cortical cataract. Twelve patients had unilateral and 2 patients had bilateral splinter cortical cataract in the inferotemporal quadrant of the crystalline lens. Thirteen eyes (81.25%) had clinically proven keratoconus and 3 eyes (18.75%) were keratoconus suspects. All patients affirmed frequent eye rubbing and 62.5% of eyes had a history of vernal keratoconjunctivitis. Best corrected visual acuity (BCVA) by the logarithm of the minimum angle of resolution (LogMAR) was reported between 0 to 0.2 in 69% of eyes (11 eyes) and 4 eyes (25%) had BCVA of 0.3 to 0.6, and 1 eye (6%) had BCVA of 1.3. CONCLUSIONS Splinter-shaped cortical cataract could be a sign of frequent eye rubbing. Careful examination of the crystalline lens with dilated pupil may reveal peripheral cortical opacities in the inferotemporal quadrant, which can alert the physician that the patient has habitual eye rubbing and is at increased risk of keratoconus development or progression.

Treatment challenges associated with a superiorly located bulbar conjunctival mass-case report and review of the literature.

PURPOSE: This report describes a recurrent case of ocular surface squamous neoplasia in a middle-aged and immunocompetent patient. OBSERVATIONS: The summary of clinical presentation, workup, and medical and surgical intervention are described, followed by a brief overview of the treatment challenges associated with superiorly located conjunctival lesions. CONCLUSIONS: In cases where topical chemotherapeutic drops cannot penetrate the lesion, the location of conjunctival lesions can sometimes pose a challenge. Hence, injections in such cases might be preferred. However, histopathology still plays a significant role in achieving a definitive diagnosis.

Microbial Keratitis following Self-Retained Cryopreserved Amniotic Membrane.

The aim of this study was to report a severe case of mixed fungal and bacterial microbial keratitis following implantation of a self-retained cryopreserved amniotic membrane, PROKERA® SLIM (Bio-Tissue, Inc) in a patient with history of neurotrophic ulcer secondary to herpetic epithelial keratitis. Despite maximally tolerated topical and systemic therapy, the patient's eye continued to deteriorate and eventually required evisceration. PROKERA implantation might be associated with severe recalcitrant microbial keratitis. Caution is urged when considering implantation especially in monocular patients.

Outcomes and complications of implantable collamer lens for mild to advance keratoconus.

PURPOSE: To evaluate the outcome and safety of implantable collamer lens (ICL; (Visian, STAAR Surgical, Monrovia, CA, USA) in mild to advance keratoconus patients with myopia and myopic astigmatism. METHODS: This retrospective study evaluated all patients who underwent ICL implantation for the management of keratoconus at a tertiary care eye hospital from January 2012 to January 2018. The mean duration of follow-up was 15.3 months (range, 3.13 to 38.97 months). Data were collected on preoperative and postoperative uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA), refraction was compared, and adverse effects were evaluated. RESULTS: Thirty-two eyes (32 patients) were evaluated. The median CDVA was 20/30 preoperatively and 20/20 at last follow-up. The median UDVA was 20/25 at last follow-up. Thirteen patients (40.6%) had 20/20 UDVA in comparison to none at baseline. The median spherical equivalent in diopters (D) was -7.875 D (-4.125 to -10.0 D) preoperatively and decreased to -0.3125 D at last follow-up. The median manifest refractive cylinder was 3.00 D (2.25 to 5.25 D) preoperatively and decreased to 1.125 D postoperatively. Cylinder axis rotation of 10° or greater occurred in 3 eyes (9.375%) and required repositioning of the ICL. One patient (3%) developed nonvisually significant anterior subcapsular cataract. One ICL (3.125%) had to be explanted due to residual refractive error and unsatisfactory vision. CONCLUSION: ICLs are a suitable refractive option for the correction of refractive error associated with stable, nonprogressive keratoconus even in advance cases. However, the risk of ICL rotation and subsequent repositioning remain. Careful patient selection is necessary for achieving good outcomes and mitigating intraoperative and postoperative complications.